Journal Article

Patient-centered results from a multicenter study of continuous peripheral nerve blocks and postamputation phantom and residual limb pain: secondary outcomes from a randomized, clinical trial

Mariano, Edward R, Mascha, Edward, Li, Shuyi, Khatibi, Bahareh, Hanling, Steven, Kent, Michael, Sessler, Daniel I, Ali Sakr Esa, Wael, Turan, Alparslan, Cohen, Steven P, Eisenach, James C, Madison, Sarah, Maheshwari, Kamal, Ilfeld, Brian M

2023

Overview

IntroductionWe previously reported that a 6-day continuous peripheral nerve block reduces established postamputation phantom pain. To provide patients and providers with the information to best inform treatment decisions, here we reanalyze the data and present the results in a more patient-centered format. We also provide information on patient-defined clinically relevant benefits to facilitate evaluation of available studies and guide future trial design.MethodsThe original trial enrolled participants with a limb amputation and phantom pain who were randomized to receive a 6-day continuous peripheral nerve block(s) of either ropivacaine (n=71) or saline (n=73) in a double-masked fashion. Here we calculate the percentage of each treatment group that experienced a clinically relevant improvement as defined by previous studies as well as present what the participants of our study defined as small, medium, and large analgesic improvements using the 7-point ordinal Patient Global Impression of Change scale.ResultsAmong patients who were given a 6-day ropivacaine infusion, 57% experienced at least a 2-point improvement on the 11-point numeric rating scale in their average and worst phantom pain 4 weeks postbaseline as compared with 26% (p<0.001) for average and 25% (p<0.001) for worst pain in patients given a placebo infusion. At 4 weeks, the percentage of participants rating their pain as improved was 53% for the active vs 30% for the placebo groups (95% CI 1.7 (1.1, 2.7), p=0.008). For all patients combined, the median (IQR) phantom pain Numeric Rating Scale improvements at 4 weeks considered small, medium, and large were 2 (0–2), 3 (2–5), and 5 (3–7), respectively. The median improvements in the Brief Pain Inventory interference subscale (0–70) associated with small, medium, and large analgesic changes were 8 (1–18), 22 (14–31), and 39 (26–47).ConclusionsAmong patients with postamputation phantom pain, a continuous peripheral nerve block more than doubles the chance of a clinically relevant improvement in pain intensity. Amputees with phantom and/or residual limb pain rate analgesic improvements as clinically relevant similarly to other chronic pain etiologies, although their smallest relevant improvement in the Brief Pain Inventory was significantly larger than previously published values.Trial registration number NCT01824082.

• Publisher: BMJ Publishing Group Ltd,BMJ Publishing Group LTD,BMJ Publishing Group
• Subject: Amputation / analgesia / Anesthesia, Local / Caregivers / CHRONIC PAIN / Clinical trials / Diabetic neuropathy / Humans / Hypotheses / Hypothesis testing / Intervention / Lower Extremity / Original Research / Pain / Pain, Postoperative - etiology / Patient-Centered Care / Patients / Peripheral Nerves / Phantom limb / Phantom Limb - complications / Phantom Limb - drug therapy / Regional anesthesia / Ropivacaine - therapeutic use / Upper Extremity