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Christopher A. Hinnant, MD Physical Medicine & Rehabilitation Laguna Honda Hospital & Rehabilitation Center San Francisco, California
Herman Melville immortalized phantom limb pain in American literature, with graphic descriptions of Captain Ahabs phantom limb in Moby-Dick "A dismasted man never entirely loses the feeling of his old spar. . . And I still feel the smart of my crushed leg, though it be now so long dissolved"
Besides the limbs, painful phantoms have been described for eyes, nose, teeth, tongue, breast, bladder, testicle & penis
Amputation Statistics
200,000 Surgical Amputations performed per year in the U.S. 1.7 million people living with limb loss (Ziegler-Graham 2008) It is estimated that one out of every 200 people in the U.S. has had an amputation (Adams) Pain is the most common complaint after amputation
Amputation Statistics
82% of amputations are dysvascular 97% of lower limb amputations are dysvascular 69% of all traumatic amputations are in upper limb
Immediately post-op, PLP= 72% (& PLS= 84%) After 6 months, PLP= 67% (& PLS= 90%) After one year, PLP= 61% After two years, PLP= 59%
After one month, RLP= 72% After 13 months, RLP= 13% (Cascale)
RLP in 100% post op, but decreases with time to 10 to 25% range (Ehde)
48% experienced pain a few times per day or more (Kooijman) A quarter of those with pain reported their pain to be extremely bothersome (Ephraim) Sofor most, the pain is episodic and not particularly disabling, but for a subset of patients, can be quite severe(Ehde)
Good history Thorough physical examination Appropriate Tests Resist the initial tendency to consider all pain as being phantom pain Amputee Pain can be of different etiologies Amputation is not a static condition progressive deteriorating condition affecting the health of the amputee over time Understand pain impact on function
Early complications Dehiscence Superficial infection Deep infection Infection can also present late with residual limb osteomyelitis having an average time between amputation and diagnosis of187 days RLO should be considered when delayed wound healing or residual limb pain (Smith)
RLP- Neuromas
Develop in all residual limbs after amputation Problematic when entrapped in scar tissue or in position where they are exposed to external mechanical loading Neuropathic lancinating pain
Manual palpation Socket pressure Traction of adherent scar tissue Tinels sign
Socket modification Gel socks, liners, redistribute loads, reduce shear pressures Local anesthetic / steroid injection Resection of Neuroma
therapeutic and diagnostic
neuroma moved to a deeper site or by placing the end of nerve in bone Can reform and become symptomatic
Use of a prosthesis can place more strain on the joints proximal to the amputation contributing to arthritis pain Treatment algorithms for non-amputees should be used to maintain function in prosthesis users (NSAIDs, intraarticular steroids, THA, TKA, etc.) Knee osteoarthritis may be partially relieved by the addition of knee joint & thigh corset to allow shared weight bearing between the residual limb and the thigh
hips, knees, shoulder
Terminal overgrowth of bone mostly in skeletally immature 4-35% in peds amputations Case reports of bone overgrowth in adults (Dudek) Most often in traumatic amputations in peds & only cases in adults were also due to trauma Distal stump pain & tenderness, tissue compression, bursa formation, skin ulceration X-ray diagnosis (& by exam) Treatment Socket modification Surgical resection of bone
Heterotopic Ossification More common in traumatic/combat (63%) Most often in blast injuries or with amputations performed at the zone of injury Most are asymptomatic When painful and refractory surgical excision (Potter)
Fractures of residual limb Decreased bone density in residual limb (Sherk) Hip & distal portion most common sites (Sherk) Overall incidence is 3% in LE amputees (Denton) Fall while wearing the prosthesis is the most mechanism of injury
Suspect when late pain occurs in a limb amputated because of tumor Local recurrence is a possibility
