Pain site and impairment in individuals with amputation pain

OBJECTIVE: To determine the association between pain site and pain interference with activities of daily living (ADLs) among persons with acquired amputation. DESIGN: Survey. SETTING: Community-based survey from clinical databases, flyer postings, and an advertisement in the inMotion magazine. PARTICIPANTS: Persons with lower-limb amputations (N=478). INTERVENTIONS: Six or more months after lower-limb amputation, participants completed an amputation pain questionnaire that included several standardized pain measures. MAIN OUTCOME MEASURES: Numeric rating scale measures of average phantom limb, residual limb, and back pain and pain-related impairment as measured by a modified version of the Pain Interference Scale of the Brief Pain Inventory. RESULTS: Phantom limb, residual limb, and back pain intensity ratings, as a group, accounted for 20% of the variance in pain interference. The pain intensity ratings associated with each individual pain site made a statistically significant contribution to the prediction of pain interference with ADLs even after controlling for the pain intensity of the other 2 sites. CONCLUSIONS: Pain in each of 3 sites (phantom limb, residual limb, back) appears to be important to pain-related impairment and function. Measurement of the intensity of pain at each site appears to be required for a thorough assessment of amputation pain-related impairment.     

Defining mild,moderate, and severe pain in young people with physical disabilities

Purpose: The purpose of this study is to identify the cutoffs that are most suitable for classifying average and worst pain intensity as being mild, moderate, or severe in young people with physical disabilities.

Method: Survey study using a convenience sample of 113 young people (mean age?=?14.19; SD?=?2.9; age range: 8–20) with physical disabilities (namely, spinal cord injury, cerebral palsy, spina bifida, limb deficiency (acquired or congenital), or neuromuscular disease).

Results: The findings support a non-linear association between pain intensity and pain interference. In addition, the optimal cutoffs for classifying average and worst pain as mild, moderate, or severe differed. For average pain, the best cutoffs were the following: 0–3 for mild, 4–6 for moderate, and 7–10 for severe pain, whereas the optimal classification for worst pain was 0–4 for mild, 5–6 for moderate, and 7–10 for severe pain.

Conclusions: The findings provide important information that may be used to help make decisions regarding pain treatment in young people with disabilities and also highlight the need to use different cutoffs for classifying pain intensity in young people with disabilities than those that have been suggested for adults with chronic pain.

• Implications for rehabilitation

• Most clinical guidelines make treatment recommendations based on classifications of pain intensity as being mild, moderate, and severe that do not have a clear cut association with pain intensity ratings.

• Cutoffs that are deemed to be the most appropriate for classifying pain intensity as mild, moderate, and severe appear to depend, at least in part, on the pain population that is being studied and pain domain that is being used.

• This work helps to advance our knowledge regarding the meaning of pain intensity ratings in young people with physical disabilities.

• Clinicians can use this information to make empirically guided decisions regarding when to intervene in young people with disabilities and chronic pain.

     

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.     

Phantom pain, residual limb pain, and back pain in amputees: results of a national survey

OBJECTIVES: To describe the prevalence of amputation-related pain; to ascertain the intensity and affective quality of phantom pain, residual limb pain, back pain, and nonamputated limb pain; and to identify the role that demographics, amputation-related factors, and depressed mood may contribute to the experience of pain in the amputee. DESIGN: Cross-sectional survey. SETTING: A sample of persons who contacted the Amputee Coalition of America from 1998 to 2000 were interviewed by telephone. PARTICIPANTS: A stratified sample by etiology of 914 persons with limb loss. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Prevalence, intensity, and bothersomeness of residual, phantom, and back pain, depressed mood as measured by the Center for Epidemiologic Study Depression Scale, characteristics of the amputation, prosthetic use, and sociodemographic characteristics of the amputee. RESULTS: Nearly all (95%) amputees surveyed reported experiencing 1 or more types of amputation-related pain in the previous 4 weeks. Phantom pain was reported most often (79.9%), with 67.7% reporting residual limb pain and 62.3% back pain. A large proportion of persons with phantom pain and stump pain reported experiencing severe pain (rating 7-10). Across all pain types, a quarter of those with pain reported their pain to be extremely bothersome. Identifiable risk factors for intensity and bothersomeness of amputation-related pain varied greatly by pain site. However, across all pain types, depressive symptoms were found to be a significant predictor of level of pain intensity and bothersomeness. CONCLUSIONS: Chronic pain is highly prevalent among persons with limb loss, regardless of time since amputation. A common predictor of an increased level of intensity and bothersomeness among all pain sites was the presence of depressive symptoms. Further studies are needed to elucidate the relationship between pain and depressive symptoms among amputees.     

