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History of Phantom Limb Pain
First described in 1552 by Ambroise Par
-"the patients who have, many months aftercutting away of the leg, grievously complainedthat they still felt great pain of the leg so cut off. . .the patients imagine they have their members yetentire
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History of Phantom Limb Pain
Herman Melville immortalized phantom limbpain in American literature, with graphicdescriptions of Captain Ahabs phantom limbin Moby-Dick
"A dismasted man never entirely loses thefeeling of his old spar. . . And I still feel thesmart of my crushed leg, though it be now solong dissolved"
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History of Phantom Limb Pain
Phantom limb pain was not formally
recognized in the medical community until aMayo Clinic study of 1941
Index Medicus recognized this term in 1954
Besides the limbs, painful phantoms have beendescribed for eyes, nose, teeth, tongue, breast,bladder, testicle & penis
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Amputation Statistics
200,000 Surgical Amputations performedper 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
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Amputation Statistics
82% of amputations are dysvascular
97% of lower limb amputations aredysvascular
69% of all traumatic amputations are in
upper limb
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Prevalence of Pain Symptoms
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)
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Prevalence of Pain Symptoms
PLP in 0.5% to 100%, but most sources
use 50-85% Usually intermittent & of moderateintensity (VAS average = 5)
RLP in 100% post op, but decreaseswith time to 10 to 25% range (Ehde)
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Amputee Pain- Severity
48% experienced pain a few times per day ormore (Kooijman)
A quarter of those with pain reported their pain tobe extremely bothersome (Ephraim) Sofor most, the pain is episodic and not
particularly disabling, but for a subset of patients,can be quite severe(Ehde)
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Amputee Pain- Evaluation
Good history Thorough physical examination Appropriate Tests Resist the initial tendency to
consider all pain as being phantompain
Amputee Pain can be of differentetiologies
Amputation is not a static condition progressive deteriorating condition
affecting the health of the amputeeover time
Understand pain impact on function
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Residual Limb Pain
Pain affecting andoriginating in the residualportion of the limb
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Residual Limb Pain
Residual Limb Pain Etiologies Neuroma Prosthetic Fit Issues Scarring and Healing Issues Orthopaedic Problems
Bony Overgrowth
Osteomyelitis
Stress Fracture
Arthritis
Trophic Skin Changes Cellulitis
Folliculitis
Tumor Recurrence
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Residual Limb Pain
Early complications Dehiscence Superficial infection
Deep infection Infection can also present late with residual
limb osteomyelitis having an average timebetween amputation and diagnosis of187
days RLO should be considered when delayed
wound healing or residual limb pain(Smith)
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RLP- Neuromas
Develop in all residual limbs after amputation Problematic when entrapped in scar tissue or in
position where they are exposed to externalmechanical loading
Neuropathic lancinating pain Manual palpation Socket pressure
Traction of adherent scar tissue Tinels sign
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RLP- Neuromas Treatment
Socket modification Gel socks, liners, redistribute loads,
reduce shear pressures Local anesthetic / steroid injection
therapeutic and diagnostic
Resection of Neuroma neuroma moved to a deeper site or byplacing the end of nerve in bone
Can reform and become symptomatic
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RLP- Bone Issues
Use of a prosthesis can place more strainon the joints proximal to the amputationcontributing to arthritis pain
hips, knees, shoulder Treatment algorithms for non-amputees
should be used to maintain function inprosthesis users (NSAIDs, intraarticularsteroids, THA, TKA, etc.)
