TMR: Pioneering doctor eases amputation pain

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Two million people in the United States are living without a limb.

Now, surgeons at Ohio State University and other top centers in the country are performing a surgery called targeted muscle reinnervation, or TMR, to rewire the body. It's a procedure that is lessening or eliminating limb pain for patients.

Emilee Lester has come a long way in two years. Just four days before her college graduation, she was driving her car back to school when a large piece of debris was suddenly on the roadway.

"Even though I know you aren't supposed to, I swerved to avoid it and hit another car head on," she said.

The impact crushed Lester right foot between the ankle and toes.

"My family, we like to describe it as taking a handful of chips, crunching them with your hand, putting them on the table and trying to put them back together," she said. "Too many pieces. Pieces don't exist anymore. It's just way too hard to put them back together."

Lester made the decision to have doctors amputate. During the surgery, Dr. Ian Valerio also performed another procedure designed to eliminate stump pain and phantom limb pain, the feeling of pain in a limb that is no longer there.

Valerio is pioneering the use of primary targeted muscle reinnervation, or TMR, rerouting the nerves that are cut during amputation into surrounding muscle, lessening the pain.

"By hooking the peripheral nerve up to the motor nerve, it sends new signals as the nerve regrows, thus reinnervating the muscle," Valerio said.

One week after her amputation, Lester's college held a graduation ceremony for her in the hospital. Three months later, she went to Parris Island for her brother's graduation from Marine Corps boot camp, walking 5 miles on her new prosthetic leg.

"It has not stopped me from doing anything I want," Lester said. "If I have to figure out a different way to do it, I do."

Valerio and his colleagues at Ohio State Wexner Medical Center say TMR was traditionally performed months or years after the amputation. Valerio says when TMR is done at the same time, most patients will be off pain medication within three months.

RESEARCH SUMMARY
MEDICAL BREAKTHROUGHS
TOPIC: TMR: PIONEERING DOCTOR EASES AMPUTATION PAIN
REPORT: MB #4572

BACKGROUND: Amputation pain occurs in approximately 60 to 70 percent of patients. Symptoms emerge weeks or months after a limb has been removed. Limbs are either removed because of an accident, injury, or disease. Pain following an amputation may be residual limb pain, phantom limb pain, or phantom limb sensation. The pain can be described as aching, throbbing, shooting, cramping, or burning. However, there are non-painful sensations as well, such as numbness, itching, twisting, or pressure. Phantom limb pain is a very common type of post-amputation pain that can occur even after tooth extraction. The pain may be mild at first but the discomfort it causes patients will cause severe pain including intermittent shivers and muscle spasms. This sensation can fade away with time. However, in 50 percent of cases, especially upper limb phantoms, the missing arm seems to get shorter over time until the patient only feels the phantom hand alone, dangling from the stump. This symptom change is called telescoping. (Source: https://www.neuromodulation.com/amputation-pain)

TREATMENT: Post-amputation pain is a common condition that can be difficult to treat. Although there is no specific medication for phantom pain, some drugs can be prescribed as a help to relieve pain. However, not all drugs work for everyone, which is why doctors look for the cause of stump pain in each patient and treat them by targeting the cause to reduce the frequency or severity of their pain. As a result, doctors often give a patient medication and if pain continues, they add non-invasive therapies, such as acupuncture, mirror box, repetitive transcranial magnetic stimulation (rTMS), or spinal cord stimulation. More invasive treatments may include injections or implanted devices, but surgery is the last option. Surgery involves brain stimulation. If pain remains after surgery, home remedies may include looking for distractions, staying physically active, taking medications, finding ways to relax, and seeking support from other people. (Source:https://www.mayoclinic.org/diseases-conditions/phantom-pain/diagnosis-treatment/drc-20376278)

VIRTUAL REALITY GOGGLES: A new method developed by Bo Geng in collaboration with Dr. Martin Kraus and master's students Bartal Henriksen and Ronni Nedergaard Nielsen from Medialogy at Aalborg University helps relieve phantom pain by using virtual reality goggles. The patient puts goggles and a glove on while small electrodes are attached to the residual limb. The computer program stimulates the limb with very small electrical impulses in order to act as the person's intact limb, this way it looks like there hasn't been an amputation. The goggles trick the patient's brain into thinking that it is still in control of the missing limb, therefore easing the phantom limb pain. The patient is encouraged to move their virtual limb around to achieve various activities, such as batting away a ball hanging in midair. And they are able to achieve this because of the convincing virtual reality. (Source: https://www.sciencedaily.com/releases/2017/05/170531102921.htm)