Back pain as a secondary disability in persons with lower limb amputations

OBJECTIVE: To evaluate the frequency, duration, intensity, and interference of back pain in a sample of persons with lower limb amputations. DESIGN: Retrospective, cross-sectional survey. SETTING: Community-based survey from clinical databases. PARTICIPANTS: Participants who were 6 or more months post lower limb amputation (n = 255). INTERVENTION: An amputation pain survey that included several standardized pain measures. MAIN OUTCOME MEASURES: Frequency, duration, intensity, and interference of back pain. RESULTS: Of the participants who completed the survey (return rate, 56%), 52% reported experiencing persistent, bothersome back pain. Of these, 43% reported average back pain intensity in the mild range (1-4 on 0-10 rating scale) and 25% reported pain of moderate intensity (5-6 on 0-10 scale). Most respondents with back pain rated the interference of their pain on function as none to minimal. However, nearly 25% of those with back pain described it as frequent, of severe intensity (>or=7 on 0-10 scale), and as severely interfering with daily activities including social, recreational, family, and work activities. CONCLUSIONS: Back pain may be surprisingly common in persons with lower limb amputations, and, for some who experience it, may greatly interfere with function.     

Categorizing the severity of cancer pain: further exploration of the establishment of cutpoints

Previous work by Serlin and colleagues [Serlin R C, Mendoza T R, Nakamura Y, Edwards K R, Cleeland C S. When is cancer pain mild, moderate, or severe? Grading pain severity by its interference with function. Pain 1995;61:277-84] established cutpoints for mild, moderate, and severe cancer pain based on the pain's level of interference with function. Recent work [Jensen M P, Smith D G, Ehde D M, Robinson L R. Pain site and the effects of amputation pain: further clarification of the meaning of mild, moderate, and severe pain. Pain 2001;91:317-22; Zelman D C, Hoffman D L, Seifeldin R, Dukes, E. Development of a metric for a day of manageable pain control: derivation of pain severity cutpoints for low back pain and osteoarthritis. Pain 2003;106(1/2):35-42]found differences in cutpoints for pain severity for different pain-related conditions. Reasons for these discrepancies may relate to the methods used to determine the cutpoints or to differences based on the type or the cause of the pain. The purposes of this study were to determine the optimal cutpoints for mild, moderate, and severe pain based on patients' ratings of average and worst pain severity, using a larger range of potential cutpoints, and to determine if those cutpoints distinguished among the three pain severity groups on several outcome measures. Results from a homogenous sample of oncology outpatients with pain from bone metastasis confirm a non-linear relationship between cancer pain severity and interference with function and also confirm that the boundary between a mild and a moderate level of cancer pain is at 4 on a 0-10 numeric rating scale. However, this analysis did not confirm the boundary between moderate and severe cancer pain previously described by Serlin and colleagues [Serlin R C, Mendoza T R, Nakamura Y, Edwards K R, Cleeland C S. When is cancer pain mild, moderate, or severe? Grading pain severity by its interference with function. Pain 1995;61:277-84]. In addition, these results were not consistent with the cutpoints that were found for back pain, phantom limb pain, pain 'in general', or osteoarthritis pain reported by Jensen and colleagues and Zelman and colleagues [Jensen M P, Smith D G, Ehde D M, Robinson L R. Pain site and the effects of amputation pain: further clarification of the meaning of mild, moderate, and severe pain. Pain 2001;91:317-22; Zelman D C, Hoffman D L, Seifeldin R, Dukes, E. Development of a metric for a day of manageable pain control: derivation of pain severity cutpoints for low back pain and osteoarthritis. Pain 2003;106(1/2):35-42]. Possible explanations for these differences are discussed, as well as implications for future research.     

