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PubMed1992

Pathophysiology and management of phantom limb pain.

Phantom pain phenomenon is a poorly understood but relatively common sequela of limb amputation that may result in significant psychological and physical morbidity. In this review, proposed pathoneurophysiological mechanisms for the development of phantom pain are reviewed as well as psychological mechanisms that may be involved. The authors recommend an integrated approach to management of chronic phantom pain that takes into consideration the multiple factors that may contribute to its etiology.

Adult↗
PubMed2000

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.

Humans↗
PubMed1998

Optimal treatment of phantom limb pain in the elderly.

Phantom limb and stump pain is a common sequela of amputation. In geriatric patients with an amputated limb and multiple other illnesses, drug therapy may be problematic and invasive techniques may be risky. Interactions between pathophysiological mechanisms in the peripheral and central nervous systems may be responsible for the initiation and maintenance of chronic phantom limb and stump pain. These mechanisms include: (i) peripheral damage to nociceptive fibres and dorsal root ganglion cells, which acquire abnormal sensitivity to mechanical, thermal and chemical stimuli; (ii) the prolonged sensitisation of central nociceptive 'second order' neurons in the dorsal horn of the spinal cord, which become hyperexcitable and start responding to nonnoxious stimuli; and (iii) the degeneration of nociceptive neurons, which may trigger the anatomical sprouting of low threshold mechanosensitive terminals to form connections with central nociceptive neurons. This may subsequently induce functional synaptic reorganisation in the dorsal horn. The provision of a pain-free perioperative interval using regional anaesthetic techniques is likely to reduce the incidence of phantom limb pain. The therapy of manifest pain is difficult, and treatment should start as soon as possible to prevent chronic pain. In the acute state, the infusion of calcitonin and oral opioid analgesics have proven to be helpful, while established phantom limb pain may respond to antidepressants, anticonvulsants and drugs that mimic or enhance gamma-aminobutyric acid function. Pharmacological treatment should be combined with transcutaneous electrical nerve stimulation, sympathetic blockade and psychotherapy. In addition, new therapeutic strategies are now being tested; examples include capsaicin, new anticonvulsants and N-methyl-D-aspartate antagonists. Patients with severe pain should be referred to a pain specialist to ensure optimal and timely interventional pain management.

Amputation Stumps↗
PubMed1984

Non-painful phantom limb phenomena in amputees: incidence, clinical characteristics and temporal course.

58 patients undergoing limb amputation mainly because of peripheral vascular disease were interviewed by means of a standard questionnaire and examined 8 days, 6 months and 2 years after limb amputation regarding non-painful phantom limb phenomena. During the follow-up period, 41% of patients died. The incidence of phantom limb 8 days, 6 months and 2 years after limb loss was 84%, 90% and 71%, respectively. Phantom limb phenomena changed within the first half year after amputation from a mainly proximal and distal distribution to a mainly distal localized sensation. While approximately 3/4 of patients with phantom limb had kinaesthetic sensations in the limb (i.e. feeling of length, volume or other spatial sensation) during the first 6 months after amputation, less than 50% of patients had this later in the course; 30% of patients noticed a clear shortening of the phantom limb during the follow-up period. While the incidence of phantom limb did not decrease during the follow-up period, both the duration and frequency of phantom limb phenomena declined significantly. The distribution of non-painful and painful phantom limb did not differ significantly from each other. The present findings suggest that mechanisms both in periphery, spinal cord and brain participate in generating the phantom limb percept.

Adult↗
PubMed2006

[Phantom limb pain].

Almost everyone who has amputated a limb will experience a phantom limb. They have the vivid impression, that the limb is still present. 60 to 70% of these amputees will suffer from phantom limb pain. The present paper gives an overview of the incidence and the characteristics of the so called "post amputation syndrome". Possible mechanism of this phenomena are presented, including peripheral, spinal, and central theories. Treatment of phantom limb pain is sometimes very difficult. It includes drug therapy, psychological therapy, physiotherapy as well as the prevention of phantom limb pain with regional analgesia techniques.

Amputation, Surgical↗
PubMed1996

Regional anaesthesia for repeat Caesarean section in a patient with phantom limb pain.

The triggering of phantom limb pain by subarachnoid or epidural anaesthesia has been well described leading to the suggestion that neuraxial regional anaesthesia is relatively contraindicated in lower limb amputees. We report our experience of the provision of anaesthesia for repeat Caesarean section on two occasions in such a patient. Intrathecal fentanyl and morphine supplementation of bupivacaine successfully abolished peri-operative phantom limb pain, whereas epidural anaesthesia was associated with recurrence of phantom limb pain upon regression of the block.

