Phantom limb pain

Phantom pain is experienced by 60% to 80% of patients following limb amputation but is only severe in about 5% to 10% of cases. The mechanisms underlying pain in amputees are not fully understood, but factors in both the peripheral and central nervous system play a role. Treatment of phantom pain is not successful; a recent study on prevention of phantom pain showed negative results. The future may reveal new specific drugs for treatment.     

Phantom limb pain treated by electrical stimulation

Twenty patients suffering from phantom limb pain were assessed for suitability for treatment by electrical stimulator implant to the peripheral nerve or the spinal cord. Twelve were so treated and seven obtained excellent and three partial relief of pain. One patient maintains excellent relief of pain by transcutaneous electrical stimulation. Factors that might influence the responsiveness of pain to electrical stimulation and the qualitative results from such treatment are discussed.     

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.     

Phantom limb pain during peridural anaesthesia

We report the occurrence of severe phantom leg pain during peridural anaesthesia. The patient had no preoperative pain complaints or neurological deficits and was scheduled for surgical removal of an osteosynthesis plate from his otherwise intact femur.The pain developed parallel with the appearance of phantom sensation during peridural anaesthesia. It was independent of surgical stimulation and vanished towards the end of the operation. Phantom limb pain disappeared completely with dissipation of regional blockade.Some of the possible mechanisms of painless and painful phantoms are discussed.We suggest that investigation of similar cases may help in elucidating phantom limb pain following irreversible pathological deafferentation.     

Phantom limb pain: a report of two cases

The efficacy of pre-emptive analgesia for phantom limb pain is still unclear. It is generally accepted that pre hyphen;amputation pain increases the incidence of phantom and stump pain, even if pre-emptive analgesia is performed before and during surgery and in the postoperative period. Two cases of traumatic upper limb amputations are described here with no pre-existing pain. Both received similar antinociceptive treatment by continuous block of the brachial plexus through infusion of ropivacaine 0.375% at 5 ml/h for 10 days. Treatment of case 1 was initiated immediately after surgery; however, this amputee developed intensive phantom limb pain which persisted at 6 months. Early use of the prosthesis after surgery was not possible for this patient. The intensity of phantom limb pain in case 2 decreased significantly after 6 months, even though brachial plexus blockade was not started until 5 weeks post-trauma. This patient used a functional prosthesis intensively beginning early after amputation. Serial magnetoencephalographic recordings were performed in both patients. Only case 2 showed significant changes of cortical reorganization. In case 1 markedly less cortical plasticity was found. A combination of relevant risk factors such as a painful neuroma, behavioural and cognitive coping strategies and the early functional use of prostheses are discussed as important mechanisms contributing to the development of phantom pain and cortical reorganization.     

Phantom pain in bilateral upper limb amputation

Purpose.?To alert health professionals on presence and extent of phantom pain and sensation following bilateral upper limb amputation.

Methods.?Of a total of 140 war-related bilateral upper limb amputees in Iran, 103 subjects were thoroughly examined in this cross-sectional study by a physical medicine specialist. The patients were questioned for the presence of phantom pain and sensations, and frequency and intensity of the feeling were recorded.

Results.?At 17.1 ± 6.1 years after injury, 82.0% of the 103 amputees suffered from phantom sensation, including varying degrees of phantom limb pain in 53.9% of stumps. Phantom phenomena had a higher frequency in the right extremities, but this was not statistically significant (p > 0.01). Of those amputees who had phantom pain or sensation, 51.2% reported that they ‘always’ had phantom limb sensation; and approximately one-fourth of the subjects (24.6%) ‘always’ had phantom pain. Among the stumps who reported phantom pain (N = 112), the pain was excruciating (38.5%), distressing (34.9%) or discomforting (25.6%). A significant statistical relation between phantom limb sensation and level of amputation was observed (p < 0.01).

Conclusion.?At this time there is no healing for phantom pain; medical and surgical modalities only bring temporary relief, and less than 1% of the respondents achieve permanent relief through different treatment methods.     

