Mirror treatment of lower limb phantom pain: A case study

Purpose: Phantom limb pain (PLP) can be an enduring and distressing experience for people with amputations. Previous research has shown that 'mirror treatment' can reduce PLP for some people who have an upper limb amputation, and that it can increase a sense of motor control over the phantom in people with lower limb amputations who are not reporting PLP. There has been no previous report of therapeutic 'mirror treatment' for lower-limb phantom pain.

Method: We present the first case study of the use of 'mirror treatment' in a person with a lower limb amputation who was reporting PLP at the time of treatment.

Results: During the intervention there was a significant reduction in his PLP, an increase in sense of motor control over the phantom and a change in aspects of the phantom limb that was experienced.

Conclusion: This case study, conducted in a conventional clinical setting, supports the potential of 'mirror treatment' for PLP in people with a lower limb amputation.     

Mirror treatment of lower limb phantom pain: A case study

Purpose:?Phantom limb pain (PLP) can be an enduring and distressing experience for people with amputations. Previous research has shown that ‘mirror treatment’ can reduce PLP for some people who have an upper limb amputation, and that it can increase a sense of motor control over the phantom in people with lower limb amputations who are not reporting PLP. There has been no previous report of therapeutic ‘mirror treatment’ for lower-limb phantom pain.

Method:?We present the first case study of the use of ‘mirror treatment’ in a person with a lower limb amputation who was reporting PLP at the time of treatment.

Results:?During the intervention there was a significant reduction in his PLP, an increase in sense of motor control over the phantom and a change in aspects of the phantom limb that was experienced.

Conclusion:?This case study, conducted in a conventional clinical setting, supports the potential of ‘mirror treatment’ for PLP in people with a lower limb amputation.     

Motor and parietal cortex stimulation for phantom limb pain and sensations

Limb amputation may lead to chronic painful sensations referred to the absent limb, ie phantom limb pain (PLP), which is likely subtended by maladaptive plasticity. The present study investigated whether transcranial direct current stimulation (tDCS), a noninvasive technique of brain stimulation that can modulate neuroplasticity, can reduce PLP. In 2 double-blind, sham-controlled experiments in subjects with unilateral lower or upper limb amputation, we measured the effects of a single session of tDCS (2 mA, 15 min) of the primary motor cortex (M1) and of the posterior parietal cortex (PPC) on PLP, stump pain, nonpainful phantom limb sensations and telescoping. Anodal tDCS of M1 induced a selective short-lasting decrease of PLP, whereas cathodal tDCS of PPC induced a selective short-lasting decrease of nonpainful phantom sensations; stump pain and telescoping were not affected by parietal or by motor tDCS. These findings demonstrate that painful and nonpainful phantom limb sensations are dissociable phenomena. PLP is associated primarily with cortical excitability shifts in the sensorimotor network; increasing excitability in this system by anodal tDCS has an antalgic effect on PLP. Conversely, nonpainful phantom sensations are associated to a hyperexcitation of PPC that can be normalized by cathodal tDCS. This evidence highlights the relationship between the level of excitability of different cortical areas, which underpins maladaptive plasticity following limb amputation and the phenomenology of phantom limb, and it opens up new opportunities for the use of tDCS in the treatment of PLP.     

Pulsed Radiofrequency Ablation for Residual and Phantom Limb Pain: A Case Series

Residual limb pain (RLP) and phantom limb pain (PLP) can be debilitating and can prevent functional gains following amputation. High correlations have been reported between RLP and the stump neuromas following amputation. Many treatment methods including physical therapy, medications, and interventions, have been used with limited success. Pulsed radiofrequency ablation (PRFA) has shown promise in treating neuropathic pain because of the inhibition of evoked synaptic activity. We present 4 amputees who were treated with PRFA after failing conservative management for their RLP and PLP. All 4 patients underwent PRFA and demonstrated at least 80% relief of RLP for over 6 months. One patient reported a complete resolution of phantom sensation while another patient had significantly decreased frequency of spontaneous PLP and resolution of evoked PLP. In addition, all patients reported improved overall function including increased prosthetic tolerance and decreased oral pain medications. This case series suggests that PRFA is a viable treatment option which might be used for long‐term relief of intractable RLP and/or PLP.     