Adult↗
PubMed2003

Phantom limb pain in pediatric burn survivors.

Phantom limb sensation and pain are reported by youth following amputations. While youth survivors of severe burns may require amputation as a part of their treatment, the authors are unaware of any descriptions as to the rates and features of phantom limb sensation and pain in this population. A retrospective chart review of all youth that were admitted to a burn care unit over the past 30 years and received amputations as part of their treatment was conducted to describe the rate of phantom sensation and pain. In the 34 patients with major limb amputations, phantom limb pain occurred at a rate similar to that reported in other studies and was an important issue in their care. Patients with amputations following electrical burn injury had a significantly higher rate of phantom limb pain than those with amputations following flame burn injury.

Adolescent↗
PubMed1995

Phantom limb pain and chemotherapy in pediatric amputees.

OBJECTIVE: To determine the frequency of phantom limb pain in pediatric patients with cancer-related amputations and the relationship between phantom limb pain and chemotherapy (CHRx). DESIGN: We retrospectively reviewed the medical records of all pediatric patients who underwent major limb amputations between 5 and 17 years of age during the period from Oct. 1, 1983, to Oct. 1, 1993, and were treated at the Mayo Clinic. MATERIAL AND METHODS: One investigator reviewed 293 medical records and selected cases on the basis of specific inclusion and exclusion criteria. The study group consisted of 75 patients (67 with cancer-related and 8 with trauma-associated amputations). All reports of phantom limb pain and its temporal relationship to administration of CHRx were recorded. Data were analyzed by use of descriptive statistics. RESULTS: Phantom limb pain was reported in 48% of patients with cancer-related amputations in comparison with 12% of patients with trauma-associated amputations. Among patients with cancer, phantom limb pain was experienced by 74% who were exposed to CHRx before or at the time of amputation, 44% who received CHRx after amputation, and 12% who never received CHRx. Patients with trauma-related amputations and those who did not receive CHRx reported phantom limb pain at similar intervals after amputation (a mean of 6 days). In comparison, 76% of patients with cancer and a history of exposure to CHRx reported phantom limb pain within 72 hours after amputation. Three of four patients who first received CHRx after amputation reported phantom limb pain on the day CHRx was begun (a mean of 12.3 days after amputation). CONCLUSION: Our observations suggest that (1) phantom limb pain occurs more often in pediatric amputees with cancer than in those with trauma and (2) the hypothesis that CHRx may be a risk factor in the development of phantom limb pain in pediatric amputees should be investigated further.

Adolescent↗
PubMed1988

Phantom limb pain in amputees during the first 12 months following limb amputation, after preoperative lumbar epidural blockade.

The similarities between phantom limb pain and preoperative limb pain have been noted, and this raises the possibility of modulating the pain by a preoperative blockade. The aim of this study was to investigate if it was possible to reduce postoperative phantom limb pain by giving lumbar epidural blockade (LEB) with bupivacaine and morphine for 72 h prior to the operation. 25 patients were interviewed about their limb pain before limb amputation, and about their phantom limb pain 7 days, 6 months and 1 year after limb loss. 11 patients, of mean age 77 years (52-93), received an LEB, so that they were pain-free for 3 days prior to operation. The control group, 14 patients of mean age 73.4 years (63.86), all had preoperative limb pain. Seven days after operation, 3 patients in the LEB group and 9 patients in the control group had phantom limb pain (P less than 0.10). After 6 months all patients in the LEB group were pain-free, whilst 5 patients in the control group had pain (P less than 0.05). After 1 year, all the patients in the LEB group were still pain-free, and 3 patients in the control group had phantom limb pain (P less than 0.20). Preoperative lumbar epidural blockade with bupivacaine and morphine reduces the incidence of phantom limb pain in the first year after operation.

Aged↗
PubMed2001

Psychological distress in amputees with phantom limb pain.