Transcutaneous electrical nerve stimulation (TENS) as compared to placebo TENS for the relief of acute oro-facial pain

The present paper describes the effect of high frequency, low frequency and placebo TENS on acute oro-facial pain in 62 patients, attending to an emergency clinic for dental surgery; they had all suffered pain for 1-4 days. The patients were randomly assigned to one of three groups receiving either high frequency (100 Hz), low frequency (2 Hz) or placebo TENS. In the two groups receiving TENS (42 patients) 16 patients reported a reduction in pain intensity exceeding 50%; out of these 16 patients, 4 patients reported complete relief of pain. In the placebo group (20 patients) 2 patients reported a pain reduction of more than 50%; out of these 2 patients, none reported a complete pain relief. Mechanical vibratory stimulation augmented the pain reduction obtained by TENS in 5 out of 10 patients.     

Phantom limb pain: A case for beta blockers?

Many treatments have been recommended in the management of phantom limb pain. These have not met with widespread enthusiasm. A new therapeutic endeavour utilizes the group of beta sympathetic blocking drugs. Three case histories of patients with phantom limb pain treated with both beta₁-specific and non-specific beta blocking drugs are reported.     

Phantom limb pain as a manifestation of paclitaxel neurotoxicity

Paclitaxel is a chemotherapeutic agent with activity directed against several malignancies. It has multiple adverse effects including neurotoxicity. We describe 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. In this report, we review the pathophysiology of PLP and treatment options. Physicians should be aware that PLP can occur after initiation of paclitaxel.     

Phantom limb pain: the ghost that haunts the amputee.

Phantom limb pain is a potential complication for all amputees. Current theories consider peripheral, CNS, and psychologic causes, along with other combinations of factors. Treatment modalities include pharmacologic and neurosurgical treatment, psychologic support, and family involvement. Through preoperative teaching, the nurse can help prospective amputees through the grieving process. In addition, the nurse's initial assessment can help identify predictors for phantom limb pain.     

Phantom limb pain treated with therapeutic touch: a case report

Phantom limb pain is a widespread condition that responds poorly to conventional medical and surgical treatments. A case report is presented of the successful treatment of phantom leg pain in a 62-year-old man with peripheral vascular disease using the complementary medical technique of Therapeutic Touch. The clinical and research literature of Therapeutic Touch is briefly reviewed, with regard to subjective outcome measures like pain and anxiety, as well as to several objective measures of physiologic function. The possible role of nonspecific factors like placebo responsiveness or hypnotic dissociation in this case are considered, as are the applicability of complementary and alternative medicine to phantom limb pain, the neurologic mechanisms that generate phantom sensations, and the possible mechanism of action of Therapeutic Touch.     

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.     

Auricular transcutaneous electrical nerve stimulation (TENS) reduces phantom limb pain

The present paper evaluates the efficacy of low frequency, high intensity auricular transcutaneous electrical nerve stimulation (TENS) for the relief of phantom limb pain. Auricular TENS was compared with a no-stimulation placebo condition using a controlled crossover design in a group of amputees with (1) phantom limb pain (Group PLP), (2) nonpainful phantom limb sensations (Group PLS), and (3) no phantom limb at all (Group No PL). Small, but significant, reductions in the intensity of nonpainful phantom limb sensations were found for Group PLS during the TENS but not the placebo condition. In addition, 10 min after receiving auricular TENS, Group PLP demonstrated a modest, yet statistically significant decrease in pain as measured by the McGill Pain Questionnaire. Ratings of mood, sleepiness, and anxiety remained virtually unchanged across test occasions and sessions, indicating that the decrease in pain was not mediated by emotional factors. Further placebo-controlled trials of auricular TENS in patients with phantom limb pain are recommended in order to evaluate the importance of electrical stimulation parameters such as pulse width and rate, and to establish the duration of pain relief.     

Phantom pain and health-related quality of life in lower limb amputees

Amputation of a limb may affect quality of life. However, little is known concerning health-related quality of life in amputees. The purposes of this study were to describe health-related quality of life in a population of lower limb amputees and to investigate potential determinants, including phantom pain. Data from 437 patients with a lower limb amputation were analyzed in this cross-sectional study. Amputation-related problems were investigated using a questionnaire. Health-related quality of life was investigated using the RAND-36 DLV. Amputees with phantom pain had a poorer health-related quality of life than amputees without phantom pain. In general, the most important amputation-specific determinants of health-related quality of life were "walking distance" and "stump pain."