Prevalence 30-50% Most often related to prosthesis fit Hyperhidrosis, contact dermatitis, cellulitis, folliculitis, epidermal cysts, dermal granulomas Round or oval swellings deep within the skin The skin may break down and erode or ulcerate
Awareness of non-painful sensation in the amputated part of a limb Resembles the somatosensory experience of the physical limb before amputation Phantom limb sensations 90-98% in immediate post-op period Typically is more intense in the early stages after amputation and can gradually fade with time
warmth, itching, sense of position, and mild squeezing
The more distal segments (toes etc.) tend to present the most vivid sensations In some cases the symptoms persist treatment is not typically required (nonpainful)
Pain perceived in the amputated portion of the extremity Described as burning sensation, cramp, stabbing, squeezing, prickling, shooting Phantom Posture
Painful contortions of the limb Clenched fist Spasm Fingernails digging into palm
PLP- Pathophysiology
Not completely understood Categories of theories Peripheral and spinal sensitization Cortical neuronal rearrangements Cortical reorganization & neuroplasticity most commonly cited Deafferented cortical areas representing the amputated limb are taken over by neighboring representational zones in both primary somatosensory cortex & motor cortex Not great improvements in our understanding in the nearly 450 years its been described
PLP- Pathophysiology
Maladaptive cortical remapping so that some low threshold touch input might cross-activate high threshold pain neurons Pathological remapping can lead to chaotic output which might be interpreted as either paresthesias or pain by higher brain centers The mismatch between motor commands and the expected, but missing, visual and proprioceptive input may be perceived as pain The tendency for the pre-amputation pain whether brief (e.g. a grenade blast, car accident) or chronic (cancer) to persist as a memory in the phantom
PLP- Pathophysiology
Case series 13; upper limb amputees 8 had PLP and 5 did not Functional neuroimaging Subjects with PLP had 5x more extensive cortical reorganization than those without PLP Severity of PLP correlated with degree of cortical re-organization (r=.93, p<.0001) (Flor)
Telescoping phantoms with increased pain lead to greater cortical reorganization (Karl)
PLP- Treatment
The treatment of phantom pain is difficult No one treatment has shown to be effective in a majority of sufferers
Often requires many therapeutic modalities
PLP- Prevention
Correlation between phantom limb pain and preoperative limb pain Aggressive attempts to control peri-amputation limb pain seems to help
Epidural
PLP- Pharmacologic Tx
Anti-seizure / nerve stabilizing medications Tricyclic antidepressants Opiates Anesthetic agents N-methyl-D-aspartate (NMDA) receptor antogonist Ca channel blockers Topical agents such as capsaicin Botox injections Beta-blockers Alpha-2 adrenergic agonists Antiarrhythmics
PLP- Pharmacologic Tx
Double Crossover Study 24 patients with RLP or PLP 5-week washout interval Titrated 300 mg - 3,600 mg Measures of pain intensity, pain interference, depression, life satisfaction, and functioning were collected throughout the study. Analyses revealed no significant group differences in pre- to posttreatment scores on any of the outcome measures (Smith)
Double Crossover Study 19 patients 6 weeks UE/LE PLP 1 week washout Gabapentin and placebo both reduced pain vs. baseline but after 6wks, gabapentin was better There was no difference in mood, sleep interference or function with respect to ADLs (Bone)
PLP- Pharmacologic Tx
Double Blind Controlled Study 39 patients with at least 6 mos PLP 6 wks of amitriptyline (titrated up to 125 mg/d) vs. placebo No difference between drug and placebo Not effective in the treatment of phantom limb pain at the dose used (Robinson)
PLP- Pharmacologic Tx
Suggests a peripheral cholinergic effect May be more effective if abnormal activity in stump of PLP patients
Report of 3 phantom and stump pain patients, refractory to previous treatments Total of 500u injected with EMG guidance into points of strong fasciculation Marked improvement in pain intensity & pain medication was reduced significantly in all three cases The duration of response lasted up to 11 weeks (Jin) Case series 4 patients with chronic PLP > 3yrs Injection into 4 areas with 100 IU BTX-A Follow-up 1, 2, 5 wks All reported pain decrease by 60-80% Frequency of pain in 3 down by 90% (Kern)