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.     

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.     

Cognitions, coping and social environment predict adjustment to phantom limb pain.

Biopsychosocial models of chronic pain hypothesize a role for psychological and environmental factors in adjustment to chronic pain. To test the utility of such models for understanding phantom limb pain, 61 persons with recent amputations were administered measures of average phantom limb pain intensity, pain interference, depression, pain coping use, pain cognitions and appraisals, and social environmental variables 1 month post-amputation, and the measures of pain intensity, pain interference, and depression again 5 months later. Multiple regression analyses showed that the psychosocial predictors made a statistically significant contribution to the concurrent prediction of average phantom limb pain, pain interference, and depression at the initial assessment, and a significant contribution to the prediction of subsequent change in pain interference and depression over the course of 5 months. The results support the utility of studying phantom limb pain from a biopsychosocial perspective, and identify specific biopsychosocial factors (e.g., catastrophizing cognitions, social support, solicitous responses from family members, and resting as a coping response) that may play an important role in adjustment to phantom limb pain.     

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.     

Phantom pain and phantom sensations in upper limb amputees: an epidemiological study

Phantom pain in subjects with an amputated limb is a well-known problem. However, estimates of the prevalence of phantom pain differ considerably in the literature. Various factors associated with phantom pain have been described including pain before the amputation, gender, dominance, and time elapsed since the amputation. The purposes of this study were to determine prevalence and factors associated with phantom pain and phantom sensations in upper limb amputees in The Netherlands. Additionally, the relationship between phantom pain, phantom sensations and prosthesis use in upper limb amputees was investigated. One hundred twenty-four upper limb amputees participated in this study. Subjects were asked to fill out a self-developed questionnaire scoring the following items: date, side, level, and reason of amputation, duration of experienced pain before amputation, frequencies with which phantom sensations, phantom pain, and stump pain are experienced, amount of trouble and suffering experienced, respectively, related to these sensations, type of phantom sensations, medical treatment received for phantom pain and/or stump pain, and the effects of the treatment, self medication, and prosthesis use. The response rate was 80%. The prevalence of phantom pain was 51%, of phantom sensations 76% and of stump pain 49%; 48% of the subjects experienced phantom pain a few times per day or more; 64% experienced moderate to very much suffering from the phantom pain. A significant association was found between phantom pain and phantom sensations (relative risk 11.3) and between phantom pain and stump pain (relative risk 1.9). No other factors associated with phantom pain or phantom sensations could be determined. Only four patients received medical treatment for their phantom pain. Phantom pain is a common problem in upper limb amputees that causes considerable suffering for the subjects involved. Only a minority of subjects are treated for phantom pain. Further research is needed to determine factors associated with phantom pain.     

Immediate and long-term phantom limb pain in amputees: incidence, clinical characteristics and relationship to pre-amputation limb pain

In a prospective study 58 patients undergoing limb amputation were interviewed the day before operation about their pre-amputation limb pain and 8 days, 6 months and 2 years after limb loss about their stump and phantom limb pain. All but one patient had experienced pain in the limb prior to amputation. Pre-amputation limb pain lasted less than 1 month in 25% of patients and more than 1 month in the remaining 75% of patients. At the first examination the day before amputation 29% had no limb pain. The incidence of phantom pain 8 days, 6 months and 2 years after amputation was 72, 65 and 59%, respectively. Within the first half year after limb loss phantom pain was significantly more frequent in patients with long-lasting pre-amputation limb pain and in patients with pain in the limb immediately prior to amputation. Phantom pain and pre-amputation pain were similar in both localization and character in 36% of patients immediately after amputation but in only 10% of patients later in the course. Both the localization and character of phantom pain changed within the first half year; no further change occurred later in the course. The incidence of stump pain 8 days, 6 months and 2 years after limb loss was 57, 22 and 21%, respectively. It is suggested that preoperative limb pain plays a role in phantom pain immediately after amputation, but probably not in late persistent phantom pain.     

