創傷性截肢病人之幻肢痛病理生理及臨床輔助性治療探討

職災事件的創傷性截肢病人經常有幻肢痛症狀，幻肢痛為缺失肢體的疼痛感覺，常見於截肢病人且難以管理此疼痛，上肢截肢病人的幻肢痛盛行率約為30%～80%，下肢則約為50%～85%。幻肢痛廣泛呈現於各式臨床表徵，經常是截肢後立即性的發生，然而在某些族群可能在截肢後幾年才出現此症狀。常見病人針幻肢痛的描述為尖銳、抽痛、燃燒感、跳動、刺痛和癢痛，通常是間歇性的且有不同嚴重程度變化。其確切成因至今仍未知，許多理論被提出及討論，病理及生理機轉包含：周邊神經變化、脊髓變化、腦部變化及心理因素等。目前臨床上第一線治療方式以藥物治療為主，然而藥物治療對於幻肢痛的改善仍有所限制，諸多學者研究亦探討其他輔助性治療對於幻肢痛的療效，如：脊髓刺激、周邊神經刺激、經皮神經電刺激、鏡像治療及心像訓練等。本篇文章整理幻肢痛的流行病學證據、病理及生理機轉、臨床表現、臨床常用評估方法及探討不同輔助性治療介入的成效。然而，由於大多數幻肢痛治療的文獻研究證據水平較低，目前仍無法對幻肢痛的治療方式有明確的決定，需要提升研究品質，例如提升樣本量並針對樣本的異質性進行探討、對照組的設計、一致的幻肢痛評估標準、不同輔助性治療的介入一致性，以臻高證據力研究。

關鍵字

幻肢痛；截肢；輔助性治療；脊髓刺激；周邊神經刺激

並列摘要

Traumatic amputees in occupational accidents often have phantom limb pain. Phantom limb pain is defined as the pain sensation in the missing limb. It is a symptom that is common and difficult to manage in amputees. The prevalence of phantom limb pain in upper limb amputees is approximately 30% to 80 %, and is approximately 50% to 85 % in lower limb amputees. Phantom limb pain is widely present in a variety of clinical manifestations. The onset of phantom limb pain is often immediate, although in some cases, it may be several years after amputation, with painful sensations varying between sharp, shooting, burning, throbbing, stabbing, and aching. It is usually intermittent and varies in severity. The exact cause of phantom limb pain is still unclear. However, many theories have been proposed and discussed. The pathophysiology of phantom limb pain including peripheral nerve changes, spinal cord changes, brain changes, and psychological factors. At present, pharmacologic treatment has been used as first-line therapy for amputees suffering from phantom limb pain. However, the improvement of phantom limb pain is still limited in pharmacologic treatment. Many scholars have also investigated the efficacy of other adjuvant therapy for phantom limb pain, such as spinal cord stimulation, peripheral nerve stimulation, transcutaneous electrical nerve stimulation, mirror therapy and mental imagery, etc. We sorted out the epidemiological evidence, pathophysiology, clinical manifestations, commonly used clinical assessment methods of phantom limb pain, and discussed the effectiveness of different adjuvant therapy interventions in this article. Due to the low level of evidence in most of the studies on phantom limb pain treatment, it is still impossible to make a clear decision on the treatment of phantom limb pain. High-level evidence and high-quality studies are needed, such as increasing sample size, exploring sample heterogeneity, design of control groups, criteria for phantom limb pain assessment, consistency of interventions with different adjuvant treatments, and exploring the relationship between phantom limb pain and psychosis influences.

並列關鍵字

phantom pain ； amputation ； adjuvant therapy ； spinal cord stimulation ； peripheral nerve stimulation

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