Research suggesting that psychological factors play a role in phantom limb pain abounds in the literature. Despite recent research suggesting that these factors exacerbate rather than cause phantom limb pain, clinicians still frequently use personality as a rationale to explain amputees' phantom limb pain. The present study aimed to examine psychological distress in a working-age population of amputees not specifically seeking help for their pain. The study was conducted in two phases. Phase 1 included 315 amputees who completed the General Health Questionnaire (GHQ). Phase 2 included a subset of the original sample who completed the Beck Depression Inventory (BDI). In Phase 1, although over 50% of the sample reported GHQ scores over the threshold used to detect "caseness," this was not related to phantom limb pain. In Phase 2 of the study, only 15% of the sample reported moderate to severe symptoms of depression. Only 4% of the variance in phantom limb pain was accounted for using the overall BDI score. When BDI items were examined individually within regression models, a number significantly predicted phantom limb pain. However, the items most related to phantom limb pain were those involved in "performance difficulties" rather than "negative affect." The present study suggests that negative affect in amputees may be related to disability rather than pain.

Adult↗
PubMed1978

Phantom limbs and related phenomena in recent traumatic amputations.

Seventy-three soldiers who had traumatic amputations were examined from 1 to 6 months after limb loss. All experienced phantom limb sensations and 67 percent experienced phantom limb pains, usually transient. Stump pain occurred in 43 percent and was associated with phantom pain in 54 percent of these. Of the 23 percent of the entire group who had evident stump pathology, 33 percent had phantom pains only, 20 percent had stump pains only, 40 percent had both, and 7 percent were pain-free. All stump ends exhibited an area of hyperpathia with hypoesthesia. Phantom pain probably results from peripheral or spinal cord mechanisms, or both, rather then from more rostral mechanisms.

Adult↗
PubMed1997

Effects of regional anesthesia on phantom limb pain are mirrored in changes in cortical reorganization.

The causes underlying phantom limb pain are still unknown. Recent studies on the consequences of nervous system damage in animals and humans reported substantial reorganization of primary somatosensory cortex subsequent to amputation, and one study showed that cortical reorganization is positively correlated with phantom limb pain. This paper examined the hypothesis of a functional relationship between cortical reorganization and phantom limb pain. Neuroelectric source imaging was used to determine changes in cortical reorganization in somatosensory cortex after anesthesia of an amputation stump produced by brachial plexus blockade in six phantom limb pain patients and four pain-free amputees. Three of six phantom limb subjects experienced a virtual elimination of current phantom pain attributable to anesthesia (mean change: 3.8 on an 11-point scale; Z = -1.83; p < 0.05) that was mirrored by a very rapid elimination of cortical reorganization in somatosensory cortex (change = 19.8 mm; t(2) = 5.60; p < 0.05). Cortical reorganization remained unchanged (mean change = 1.6 mm) in three phantom limb pain amputees whose pain was not reduced by brachial plexus blockade and in the phantom pain-free amputation controls. These findings suggest that cortical reorganization and phantom limb pain might have a causal relationship. Methods designed to alter cortical reorganization should be examined for their efficacy in the treatment of phantom limb pain.

Adult↗
PubMed1985

Does preamputation pain influence phantom limb pain in cancer patients?

Phantom sensation and phantom limb pain are two recognized sequelae of limb amputation. In most previous surveys, amputations were done for arteriosclerotic or trauma related conditions. We studied 25 patients who had lower extremity amputation for neoplasia. In studying the features of pain before and after amputation, we found phantom limb pain in cancer patients similar in presentation and description to that in noncancer amputees. There appeared to be no correlation between the severity of each episode of phantom pain and the overall effect of the pain on the patient's life. The quality and location of the phantom pain did not resemble the preamputation pain. We recommend a multidisciplinary approach to treatment.

Adolescent↗
PubMed2001

Variation in phantom limb pain: results of a diary study.

Amputees experience multiple, complex problems in addition to phantom limb pain. Although studies have yielded useful data on the relationship between phantom limb pain and other variables, this research generally has evaluated only one aspect of phantom limb pain and measured it at only one time point. The present study examined ongoing phantom limb pain and associated factors prospectively through the use of hourly pain diaries that are completed over a 7-day period. The sample comprised a subset of 89 lower limb amputees taking part in a longitudinal research study. Subjects had a mean age of 46.1 years. Forty-seven per cent were female, 53% male. Subjects completed a Pain/Coping Diary that measured phantom limb pain intensity, activity levels, medication use, and alcohol use on an hourly basis over a 7-day period. It also asked subjects to list the coping strategies used on the same hourly basis over a 7-day period. The diaries highlighted the following: Phantom limb pain appears to be episodic in nature and there is great variation in its intensity. Amputees use a limited repertoire of coping strategies to deal with episodes of phantom limb pain, and of those strategies that are used, few reduce the level of pain. This variability in phantom limb pain has important implications for those involved in the care of amputees as a report of phantom limb pain at a given point in time may not reflect the amputee's overall pain experience.