Phantom limb, phantom pain and stump pain in amputees during the first 6 months following limb amputation

The incidence and clinical picture of non-painful and painful phantom limb sensations as well as stump pain was studied in 58 patients 8 days and 6 months after limb amputation. The incidence of non-painful phantom limb, phantom pain and stump pain 8 days after surgery was 84, 72 and 57%, respectively. Six months after amputation the corresponding figures were 90, 67 and 22%, respectively. Kinaesthetic sensations (feeling of length, volume or other spatial sensation of the affected limb) were present in 85% of the patients with phantom limb both immediately after surgery and 6 months later. However, 30% noticed a clear shortening of the phantom during the follow-up period; this was usually among patients with no phantom pain. Phantom pain was significantly more frequent in patients with pain in the limb the day before amputation than in those without preoperative limb pain. Of the 67% having some phantom pain at the latest interview 50% reported that pains were decreasing. Four patients (8%), however, reported that phantom pains were worse 6 months after amputation than originally. During the follow-up period the localization of phantom pains shifted from a proximal and distal distribution to a more distal localization. While knifelike, sticking phantom pains were most common immediately after surgery, squeezing or burning types of phantom pain were usually reported later in the course. Possible mechanisms for the present findings either in periphery, spinal cord or in the brain are discussed.     

Pain interference in persons with spinal cord injury: classification of mild, moderate, and severe pain.

Pain intensity is commonly measured by patient ratings on numerical rating scales (NRS). However, grouping such ratings into categories may be useful for guiding treatment decisions or interpreting clinical trial outcomes. The purpose of this study was to examine pain intensity classification in 2 samples of persons with spinal cord injuries (SCI) and chronic pain. The first sample (n = 307) rated the average intensity and activity interference of pain in general, and the second sample (n = 174) rated their worst pain problem. Pain intensity was categorized as mild, moderate, or severe using 4 possible classification systems; analyses were performed to determine the classification system that best distinguished the pain intensity groups in terms of activity interference. In both samples, the optimal mild/moderate boundary was lower (mild = 1-3 on a 0-10 NRS scale) than that reported previously for individuals with other pain problems. The possibility that pain may interfere with activity at lower levels for individuals with SCI requires further exploration. The moderate/severe boundary suggested by previous research was confirmed in only one of the samples. Implications for the assessment of pain intensity and functioning in persons with SCI and pain are discussed. PERSPECTIVE: Although pain in individuals with SCI is common, more research is needed regarding its characteristics and treatment. This study sought to develop an empirically based classification system for mild, moderate, and severe pain that could be useful for applying clinical treatment guidelines and for interpreting the results of much-needed clinical trials.     

Relationship between mechanical sensitivity and postamputation pain: a prospective study.

Limb amputation is followed by stump and phantom pain in a large proportion of amputees and postamputation pain may be associated with signs of hyperexcitability such as hyperalgesia to mechanical stimulation. The present study examined the possible relationship between mechanical pain threshold of the limb and early (after 1 week) and late (after 6 months) phantom pain. Thirty-five patients scheduled for amputation of the lower limb were examined before, 1 week and 6 months after amputation. On all three examination days pressure-pain thresholds were measured and compared with the simultaneous recording of ongoing pain intensity assessed on a visual analogue scale (VAS). There was a weak but significant inverse relationship between preamputation thresholds and early stump and phantom pain. There was no relationship between preamputation thresholds and late stump and phantom pain. One week after amputation there was a significant and inverse relationship between mechanical thresholds and phantom pain but no relationship was found after 6 months. The findings suggest that although tenderness of the limb before and after amputation is related to early stump and phantom pain, the relationship is weak. Neuronal sensitization peripherally or centrally may play a role in the development of phantom pain.     