PLP- Pharmacologic Tx
Opiates are effective, but less so in PLP than in pain of similar intensity of different etiology
Study of 42 cancer patients with limb amputation Monitored monthly first 2 months postoperatively & q 2 months for 2 years. Month 1 versus 2 years after addition of opioid - % with phantom pain decreased from 60% to 32% % of patients with stump pain decreased from 31% to 5% Opioids may help in management of phantom limb pain (Mishra)
PLP- Pharmacologic Tx
DBRC crossover trial with 60 patients with 6+ months of PLP 3 treatment arms morphine, mexiletine, placebo 4 wk titration, 2 wk maint, 2 wk taper, 1 wk washout period between treatment arms Pain Decrease: morphine 53%, mexiletine 30%, placebo 19% (significant for morphine vs. placebo) Morphine associated with high incidence side effects and did not improve overall functional activity nor pain-related daily activity (Wu)
PLP- Pharmacologic Tx
45 AKA & BKA Pts randomized to receive at anesthesia induction & for 72hrs post-op F/u at 6 months to eval for incidence of PLP Incidence of PLP was 71% in control group, 47% in ketamine group - not statistically significance (p=0.28) (Hayes)
Memantineperhaps
36 Post-traumatic amputees received memantine vs. placebo over 4 wk period 56% UE, 44% LE with > 12 months PLP 2 wks, then tapered off for 1 wk Pain relief in memantine avg =47%; placebo group =40% (not significant) Ten pts in the memantine group (56%) and 6 in the placebo group (33%) had pain relief greater than 50% (Maier)
PLP- Pharmacologic Tx
27yo M bilat TF on methadone 10mg TID, gabapentin 1200mg TID, amitriptyline 75mg qHS, celecoxib 200mg BID, dilaudid PCA at 100mg/day Recd memantine 10mg BID x 6 mo. Off opioids on day 1, maintained PLP free on celecoxib only at 8 mo. 21yo M R TT on methadone 5mg TID, dilaudid PCA at 80mg/day, iv fentanyl, nortriptyline 100mg qHS, gabapentin 900mg TID. Recd memantine 10-15mg BID x 4 mo. PLP free and off all meds at 4 mo (Hackworth)
PLP- Pharmacologic Tx
CBZ
- effective in one case series - mixed results in literature - No studies showing effective - No controlled trials
- evidence effective against brief stabbing pains, but not other PLP
PLP- Nonpharmacologic Tx
PLP- Nonpharmacologic Tx
ECT
Brain stimulation
One case study showing effectiveness in refractory cases May give temporary & immediate relief, but not as effective in the long term Not as good
PLP- Nonpharmacologic Tx
Deep brain stim of periventricular grey matter & somatosensory thalamus for the relief of chronic PLP in 3 patients Assessed preoperatively and at 3 month intervals postoperatively up to 13 months Periventricular gray stimulation alone was optimal in 2 patients, combination of periventricular gray & thalamic stimulation produced the greatest relief for third patient Intensity of pain was reduced by 62% (range 55-70%) In all three patients, the burning component of the pain was completely alleviated. Morphine intake was reduced in the two patients Quality of life improvement met statistically significance (Bittar)
PLP- Nonpharmacologic Tx
Case series 21 UE Amputee Constraint-induced movement therapy to reverse cortical-reorganization caused by disuse 9 pts used functional prostheses 12 pts used cosmetic prostheses VAS for pain intensity before and after prosthetic use PLP pain decrease in treatment group was significant (p<0.02) Difference between groups was significant (p<.005) (Weiss)
PLP- Nonpharmacologic Tx
Mirror box
provides a link of visual & motor systems to help recreate a coherent body image & update internal models of motor control may eliminate the remapping associated with phantom limb pains Some evidence that use of mirror reverses these changes, and decreases pain
PLP- Nonpharmacologic Tx
Often a phantom limb is painful because it is felt to be stuck in an uncomfortable or unnatural position, and the patient feels he or she cannot move it
Ramachandran
Small study of 10 patients 5/10 had clenching spasm PLP All 5 had complete relief of PLP while using mirror to unclench the fist Pain was not relieved when not using the mirror (Ramachandran)
