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Lee, Baek, and Ahn: A case report of a Phantom Limb Pain (PLP) patient treated with integrative Korean and Western medicine

Abstract

Objectives

We report a case of Phantom Limb Pain (PLP) and propose the possibility of integrative Korean and Western medicine in PLP treatment.

Methods

For 42 days, a patient who complained of pain and insomnia with PLP (December 20, 2016 to January 20, 2017) received Korean and Western medical treatment. The patient was treated with analgesic injection, a neuropathic pain inhibitor, the combined herbal formula powders Bojungikgitang, and acupuncture. Symptom improvement was assessed using the numerical rating scale (NRS) and continuous sleep time.

Results

The patient’s NRS scores decreased, and continuous sleep time increased after treatment. The NRS scores decreased from 10 to 0, and the continuous sleep time increased from 2 hours to 7 to 8 hours.

Conclusion

According to the results, this report suggests that integrative Korean and Western medicine could be effective in the treatment of PLP patients.

초록

목적

Phantom Limb Pain (PLP) 한 례를 통해 한의학 및 서양 의학의 통합적인 치료 가능성을 제안한다.

방법

PLP로 통증과 불면증을 호소 한 환자는 2016 년 12 월 20 일 ~ 2017 년 1 월 20 일 동안 한의학 및 서양 의학 치료를 받았다. 환자는 진통제, 신경 병증 성 통증 억제제, 보중익기탕 가루제 및 침치료를 받았다. 증상 개선은 NRS (Numerical Rating Scale)와 연속적 수면 시간을 이용하여 평가되었다.

결과

치료 후 환자의 NRS가 감소하고 연속적 수면 시간이 길어졌다. NRS는 10에서 0으로 감소하였고, 수면 시간은 2 시간에서 7-8 시간으로 증가 하였다.

결론

이 연구는 한의학 및 서양 의학의 통합적인 치료가 PLP 환자에 효과적 일 수 있음을 시사한다.

I. Introduction

Phantom limb pain (PLP) is characterized by painful sensations in the missing part of the amputated limb. Common causes of limb deficiency are vascular problems, trauma, cancer, and congenital limb loss1). PLP can be associated with various clinical characteristics such as aching; cramping; burning; tingling; sharp, shooting, or stabbing pain; or mixed burning-tingling2,3). About one week after amputation, 92% of patients reported phantom tingling. PLP appears in 65% of patients within the first 6 months following amputation3,4). Treatment of PLP includes medications such as analgesics, anticonvulsants, antidepressants, muscle relaxants, anesthetics, transcutaneous electrical nerve stimulation(TENS), mirror therapy and acupuncture58).
In Korea, there are few studies on PLP and there are even fewer studies regarding the use of integrative Korean and Western medicine in the treatment of PLP. In this paper, we report the results of using integrative Korean and Western medicine to treat a patient suffering from PLP after amputation surgery. The patient was admitted to Samse Oriental Hospital from December 10, 2016, to January 20, 2017.

II. Case study

1. Patient

Jang OO, male, 51 years

2. Chief complaints

Phantom pain
Insomnia

3. Onset

Amputation below right knee on November 25, 2016

4. Family history

None

5. Social history

Smoking for 35 years, drinking daily

6. Patient history

The patient had a right ankle injury in 1991 and continued to have pain in his ankle, for which he took analgesics. In 2016, the pain in his lower leg increased, and he was admitted to Pusan University Hospital for angioplasty, incision of the vessel (embolectomy or thrombectomy) of the femoral artery superficial and popliteal artery. After discharge, he had severe pain, plantar necrosis and was re-admitted for amputation below the right knee on November 25, 2016.