The Prevalence and Characteristics of Phantom Limb Pain and Non-Painful Phantom Phenomena in a Nationwide Survey of 3,374 Unilateral Limb Amputees

The experience of phantom limb pain (PLP) is a common consequence of limb amputation, resulting in severe impairments of the affected person. Previous studies have shown that several factors such as age at or site of amputation are associated with the emergence and maintenance of PLP. In this cross-sectional study we assessed the presence of several phantom phenomena including PLP and other amputation-related information in a sample of 3,374 unilateral upper and lower limb amputees. Clinical and demographic variables (age at amputation, level of amputation) explained 10.6% of the variance in PLP and perceptual variables (intensity of phantom limb sensation [PLS], referred sensations, intensity of telescoping, residual limb pain [RLP] intensity) explained 16.9% of the variance. These variables were specific for PLP and not for RLP. These results suggest that distinct variables are associated with PLP (age at amputation, level of amputation, PLS intensity, referred sensations, intensity of telescoping, RLP intensity) and RLP (PLP intensity) and point at partly different mechanisms for the emergence and maintenance of PLP and RLP.PerspectiveClinical/demographic variables as well as perceptual variables are 2 major components related to PLP and explain ～11% and ～17% of the variance. These results could potentially help clinicians to understand which factors may contribute to chronic phantom limb pain.     

Neurology (52)

Phantom limb pain as a manifestation of paclitaxel neurotoxicity. (Providence Hospital, Southfield, MI) Mayo Clin Proc 2000;75:740–742.
This case report described 2 patients with prior amputation who experienced phantom limb pain (PLP) after receiving paclitaxel therapy. A third patient experienced disabling neurotoxicity in the extremity of a prior ulnar nerve and tendon transposition after receiving paclitaxel. This unique syndrome should be identified as a direct causal effect of paclitaxel. The pathophysiology of PLP and the treatment options are reviewed. Conclude that physicians should be aware that PLP can occur after initiation of paclitaxel.     

Chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after lower limb amputation

OBJECTIVES: To determine the characteristics of phantom limb sensation, phantom limb pain, and residual limb pain, and to evaluate pain-related disability associated with phantom limb pain. DESIGN: Retrospective, cross-sectional survey. Six or more months after lower limb amputation, participants (n = 255) completed an amputation pain questionnaire that included several standardized pain measures. SETTING: Community-based survey from clinical databases. PARTICIPANTS: A community-based sample of persons with lower limb amputations. MAIN OUTCOME MEASURES: Frequency, duration, intensity, and quality of phantom limb and residual limb pain, and pain-related disability as measured by the Chronic Pain Grade. RESULTS: Of the respondents, 79% reported phantom limb sensations, 72% reported phantom limb pain, and 74% reported residual limb pain. Many described their phantom limb and residual limb pain as episodic and not particularly bothersome. Most participants with phantom limb pain were classified into the two low pain-related disability categories: grade I, low disability/low pain intensity (47%) or grade II, low disability/high pain intensity (28%). Many participants reported having pain in other anatomic locations, including the back (52%). CONCLUSIONS: Phantom limb and residual limb pain are common after a lower limb amputation. For most, the pain is episodic and not particularly disabling. However, for a notable subset, the pain may be quite disabling. Pain after amputation should be viewed from a broad perspective that considers other anatomic sites as well as the impact of pain on functioning.     

The causes and treatments of phantom limb pain

Almost all patients who undergo amputation suffer 'phantom sensations', a sensory perception of the missing limb, possibly caused by a neural imprint or memory of the limb within the brain. The patient may experience abnormal kinaesthetic sensation, such as the feeling that the limb is in an abnormal position. Perceived changes in length, size or temperature of the limb are also common. Some of these people will go on to develop phantom limb pain (PLP). Appropriate aggressive pain management is required immediately postamputation in an attempt to avoid chronic PLP.     

Phantom limb pain and residual limb pain following lower limb amputation: a descriptive analysis

Purpose: This research aimed to develop a clearer picture of the experience of residual limb pain and phantom limb pain following a lower limb amputation and to gain a greater understanding of their relationships with physical and psychosocial variables. Method: One hundred and four participants completed the Trinity Amputation and Prosthesis Experience Scales (TAPES), which includes a section on each of, psychosocial issues, activity restriction, satisfaction with a prosthesis and pain (incidence, duration, level and extent of interference). Results: The results showed that 48.1% of the sample experienced residual limb pain and 69.2% experienced phantom limb pain. While fewer people experienced residual limb pain, those who did, experienced it for longer periods, at a greater level of intensity and with a greater amount of interference in their daily lifestyle, than people who were experiencing phantom limb pain. The experience of residual limb pain was associated with other medical problems and low levels of Adjustment to Limitation. Phantom limb pain was associated with older age, being female, above knee amputation, causes other than congenital causes, not receiving support prior to the amputation, the experience of other medical problems, low scores on Adjustment to Limitation and high scores on Aesthetic Satisfaction with the prosthesis. Conclusion: These findings provide a greater understanding of the issues to be taken into consideration in the rehabilitation of people with a lower limb amputation.     