PLP- Nonpharmacologic Tx
Virtual reality therapy - Reproduces mirror box in virtual world
8 participants with PLP 2x per week for 8 wks training to follow movements & perform tasks with a virtual image of missing limb Patients reported an average 38% decrease in background pain on a VAS, with 5 patients out of 8 reporting a reduction greater than 30% This decrease in pain was maintained at 4 weeks postintervention in 4 of the 5 participants (Mercier)
PLP- Nonpharmacologic Tx
Case series with 7 UE & 7 LE amputees with PLP Motion capture of stump translated into an avatar in a VR environment Tasks include grab an apple or tap on a bass drum Pain reduction 22-100%, avg 64% Reduction in pain only resulted for pts who experienced agency VR may be useful in alleviating PLP, however effect seems tied to sense of phantom limb agency (Cole)
PLP- Treatment
The treatment of phantom pain is difficult No one treatment has shown to be effective in a majority of sufferers
Often requires many therapeutic modalities
References:
Weeks SR, et al: Phantom limb pain: theories and therapies. Neurologist. 2010 Sep: 16(5): 277-86. Hanley MA, Ehde DM, Jensen M, Czerniecki J, Smith DG, Robinson LR. Chronic pain associated with upper-limb loss. Am J Phys Med Rehabil. 2009 Sep;88(9):742-51 Kooijman CM, Dijkstra PU, Geertzen JH, Elzinga A, van der Schans CP. Phantom pain and phantom sensations in upper limb amputees: an epidemiological study. Pain. 2000 Jul;87(1):33-41 Mulvey MR, et al: Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults. Cochrane Database Sys Rev. 2010 May 12; 5. Atkinson GJ, et al: Heterotopic ossification in the residual lower limb in an adult nontraumatic amputee patient. Am J Phys Med Rehab. 2010 Mar: 89(3): 245-8. Shanthanna, H, et al: Early and effective use of ketamine for treatment of phantom limb pain. Indian J Anaesth. 2010 Mar;54(2): 157-9. Wilder-Smith, CH, et al: Postamputation pain and sensory changes in treatment-nave patients: characteristics and responses to treament with tramadol, amitriptyline, and placebo. Anesthesiology. 2005 Sep; 103(3): 619-28. Charrow A, et al: Intradermal botulinum toxin type A injection effectively reduces residual limb hyperhidrosis in amputees: a case series. Arch Phys Med Rehab. 2008 Jul:89(7): 1407-9. Ketz AK: The experience of phantom limb pain in patients with combat-related traumatic amputations. Arch Phys Med Rehab. 2008 Jun: 89(6): 1127-32. Bosmans JC, et al: Factors associated with phantom limb pain: a 3 year prospective study. Clin Rehab. 2010 May; 24(5): 444-53. Diers M, et al: Mirrored, imagined and executed movements differentially activate sensorimotor cortex in amputees with and without phantom limb pain. Pain. 2010 May: 149(2): 296-304. West M, Wu H: Pulsed Radiofrequency ablation for residual and phantom limb pain: A case series. Pain Pract. 2010 Mar 3. Borghi B, et al: The use of prolonged peripheral neural blockade after lower extremity amputation: The effect on symptoms associated with phantom limb syndrome. Anesth Analg. 2010 Sep 29. Namba Y, et al: Phantom erectile penis after sex reassignment surgery. Acta Med Okayama. 2008 Jun;62(3):213-6. Schley MT, Wilms P, Toepfner S, Schaller HP, Schmelz M, Konrad CJ, Birbaumer N. Painful and nonpainful phantom and stump sensations in acute traumatic amputees. J Trauma. 2008 Oct;65(4):858-64. Ephraim PL, Wegener ST, MacKenzie EJ, Dillingham TR, Pezzin LE. Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. Arch Phys Med Rehabil. 2005 Oct;86(10):1910-9. Ehde DM, Czerniecki JM, Smith DG, Campbell KM, Edwards WT, Jensen MP, Robinson LR. Chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after lower limb amputation. Arch Phys Med Rehabil. 2000 Aug;81(8):1039-44. Kern U, Busch V, Rockland M, Kohl M, Birklein F. [Prevalence and risk factors of phantom limb pain and phantom limb sensations in Germany. A nationwide field survey]. Schmerz. 2009 Oct;23(5):479-88 Ehde DM, Czerniecki JM, Smith DG, Campbell KM, Edwards WT, Jensen MP, Robinson LR. Chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after lower limb amputation. Arch Phys Med Rehabil. 2000 Aug;81(8):1039-44.