7. Examinations

1) Clinical chemistry

ALT 56 ↑, RBC 3520000 ↓, Hb 11.7 ↓, Hct 35 ↓

2) Radiology

Chest post-anterior (PA): No active lung lesion (Fig. 1)

8. Treatments

1) Acupuncture

Acupuncture treatment was performed twice a day (9:00 a.m. and 2:00 p.m.) during the patient’s hospitalization and done using disposable stainless-steel needles 0.20mm in diameter and 30mm in length (Dongbang Acupuncture Inc., Korea) for 15 minutes. In the morning, acupuncture was applied at Sinjeongkyuk (腎正格), Hapgok (合谷, LI4) with no stimulation. In the afternoon, the patient was treated at ten acupoints on the unaffected side, Baekhoe (百會, GV20), Sasinchong (四神總, EX-HN1), Sakwan (四關), Taebaek (太白, SP3), Joksamni (足三里, ST36), Sinmun (神門, HT7) with manual stimulation of rotation. The depth of needle insertion was 5~15 mm. Needle sensation including de-qi was not vigorously sought. The acupuncture treatment was performed by two Korean medical doctors with 8 years and 3 years of clinical experience.

2) Herbal medicine (2016.12.10-2017.01.20)

Bojungikgitang (補中益氣湯) powder insurance medicine (Mixed extract, JungWoo Medicines Co.) was prescribed from December 20, 2016 to January 20, 2017. One packet was taken 3 times a day after meals.

3) Moxibustion

Moxibustion was performed once a day around Jungwan (中脘, CV12) in the abdominal.

4) Western- medicine treatment

Western medicine was prescribed after the operation and taken daily (Table 1).

9. Assessment

We asked the patient about pain and sleep time in the morning before treatment. The measured value is the average value of the previous day.

1) Numerical rating scale (NRS)

The state of no pain at all was 0; the most severe pain was 10, and the intensity of the pain felt was reported by the patient himself9).

2) Continuous Sleep Time

We measured the amount of time the patient slept continuously without waking with pain.

10. Result

1) Session 1. (12/10/2016 to 12/16/2016)

On the date of admission, the patient complained of phantom pain in his amputated foot, swelling in, and tingling. Since the PLP was severe at night, he was given an analgesic injection (Toraren INJ Myoungmoon Co.), but he woke every 2 hours. After 5 days of hospitalization, the patient could sleep without analgesic. The pain was NRS 10.

2) Session 2. (12/17/2016 to 12/23/2016)

Eight days after admission, the PLP reduced to NRS 3–4, so analgesic injections were not needed every day. After 10 days of hospitalization, the PLP in the amputated soles and feet decreased, but the pain increased due to recognition of the remaining portion of the amputated lower limb. On the 13th day of hospital admission, an analgesic patch (Durogesic D-trans Patch, 25 µg/h) possessed by the patient’s friend was obtained and attached arbitrarily. After 24 hours, the patch was removed immediately due to side effects it caused. After the patch was removed, an analgesic injection was administered because the PLP was more severe with the patch attached. The pain increased to NRS 7 and continuous sleep time decreased to 3 hours.

3) Session 3. (12/24/2016 to 12/30/2016)

The PLP was reduced on the 18th day of hospitalization, and the analgesic injection was not administered until discharge. During the hospitalization period, the analgesic injection was given five times. After 18 days of hospitalization, the PLP decreased to NRS 2–3. PLP decreased at night and appeared during the day

4) Session 4. (12/31/2016 to 01/06/2017)

After 25 days of hospitalization, there was almost no PLP. The NRS score was measured as 2; continuous sleep time was measured as 4–6 hours.

5) Session 5. (01/07/2017 to 01/13/2017)

After 33 days of hospitalization, the patient began wearing the prosthetic leg and walked using it. After the walking exercise, the PLP increased to NRS 5, and the patient slept for 3 consecutive hours. The pain increased, but the use of analgesics did not. After one day, the pain decreased to NRS 2, and continuous sleep time increased to 6 hours.

6) Session 6. (01/14/2017 to 01/20/2017)

After 36 days of hospitalization, PLP was NRS 0. Continuous sleep time increased up to 8 hours. After 40 days of hospitalization, the patient walked for 5 hours and the pain increased to NRS 3–4. The continuous sleep time decreased to 3.5 hours. The next day, after reducing exercise time, the intensity of pain and continuous sleep time measured the same as before exercise. The patient had no pain at discharge, but he was worried about the pain, so he was prescribed for 7 days (Table 2) (Fig. 2, 3).