Association of pain with employment status and satisfaction among amputees in Japan

OBJECTIVE: To assess the relationship between residual and phantom limb pain and working life among persons with limb amputation. DESIGN: Cross-sectional study in which amputee patients completed a mailed questionnaire about their residual limb and phantom limb pain, employment status, and satisfaction with working life. SETTING: Department of rehabilitation medicine of a major hospital in Japan. PARTICIPANTS: All participants were registered at the industrial rehabilitation center of a general hospital in Japan. Responses were received from 101 of the 147 patients (response rate, 68.7%) who were sent the questionnaire. INTERVENTION: An amputation pain and employment status survey that included a standardized pain measure. MAIN OUTCOME MEASURES: A self-report questionnaire, with 1 part concerning employment status and satisfaction with working life, and the other regarding amputation-related pain, which the participant described according to the Chronic Pain Grade (CPG). RESULTS: We found (1) no statistically significant association between types of pain and the return to work rate, (2) no statistically significant association between the pain severity as graded by the CPG and return to work rate, and (3) satisfaction with working life was significantly related to the CPG categories. CONCLUSION: The severity of pain does not appear to be associated with return to work among limb amputees. However, it is associated with satisfaction with working life. Appropriate treatment of pain may therefore improve work-related satisfaction.     

Phantom pain and risk factors: a multivariate analysis

Phantom pain has been given considerable attention in literature. Phantom pain reduces quality of life, and patients suffering from phantom pain make heavy use of the medical system. Many risk factors have been identified for phantom pain in univariate analyses, including phantom sensations, stump pain, pain prior to the amputation, cause of amputation, prosthesis use, and years elapsed since amputation. Multivariate analyses are lacking in the literature and, therefore, no estimation of an overall risk for phantom pain can be made. The aim of this study was to analyze risk factors in a multivariate analysis in 536 subjects (19% upper limb amputees and 81% lower limb amputees). These subjects filled out a questionnaire in which the following items were assessed; side, date, level, and reason of amputation, pre-amputation pain, presence or absence of phantom pain, phantom sensations and or stump pain, and prosthesis use. The prevalence of phantom pain was 72% (95% CI: 68 to 76%) for the total group, 41% (95% CI: 31 to 51%) in upper limb amputees and 80% (95% CI: 76 to 83%) in lower limb amputees. The most important risk factors for phantom pain were “bilateral amputation” and “lower limb amputation.” The risk for phantom pain ranged from 0.33 for a 10-year-old patient with a distal upper limb amputation to 0.99 for a subject of 80 years with a bilateral lower limb amputation of which one side is an above knee amputation.     

A preliminary examination of the relationship between employment,pain and disability in an amputee population

Purpose : To examine amputees' use of health, social and voluntary services and to assess the perceived benefit of such use. Additionally, to examine the degree and type of changes made in occupational status in relation to both pain and prosthetic limb use following amputation. Method : A survey methodology was employed to examine the services used by amputees and their experiences of occupational change. A response rate of 62% resulted in 315 amputees completing the study. The study sample was drawn from patient records at three artificial limb and appliance centres in the central belt of Scotland. Results : Overall the data suggest that few amputees make use of the available services for general amputation-related problems. Even fewer services were utilized for phantom limb pain or for other pain problems. Moreover, of those services that were used, very few were reported as being helpful. Amputation had severe consequences in terms of employment with 75% of the sample in employment prior to the amputation and only 43.5% remaining following amputation. Additionally, of those who did remain in employment there were a number of changes from pre- to post-amputation occupational classification. Employment status was related to the intensity of phantom limb pain, and daily prosthetic limb use with unemployed amputees reporting higher levels of pain and lower levels of prosthesis use. Conclusions : The study demonstrates the need for further research to determine whether the results obtained regarding occupational changes following amputation result pain, disability, amputees' attitudes towards themselves in relation to work, or to employers' attitudes and beliefs about their capabilities. Further research is also required to determine why so few amputees make use of available services and why, even when they are used, such services are not perceived as being helpful. Finally, there is a need to clarify the relationship between the extent of daily prostheses use, the experience of phantom limb pain and employment status.