amputation & phantom pain
DESCRIPTION
Amputation & Phantom Pain. Thom Bloomquist MSN, CRNA, CH, FAAPM Advanced Anesthesia & Pain Management Bow, NH. Mass. knows about amputees. Learning Objectives. To explore and discuss; the incidence and causes the pathophysiology - PowerPoint PPT PresentationTRANSCRIPT
Amputation & Phantom PainAmputation & Phantom Pain
Thom BloomquistThom BloomquistMSN, CRNA, CH, FAAPMMSN, CRNA, CH, FAAPM
Advanced Anesthesia Advanced Anesthesia
& Pain Management& Pain Management
Bow, NHBow, NH
Mass. knows about amputeesMass. knows about amputees
Learning ObjectivesLearning Objectives To explore and discuss; To explore and discuss;
the incidence and causes the incidence and causes
the pathophysiology the pathophysiology
neuroplasticity in phantom pain and other acute-to-chronic neuroplasticity in phantom pain and other acute-to-chronic
pain statespain states
strategies for management with a multimodal and strategies for management with a multimodal and
multidisciplinary approachmultidisciplinary approach
the possibility of phantom pain preventionthe possibility of phantom pain prevention
AmputationAmputation
New amputee each year – New amputee each year – 185,000185,000
Estimated total US Estimated total US amputees (limb) – amputees (limb) –
2, 000,0002, 000,000..
Lower extremity Lower extremity amputation,amputation,
(diabetes) - 55% will (diabetes) - 55% will
require amputation of require amputation of
other leg within 2‐3 years other leg within 2‐3 years
Amputation health care
costs per year $8.3 billion
(U.S. only)
Incidence of Phantom PainIncidence of Phantom Pain 70% - burning, cramping 70% - burning, cramping other qualities of other qualities of phantom pain phantom pain
first few weeks post-op first few weeks post-op
50% suffer50% suffer 7yrs after7yrs after some life-long continuous some life-long continuous or intermittent or intermittent
BurningBurning
StabbingStabbing
CrushingCrushing
TwistingTwisting
Lightning-likeLightning-like
Mal-positioned partMal-positioned part
Phantom painPhantom pain
Also reported after Also reported after amputation of amputation of intestines, breasts, intestines, breasts, teeth and genitals. teeth and genitals.
What is special about What is special about cuts nerves and cuts nerves and amputation?amputation?
NOTHING!NOTHING!
Wow! I didn’t know that!
CausesCauses
Vascular disease (54%) including diabetes Vascular disease (54%) including diabetes and peripheral arterial disease, and peripheral arterial disease, amputations caused by diabetes amputations caused by diabetes
increased 24% from 1988 to 2009.increased 24% from 1988 to 2009. Trauma (45%),Trauma (45%), Cancer (less than 2%)Cancer (less than 2%) Congenital malformation (small %)Congenital malformation (small %)
Under-treated Amputation PainUnder-treated Amputation Pain
Can lead to chronic painCan lead to chronic pain
Also common after thoracotomy +Also common after thoracotomy + mastectomy, herniorrhaphy….mastectomy, herniorrhaphy….
~20-40% of ALL surgeries~20-40% of ALL surgeries
Elements of Chronic Elements of Chronic Phantom PainPhantom Pain
Somatic painSomatic pain
Psychogenic aspectsPsychogenic aspects
Myofacial PainMyofacial Pain
Neuropathic painNeuropathic pain Sympathetically MaintainedSympathetically Maintained Pain (SMP)Pain (SMP)
Psychogenic FactorsPsychogenic Factors
Of course! But not Of course! But not psychosomatic - there psychosomatic - there is true anatomic basis is true anatomic basis for this pain for this pain
The illogic of pain in a The illogic of pain in a part that is no longer part that is no longer there - “Am I nuts?”there - “Am I nuts?”
Life long phantom Life long phantom limb pain?limb pain?
Somatic PainSomatic Pain
Remaining primary pathology (vascular Remaining primary pathology (vascular disease, tissue damage from trauma)disease, tissue damage from trauma)
Additional stress on affected Additional stress on affected && non- non-affected joints/tissues due to altered affected joints/tissues due to altered biomechanics. biomechanics.
Overuse syndrome of remaining structures Overuse syndrome of remaining structures and tissuesand tissues
Neuropathic painNeuropathic pain Post amputation neuroma - can take Post amputation neuroma - can take
weeks to form but spontaneous ectopic weeks to form but spontaneous ectopic discharge begins at moment of nerve discharge begins at moment of nerve division and in some nerves never fades. division and in some nerves never fades.