III. Discussion

Amputees may experience severe pain. In general, natural pain relief of PLP is prolonged and can take months, often years. The pain becomes chronic10,11). Approximately 59% of patients show a 5–10% reduction in pain intensity even 2 years after amputation12).
Although the mechanism of PLP is not fully understood, a recently reported possible cause is cortical reorganization1). The cortical areas representing the amputated limb involves an increased excitability of the corticospinal neurons and a reduction of GABA activity in the primary motor cortex1,13,14). Since PLP mechanism has not yet been clearly proven, there are various treatment methods, including medications, surgical procedures, and other adjuvant therapies.
Pharmacotherapy includes opioids, tramadol, tricyclic antidepressants, anticonvulsants, sodium channel blockers, NMDA receptor antagonist, ketamime1). The Neurontin capsule (Gabapentin) is effective in treating several syndromes of neuropathic pain, but some studies show no efficacy for this15,16).
Mirror therapy is a well-known treatment for PLP. Mirror therapy, through the senses of movement and sight, is a neurorehabilitation treatment that induces somatosensory and motor pathway coupling between the phantom and real limb11,17). From the viewpoint of neurological pain treatment, acupuncture treatment uses sight, stimulation, etc. and increases cerebral blood circulation17,18). Acupuncture treatment is suggested to alter cortical mapping19).
In our case, we used the Gyozai (巨刺) acupuncture treatment method. In the basic theory of Oriental medicine, Naekyoung (內經), is a method of treating the right side for diseases on the left side, and the other way around20). Acupuncture treatment was performed twice a day at 9:00 a.m. and 2:00 p.m. except on Sunday. In the morning, Sinjeongkyuk (腎正格) and Hapgok (合谷 LI4) were used to strengthen the circulatory function in the lower limb. In the afternoon, Baekhoe (百會, GV20), Sasinchong (四神總, Ex-HN1), Sakwan (四關), Taebaek (太白, SP3), Joksamni (足三里, ST36), and Sinmun (神門, HT7) were performed to improve cerebral blood flow, improve systemic blood circulation and stabilize the heart. During the afternoon treatment, we explained to the patient that he was being treated by placing a needle on the opposite side of the PLP. These stimuli are considered important in phantom limb therapy21). The herbal medicine regimen included the insurance medicine Bojungikgitang powder due to the patient’s low energy level after the surgery.
The patient received a pain killer injection at session 1, but the pain persisted. The painkillers used at the hospital were weaker than the painkillers used at the previous hospital. As the duration of treatment increased, the pain decreased and sleep time increased without analgesic injection. In the present study, it is noteworthy that pain significantly decreased after 18 days of treatment and that the symptoms improved. After surgery, the patient’s condition generally improved.
This case study was limited for various reasons. The case was insufficient, and there was no follow-up after discharge. Continuous sleep time must be based on the objective outcome measurements. In the future, larger-sample clinical trials are needed to confirm the effectiveness of integrative Korean and Western medicine for PLP.

Fig. 1
Amputation below right knee X-ray
acup-34-3-101f1.tif
Fig. 2
Change in NRS after treatment during admission
acup-34-3-101f2.tif
Fig. 3
Change in continuous sleep time after treatment during admission
acup-34-3-101f3.tif
Table 1
Mediation
Ingredients Label Dose Medication Purpose
Astrix BoRyung CAP. 100mg 1C QD(8A) Antithrombotics
Plavix TAB. 75mg 1T QD(8A) Antithrombotics
Crestor TAB. 10mg 1T QD(7P) Antilipidemic agents
Nexium TAB. 20 mg 1T QD(7A) H+ pump inhibitors
Neurontin CAP. 100mg 1C TID Neuropathic pain

CAP, C : capsule, TAB, T : tablet, QD : quaque die, BID : bis in die, TID: ter in die.

A: ante meridiem, P post meridiem.

Table 2
Discharge Medication
Ingredients Label Dose Medication Purpose
Anyrac TAB. 1T BID Nonsteroidal anti inflammatory drugs
Kiase TAB. 1T TID Digestants
K Peri TAB. 1T TID Skeletal muscle relaxants
Levoron 25mg TAB. 1T TID GI tract regulators

CAP, C : capsule, TAB, T : tablet, QD : quaque die, BID : bis in die, TID: ter in die.

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