Knee osteoarthritis may be partiallyrelieved by the addition of knee joint &thigh corset to allow shared weightbearing between the residual limb andthe thigh
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RLP- Bone Issues
Terminal overgrowth of bone mostly inskeletally 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, tissuecompression, bursa formation, skin ulceration
X-ray diagnosis (& by exam) Treatment Socket modification Surgical resection of bone
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RLP- Bone Issues
Heterotopic Ossification More common in
traumatic/combat (63%)
Most often in blast injuries orwith amputations performed atthe zone of injury
Most are asymptomatic When painful and refractory -
surgical excision(Potter)
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RLP- Bone Issues
Fractures of residual limb Decreased bone density in
residual limb (Sherk)
Hip & distal portion mostcommon sites (Sherk)
Overall incidence is 3% in LEamputees (Denton)
Fall while wearing theprosthesis is the mostmechanism of injury
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RLP- Dermatologic Disorders
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 orulcerate
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Phantom Limb Pain
Pain perceived in the amputated portionof 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
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Phantom Limb Pain
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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 byneighboring representational zones in both primary somatosensory cortex & motorcortex
Not great improvements in our understanding in the nearly 450 years its beendescribed
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PLP- Pathophysiology
Maladaptive cortical remapping so that some low thresholdtouch input might cross-activate high threshold painneurons
Pathological remapping can lead to chaotic output whichmight be interpreted as either paresthesias or pain byhigher brain centers
The mismatch between motor commands and the
expected, but missing, visual and proprioceptive input maybe perceived as pain
The tendency for the pre-amputation pain whether brief(e.g. a grenade blast, car accident) or chronic (cancer) topersist as a memory in the phantom
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PLP- Pathophysiology
Phantom limb pain and cortical re-organizationare positively related
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
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PLP- Treatment
The treatment of phantom pain isdifficult
No one treatment has shown to beeffective in a majority of sufferers Often requires many therapeutic
modalities
In a survey of 10,000 amputees,treatment for PLP was successfulin 1% (Jin)
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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
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PLP- Pharmacologic Tx
Gabapentin evidence is mixedDouble 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 post-
treatment 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)
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PLP- Pharmacologic Tx
Evidence for tricyclics is also mixed
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)
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PLP- Pharmacologic Tx
Botox appears to be effective in some patients 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 previoustreatments
Total of 500u injected with EMG guidance into points of strongfasciculation
Marked improvement in pain intensity & pain medication wasreduced 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)
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PLP- Pharmacologic Tx
Opiates are effective, but less so in PLPthan in pain of similar intensity of differentetiology
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)
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PLP- Pharmacologic Tx
Opioids vs. Mexilitene
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 anddid not improve overall functional activity nor pain-related
daily activity (Wu)
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PLP- Pharmacologic Tx
Ketamine may help
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)
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PLP- Pharmacologic Tx
Mirtazepine - effective in one case series
Calcitonin - mixed results in literature Pregabalan - No studies showing effective NSAIDs - No controlled trials CBZ - evidence effective against
brief stabbing pains,but not other PLP
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PLP- Nonpharmacologic Tx
Acupuncture Mostly case studies
Mirror box 60% efficacy
TENS, massage, vibration, contrast baths
Some evidence for TENS; Gate TheoryMechanism
Nerve blocks Mixed results
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PLP- Nonpharmacologic Tx
ECT One case study showing effectiveness in refractorycases
Brain stimulation May give temporary & immediate relief, but not as
effective in the long term
Spinal cord stimulation
Not as good Dorsal rhizotomy / dorsal column tractectomy /
DREZ ablation / thalamotomy May be effective in refractory cases
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PLP- Nonpharmacologic Tx
Deep Brain Stimulation (DBS) seems to help
Deep brain stim of periventricular grey matter & somatosensorythalamus for the relief of chronic PLP in 3 patients
Assessed preoperatively and at 3 month intervals postoperativelyup to 13 months Periventricular gray stimulation alone was optimal in 2 patients,
combination of periventricular gray & thalamic stimulation producedthe 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)
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PLP- Nonpharmacologic Tx
Prosthesis use appears to be effective Gate theory effect & suggests cortical re-
organization also
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
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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
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PLP- Nonpharmacologic Tx
Often a phantom limb is painful because it is felt tobe 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)
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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 virtualimage of missing limb
Patients reported an average 38% decrease in
background pain on a VAS, with 5 patients outof 8 reporting a reduction greater than 30% This decrease in pain was maintained at 4
weeks postintervention in 4 of the 5participants (Mercier)
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PLP- Nonpharmacologic Tx
Virtual reality therapy with motioncapture technology Avatar motion controlled by stump
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)
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PLP- Treatment
The treatment of phantom pain isdifficult
No one treatment has shown to beeffective in a majority of sufferers Often requires many therapeutic
modalities
There are many therapeuticoptions.so try lots of stuff
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Thank You