“…“…self sustaining neuronal activity at the self sustaining neuronal activity at the spinal cord level….if exceeds a critical spinal cord level….if exceeds a critical level pain may occur in the phantom limb” level pain may occur in the phantom limb” (Raj)(Raj)
Sympathetically Maintained Sympathetically Maintained Pain (SMP)Pain (SMP)
Neuroma firing is increased by Neuroma firing is increased by sympathetic activity (Nor-Epi) sympathetic activity (Nor-Epi)
Example: urination, defecation and Example: urination, defecation and ejaculation can activate sympathetic ejaculation can activate sympathetic efferents and trigger episodes of phantom efferents and trigger episodes of phantom arm pain. arm pain.
““Wind-Up” Wind-Up”
Once the noiceptive system is stimulated, Once the noiceptive system is stimulated, suppression of pain signaling becomes suppression of pain signaling becomes more difficult and leads to … more difficult and leads to … Hyperalgesia (severe pain from mildly noxious Hyperalgesia (severe pain from mildly noxious
stimuli)stimuli)
Allodynia (pain produced by innocuous Allodynia (pain produced by innocuous stimuli)stimuli)
Sherman, R.A. , Phantom Pain, 1997, New York: Plenum Publishing.
Transmission in Spinal CordTransmission in Spinal Cord
Neuroplasticity of Entire Neuroplasticity of Entire Nocoiceptive System? Nocoiceptive System?
Peripheral,.e.g., neuromaPeripheral,.e.g., neuroma
Spinal cord level Spinal cord level (sensitization and perhaps (sensitization and perhaps hardwired WDRs) hardwired WDRs)
Cortical-reorganization Cortical-reorganization alteration of neuromatrix alteration of neuromatrix
NeuroplasticityNeuroplasticity
Critical adaptability us evolve when Critical adaptability us evolve when dinosaurs died out (a trait we may need in dinosaurs died out (a trait we may need in the future?) can work against us in this the future?) can work against us in this situation. situation.
However, that very stimulus-response However, that very stimulus-response relationship gives us a clue. relationship gives us a clue. Cause Cause Effect Effect
Cause of Phantom Limb PainCause of Phantom Limb Pain Not clearly established Not clearly established Combination of peripheral, central and Combination of peripheral, central and
sympathetic factorssympathetic factors Positive correlation between painful limb Positive correlation between painful limb
pre-op and developing phantom limb pain pre-op and developing phantom limb pain Recruitment of normally silent high-Recruitment of normally silent high-
threshold nociceptorsthreshold nociceptors Genetics Genetics Chemically induced?Chemically induced?
How to Treat Changed Anatomy?How to Treat Changed Anatomy?
Best Rx may be prevention!Best Rx may be prevention!
Nociception drives the changes. Nociception drives the changes. Effective pain management may Effective pain management may decouple the stimulus-response decouple the stimulus-response relationship.relationship.
Diminish stimulus – prevent the Diminish stimulus – prevent the response! response!
Evidence? Yes!Evidence? Yes!
““Pre-op epidural……. (Bach).Pre-op epidural……. (Bach).
““Perioperative epidural with diamorphine, Perioperative epidural with diamorphine, clonidine and bupivacaine….. (Jahangiri).clonidine and bupivacaine….. (Jahangiri).
““Pre-, intra- and postoperative epidural…Pre-, intra- and postoperative epidural…(Gehling)(Gehling)
In other words …In other words …
Preliminary evidence - effective Preliminary evidence - effective
pre-operative analgesia pre-operative analgesia
IN COMBINATION WITH IN COMBINATION WITH
effective sustained post-operative pain effective sustained post-operative pain management management
…………can lower the incidence +/or severity of can lower the incidence +/or severity of phantom limb pain. phantom limb pain.
How?How?
““Because of the Because of the low success rate of low success rate of treatment in treatment in chronic phantom chronic phantom limb pain, … limb pain, … prevention cannot prevention cannot be be overemphasized” overemphasized” (Raj).(Raj).
Multi-Modal and Multidisciplinary Multi-Modal and Multidisciplinary Pain Management Pain Management
• Pharmacological• Non pharmacological• Psychchological / social
Primum non nocere!Primum non nocere!