Adult↗
PubMedDate not supplied

Central representation of phantom limb phenomenon in amputees studied with single photon emission computerized tomography.

To explore the possible mechanisms of phantom limb discomfort after amputation, three amputees with phantom limb pain were studied. This study examined the change of regional cerebral blood flow using technetium-99m hexamethylpropyleneamine oxime-single photon emission computerized tomography, which was arranged at the time of severe phantom limb discomfort and after the discomfort subsided or was completely relieved. Nine representative transverse slices parallel to the orbitomeatal line were selected for quantification. The cortical ribbon (2-cm thickness) was equally subdivided into 12 symmetrical pairs of sector regions of interest in each slice. The irregularly shaped regions of interest were drawn manually around the right thalamus and basal ganglion and then mirrored to the left thalamus and basal ganglion. The contralateral to ipsilateral ratio of regional cerebral blood flow for each area was calculated. The intensity of phantom limb pain was evaluated on a 0 to 10 visual analog scale. In Cases 1 and 2, the contralateral to ipsilateral regional cerebral blood flow ratios of multiple areas of the frontal, temporal, or parietal lobes were increased at the time of more severe phantom limb pain, and the ratios were normalized or even decreased when the phantom limb pain subsided. In Case 3, increased contralateral to ipsilateral regional cerebral blood flow ratios were also found over the frontal, temporal, and parietal lobe. However, most of the increased regional cerebral blood flow ratios of regions of interest in the first study persisted in the follow-up study. Also, the regional cerebral blood flow ratios of greater number of regions of interest of the same gyrus and new gyrus were increased. There was no significant right-left difference of regional cerebral blood flow over bilateral thalami and basal ganglia in all three cases. The results suggested that phantom limb pain might be associated with cortical activation involving the frontal, temporal, or parietal cortex, and it may imply the possibility of the existence of an ascending polysynaptic pathway that conveys the uncomfortable phantom limb sensation to the cerebral cortex. These findings may also indicate that reorganization of the cortical blood flow occurs in amputees. However, it is still difficult to conclude that the changes in regional cerebral blood flow were attributable directly to pain. With no comparison group of amputees and because of the small number of cases, it is hard to generalize about cerebrocortical involvement in phantom pain, and it is possible that the findings represent a normal phenomenon seen after 'amputation. Another possibility is that the findings represent increased arousal caused by pain rather than an intrinsic pain pathway. Further study is worthwhile.

Adolescent↗
PubMed2000

Focal cerebral hyper-perfusion in phantom limbs: assessed by Tc-99m HMPAO SPECT.

Phantom limb pain is a common experience for patients who have received amputation. However, the definite mechanism is still not clear. Here, we describe a patient who suffered from phantom limb pain after left above-elbow amputation. The Tc-99m hexamethylpropylene amine oxime (HMPAO) brain single photon emission computed tomography (SPECT) study revealed increased regional cerebral blood flow in the right parietal cortex. This finding may imply the involvement of cerebral cortex in the development of phantom limb pain. Further study is worthwhile to elucidate the utility of SPECT and the role of cortex in phantom limb pain.

Adult↗
PubMed2002

Phantom-limb pain: characteristics, causes, and treatment.

Phantom-limb pain is a common sequela of amputation, occurring in up to 80% of people who undergo the procedure. It must be differentiated from non-painful phantom phenomena, residual-limb pain, and non-painful residual-limb phenomena. Central changes seem to be a major determinant of phantom-limb pain; however, peripheral and psychological factors may contribute to it. A comprehensive model of phantom-limb pain is presented that assigns major roles to pain occurring before the amputation and to central as well as peripheral changes related to it. So far, few mechanism-based treatments for phantom-limb pain have been proposed. Most published reports are based on anecdotal evidence. Interventions targeting central changes seem promising. The prevention of phantom-limb pain by peripheral analgesia has not yielded consistent results. Additional measures that reverse or prevent the formation of central memory processes might be more effective.

Humans↗
PubMed2004

The challenge and management of phantom limb pain after amputation.

Phantom limb pain (PLP) is thought to occur in most amputees. This common clinical phenomenon often provides a challenge to those involved in the treatment and management of pain, since the causes of PLP are often misunderstood. This article will look at some of the theories of PLP which will highlight why normal analgesic drugs are often not effective. The article will then consider pain management strategies used in PLP in the ward setting. These pain management strategies include the use of drugs not traditionally known as analgesics, but which are usually used in the treatment of epilepsy and depression.

Amputation, Surgical↗