References (contd):
Ziegler-Graham K et al. Estimating the Prevalence of Limb Loss in the United States - 2005 to 2050. Archives of Physical Medicine and Rehabilitation 89 (2008): 422-429. Adams PF, et al, Current Estimates from the National Health Interview Survey, 1996. Vital and Health Statistics 10:200 (1999). Flor H. Phantom-limb pain: characteristics, causes, and treatment. Lancet Neurol. 2002 Jul;1(3):182-9. Nikolajsen L, et al: A randomized study of the effects of gabapentin on postamputation pain. Anesthesiology. 2006 Nov;105(5): 100815. Roullet S, et al: Preoperative opioid consumption increases morphine requirement after leg amputation. Can J Anaesth. 2009 Dec: 56(12): 908-13. Finger, Stanley, Hustwit, Meredith P. Five Early Accounts of Phantom Limb in Context: Pare, Descartes, Lemos, Bell, and Mitchell. Neurosurgery. 52(3):675-686, March 2003. Nikolajsen L, Jesnon TS. Phantom Limb Pain. British Journal Anaesthesiology. 2001; 87:107-116. Hill A. Phantom Limb Pain: A review the literature on attributes and potential mechanisms. Journal of Pain Symptom Management. 1999;17:125-142 Soroush M, Modirian E, Soroush M, Masoumi M. Neuroma in bilateral upper limb amputation. Orthopedics. 2008 Dec;31(12). O'Neal ML, Bahner R, Ganey TM, Ogden JA. Osseous overgrowth after amputation in adolescents and children. J Pediatr Orthop. 1996 Jan-Feb;16(1):78-84. Dudek NL, DeHaan MN, Marks MB. Bone overgrowth in the adult traumatic amputee. Am J Phys Med Rehabil. 2003 Nov;82(11):897-900. Potter BK, Burns TC, Lacap AP, Granville RR, Gajewski DA. Heterotopic ossification following traumatic and combat-related amputations. Prevalence, risk factors, and preliminary results of excision. J Bone Joint Surg Am. 2007 Mar;89(3):476-86. Stitik TP, Foye PM. The prevalence of knee pain and symptomatic knee osteoarthritis among veteran traumatic amputees and nonamputees. Arch Phys Med Rehabil. 2005 Mar;86(3):487-93. Esquenazi A, Meier RH. Rehabilitation in limb deficiency. Limb Amputation. Archives of Physical Medicine and Rehabilitation. 1996; 77:S18-S28 Hill A. Phantom limb pain: a review of the literature on attributes and potential mechanisms. J Pain Symptom Management 1999;17:125-42. Halbert J, Crotty M, Camerson ID. Evidence for the optimal management of acute and chronic phantom pain: a systematic review. Clinical Journal of Pain 2002;18:84-92. Smith DG, Ehde DM, Hanley MA, Campbell KM, Jensen MP, Hoffman AJ, Awan AB, Czerniecki JM, Robinson LR. Efficacy of gabapentin in treating chronic phantom limb and residual limb pain. J Rehabil Res Dev. 2005 Sep-Oct;42(5):645-54. Bone M, et al. 2002: Gabapentin in post-amputation phantom limb pain: a randomized, double-blind, placebo-controlled, cross-over study. Reg Anesth Pain Med. 2002 Sep-Oct;27(5):481-6. Rasmussin KG, Rummans TA. Electroconvulsive Therapy for phantom limb pain. Pain. 200 Mar 85(1-2): 301-2.