A Retrospective Trial Comparing the Effects of Different Anesthetic Techniques on Phantom Pain After Lower Limb Amputation

Background

Pain and other sensations from an amputated or absent limb, called phantom pain and phantom sensations, are well-known phenomena.

Objective

The aim of this retrospective study was to evaluate the effects of anesthetic techniques on phantom pain, phantom sensations, and stump pain after lower limb amputation.

Methods

Ninety-two patients with American Society of Anesthesiologists physical status I to III were analyzed for 1 to 24 months after lower limb amputation in this retrospective study. Patients received general, spinal, or epidural anesthesia or peripheral nerve block for their amputations. Standardized questions were used to assess phantom limb pain, phantom sensation, and stump pain postoperatively. Pain intensity was assessed on a numeric rating scale (NRS) of 0 to 10. Patients' medical histories were determined from hospital records.

Results

Patients who received epidural anesthesia and peripheral nerve block perceived significantly less pain in the week after surgery compared with patients who received general anesthesia and spinal anesthesia (NRS [SD] values, 2.68 [1.0] and 2.70 [1.0], respectively). After approximately 14 to 17 months, there was no difference in phantom limb pain, phantom sensation, or stump pain among the anesthetic techniques for amputation.

Conclusions

In patients undergoing lower limb amputation, performing epidural anesthesia or peripheral nerve block, instead of general anesthesia or spinal anesthesia, might attenuate phantom and stump pain in the first week after operation. Anesthetic technique might not have an effect on phantom limb pain, phantom sensation, or stump pain at 14 to 17 months after lower limb amputation.     

A comparison of phantom sensations among amputees whose amputations were of civilian and military origins

436 people experiencing phantom limb pain, whose amputations were unrelated to military service, filled out a survey concerning stump, phantom and other pain problems as well as demographic data. Their responses were compared with responses of American veterans, whose amputations were related to military service, who filled out an identical survey. The experiences of the two groups and the characteristics of the reported phantom sensations were remarkably similar. Treatment effectiveness was equally dismal for both groups with about 1% reporting effective relief.     

Phantom limb pain and residual limb pain following lower limb amputation: a descriptive analysis

Purpose: This research aimed to develop a clearer picture of the experience of residual limb pain and phantom limb pain following a lower limb amputation and to gain a greater understanding of their relationships with physical and psychosocial variables. Method: One hundred and four participants completed the Trinity Amputation and Prosthesis Experience Scales (TAPES), which includes a section on each of, psychosocial issues, activity restriction, satisfaction with a prosthesis and pain (incidence, duration, level and extent of interference). Results: The results showed that 48.1% of the sample experienced residual limb pain and 69.2% experienced phantom limb pain. While fewer people experienced residual limb pain, those who did, experienced it for longer periods, at a greater level of intensity and with a greater amount of interference in their daily lifestyle, than people who were experiencing phantom limb pain. The experience of residual limb pain was associated with other medical problems and low levels of Adjustment to Limitation. Phantom limb pain was associated with older age, being female, above knee amputation, causes other than congenital causes, not receiving support prior to the amputation, the experience of other medical problems, low scores on Adjustment to Limitation and high scores on Aesthetic Satisfaction with the prosthesis. Conclusion: These findings provide a greater understanding of the issues to be taken into consideration in the rehabilitation of people with a lower limb amputation.     

Preamputation pain and acute pain predict chronic pain after lower extremity amputation.

Although previous research suggests that preamputation pain is a risk factor for pain after amputation, little is known about the association between acute postsurgical pain and chronic amputation-related pain. The current prospective study examined the associations of preamputation pain and acute postamputation pain with chronic amputation-related pain. The sample consisted of patients with lower limb amputation (N = 57) who provided both preamputation and postamputation data during a 2-year study period. Preamputation pain intensity and duration were assessed before amputation; acute phantom limb pain (PLP) and residual limb pain (RLP) intensity were assessed on postsurgical days 4 and 5. Acute PLP intensity was the only significant independent predictor of chronic PLP intensity at 6 and 12 months after amputation, whereas preamputation pain intensity was the only significant predictor of chronic PLP intensity at 24 months. Similarly, acute RLP was found to be the best overall predictor of chronic RLP. Other variables (age, gender, level and etiology of amputation, amount of postsurgical pain medication, and duration of preamputation pain) were not associated with chronic pain. These results suggest that higher levels of pain either before or soon after amputation might help to identify individuals at greatest risk for chronic pain problems and most in need of early, intensive pain interventions. PERSPECTIVE: This study suggests that both preamputation pain and acute pain soon after amputation might be associated with bothersome chronic pain. The results support further research on acute pain mechanisms and the effectiveness of early interventions aimed at preventing or managing amputation-related pain.     

Performance of persons with juvenile-onset amputation in driving motor vehicles

OBJECTIVE: To study the driving of motor vehicles by persons with juvenile-onset amputation and to compare the percentage of drivers among them with that found in the general population. DESIGN: A follow-up study of subjects who were younger than 18 years of age at amputation and who underwent one-sided amputation, covering the period 1976 to 1996. SETTING: The Prosthesis Service of the Asturias Central Hospital, Spain. SUBJECTS: A total of 236 juvenile amputee patients. RESULTS: The percentage of women with amputations who drive is lower than that of their male counterparts (p<.05). The percentage of drivers with upper limb amputations is greater than that of drivers with amputation of the lower limb (p<.05). Motor vehicle adaptations were used more frequently by people with upper limb amputations (p<.05). The ability to drive was not affected by the etiology or the side of amputation, or by the use of a prosthesis. The level of amputation affected driving ability in cases of amputation of the lower limb, but not in those of amputation of the upper limb. CONCLUSION: The percentage of persons with juvenile-onset amputation who drive (47.4%) is similar to that found in the general population (40.8%), and the use of a prosthesis does not have any influence on the capacity to drive a car--89.2% of drivers and 93.5% of nondrivers used a prosthesis.     

Das 8 %ige Capsaicin-Pflaster bei Phantomschmerz

Background

Post amputation pain presents a challenge for pain physicians and is often detrimental to the patient’s quality of life.

Patients and methods

A prospective 12-week non-interventional study (NIS) was conducted in Germany to obtain data on the effectiveness and safety of capsaicin 8?% cutaneous patches from real life use in patients with peripheral neuropathic pain. For the first time in a subgroup of amputees data on post amputation pain were collected. This article presents the results for patients who suffered from phantom limb pain (PLP), stump pain (SP) and combined phantom limb/stump pain (PLP/SP).

Results

The analyses included 21 patients with post amputation pain (PLP: n?=?10, SP: n?=?4, PLP/SP: n?=?7). The mean duration of pain (± standard deviation) was 12.8?±?13.0 years for PLP, 23.1?±?29.9 years for SP and 11.0?±?15.8 years for PLP/SP. A single treatment with capsaicin 8?% cutaneous patches significantly reduced the average pain intensity over the observational period of 12 weeks. The mean numeric pain rating scale (NPRS) baseline score changed by ??2.4 for PLP with a standard error of the mean (SEM) of 0.4 (median: ??2.9, Q1: ??3.5, Q3: ??1.0), ??1.7 for SP (SEM: 0.8, median: ??1.1, Q1: ??2.9, Q3: ??0.5) and ??1.5 for PLP/SP (SEM: 0.6, median: ??2.0, Q1: ??2.3, Q3: 0) during weeks 1–12. The 30 % responder rates (i.e. ≥?30?% reduction in pain, day 7/14 to week 12) were 70.0?% (PLP), 50.0?% (SP) and 28.6?% (PLP/SP). PLP and PLP/SP patients in particular, benefited from improvements in pain attacks, sleep duration and sleep quality and one patient (PLP/SP) reported an adverse drug reaction (increase of pain). Physicians rated the tolerability of the patch as very good or good in 90.5?% of patients. A poor tolerability was stated for none of the 21 amputees. Of the patients 80 % for PLP and 50?% for both SP and PLP/SP expressed the wish to receive retreatment with capsaicin 8?% patches.

Conclusion

Capsaicin 8?% cutaneous patches seem to be effective and safe for the treatment of post amputation pain, notably in patients suffering from phantom limb pain.