References (contd):
Robinson LR, et al. 2004: Trial of amitriptyline for relief of pain in amputees: results of a randomized controlled study. Arch Phys Med Rehabil. 2004 Jan;85(1):1-6. Jin L, Kollewe K, Krampfl K, Dengler R, Mohammadi B. Treatment of phantom limb pain with botulinum toxin type A. J Pain Med. 2009 Mar;10(2):300-3. Kern U, et al. 2003: Treatment of phantom limb pain with botulinum-toxin A: a pilot study. Schmerz. 2003 Apr;17(2):117-24. Mishra S, Bhatnagar S, Gupta D, Diwedi A. Incidence and management of phantom limb pain according to World Health Organization analgesic ladder in amputees of malignant origin. Am J Hosp Palliat Care. 2007 Dec-2008 Jan;24(6):455-62. Wu CL, et al. 2008: Morphine versus mexiletine for treatment of post-amputation pain: a randomized, placebo-controlled, cross-over trial. Anesthesiology. 2008 Aug;109(2):289-96. Maier C, et al. 2002. Efficacy of the NMDA-receptor antogonist memantine in patients with chronic phantom limb pain: results of a randomized double-blinded, placebo-controlled trial. Pain. 2003 Jun;103(3):277-83. Hayes C, et al. 2004: Perioperative intravenous ketamine infusion for the prevention of persistent post-amputation pain: a randomized, controlled trial. Anaesth Intensive Care. 2004 Jun;32(3):330-8. Hackworth RJ, et al. 2008: Profound pain reduction after induction of memantine treatment in two patients with severe phantom limb pain. Anesth Analg. 2008 Oct;107(4):1377-9. Bittar RG, Otero S, Carter H, Aziz TZ. Deep brain stimulation for phantom limb pain. J Clin Neurosci. 2005 May;12(4):399-404. Smith E, Ryall N. Residual limb osteomyelitis: A case series from a national prosthetic centre. Disabil Rehabil. 2009 May 21:1-5. Katayama Y, et al. 2001: Motor cortex stimulation (MCS) for phantom limb pain: comprehensive therapy with spinal cord (SCS) and thalamic stimulation (DBS). Stereotact Funct Neurosurg. 2001;77(1-4):159-62. Bradbrook D. Acupuncture treatment of phantom limb pain and phantom limb sensation in amputees. Acupunct Med. 2004 Jun;22(2):93-7. Flor, et al. 1995. Phantom-limb pain as a perceptual correlate of cortical reorganization following arm amputation. Nature. 1995 Jun 8;375(6531):482-4. Wiech K, et al. 2004: A placebo-controlled randomized cross-over trial of the N-methyl-D-aspartic acid (NMDA) receptor antagonist memantine in patients with chronic phantom limb pain. Anesth Analg. 2004 Feb;98(2):408-13 Mercier C, Sirigu A. Training with virtual visual feedback to alleviate phantom limb pain. Neurorehabil Neural Repair. 2009 JulAug;23(6):587-94 Cole J, et al. 2009: Exploratory findings with virtual reality for phantom limb pain; from stump motion to agency and analgesia. Disabil Rehabil. 2009;31(10):846-54. Ramachandran VS, Altschuler EL. The use of visual feedback, in particular mirror visual feedback, in restoring brain function. Brain 2009 132(7):1693-1710 Weiss T, et al. 1999: Decrease in phantom limb pain associated with prosthesis-induced increased use of an amputation stump in humans. Neurosci Lett. 1999 Sep 10;272(2):131-4. Lotze M, et al. 1999. Does use of a myoelectric prosthesis prevent cortical reorganization and phantom limb pain? Nat Neurosci. 1999 Jun;2(6):501-2. Casale, et al: Phantom limb related phenomena after lower limb amputation. Eur J Phys Rehabil Med. 2009 Dec;45(4):559-66.
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