Acute pain strategies can be Acute pain strategies can be counterproductive in chronic paincounterproductive in chronic pain
Higher amputation attempted – Higher amputation attempted –
------ ------ restarted same process!restarted same process!
Neuropathic Pain - RxNeuropathic Pain - Rx
NSAIDs are ineffective and opiates are not NSAIDs are ineffective and opiates are not first line for neuropathic painfirst line for neuropathic pain
Local anesthetics (Na+ Channel blockers) Local anesthetics (Na+ Channel blockers) can provide pain relief in doses that will can provide pain relief in doses that will not cause sensory or motor blocknot cause sensory or motor block
MMPM - Medications for MMPM - Medications for Chronic PainChronic Pain
Antidepressants (Tricyclics, SNERIs, Antidepressants (Tricyclics, SNERIs, SSRIs, Dopamenerics)SSRIs, Dopamenerics)
Alpha 2 agonists (clondine)Alpha 2 agonists (clondine)
Antiarrhythmics (mexiletine, lido)Antiarrhythmics (mexiletine, lido)
NSAIDs (Cox 1 or Cox 2)NSAIDs (Cox 1 or Cox 2)
Opiates - when appropriate Opiates - when appropriate
Anticonvulsants Anticonvulsants Carbamazepine Gabapentin Lamotrigine
Pregabalin P.O. Pre-op -D.O.S..
Topiramate Topiramate Valproic Acid and Valproic Acid and
Derivatives Derivatives ******
Narcotics for Chronic PainNarcotics for Chronic Pain(selected cases)(selected cases)
Oxycontin and MSContin - work well Oxycontin and MSContin - work well (expensive) (expensive)
Methadone (just as effective and less Methadone (just as effective and less expensive)expensive)
Provide immediate release preparation for Provide immediate release preparation for breakthrough painbreakthrough pain
Use MMPM to lower narcotic requirement Use MMPM to lower narcotic requirement and increase effectivenessand increase effectiveness
EUPHORIA
METHADONEMETHADONEOXYCONTINOXYCONTINMS CONTINMS CONTIN
PERCOCETPERCOCETVICONDINVICONDIN
PAINLEVEL
WITHDRAWAL
Topical - PharmacolgicTopical - Pharmacolgic(peripheral factors)(peripheral factors)
Mutli-cmpd topical preparationsMutli-cmpd topical preparations E.g. gabapentin, NSAID, local anesthetic E.g. gabapentin, NSAID, local anesthetic
combination from compounding pharmacist. combination from compounding pharmacist.
5% lidocaine patches (Lidoderm)5% lidocaine patches (Lidoderm)
OTCs (capsaicin, ASA) OTCs (capsaicin, ASA)
NMDA Blockers NMDA Blockers
Receptor site modulates nociceptive Receptor site modulates nociceptive afferent signals. afferent signals. resting state, blocked by Mg+. resting state, blocked by Mg+.
KetamineKetamine
AlsoAlso amantadine (antiviral), amantadine (antiviral), dextromethorphan (cough medicine).dextromethorphan (cough medicine).
Perioperative Epidurals Perioperative Epidurals
Effective but may not feasible in your Effective but may not feasible in your setting setting
Expensive Expensive
InvasiveInvasive
Complication rateComplication rate
Option? – O. P. MMPM Option? – O. P. MMPM
Consider mutli-modal program including:Consider mutli-modal program including: NSAID (Cox1 or Cox2)NSAID (Cox1 or Cox2) Opiates (SR & IR)Opiates (SR & IR) Antidepressants (multi-pathway)Antidepressants (multi-pathway) AnticonvulsantAnticonvulsant NMDA blocker (dextromethorphan)NMDA blocker (dextromethorphan) Clonidine ?Clonidine ?
Outpatient Program - cont’dOutpatient Program - cont’d
Important - include counseling with Important - include counseling with prepared amputee & psych.prepared amputee & psych.
Meet with ProsthetistMeet with Prosthetist Include family/spouseInclude family/spouse Amputee support groupAmputee support group
(no “Whine fests)(no “Whine fests) ACA Peer VisitorACA Peer Visitor
Non-Pharmacologic Modalities Non-Pharmacologic Modalities HeatHeat
MassageMassage
MeditationMeditation
PsychotherapyPsychotherapy
Shrinker SocksShrinker Socks
Wearing Your Artificial Wearing Your Artificial Limb Limb
AcupunctureAcupuncture
BiofeedbackBiofeedback
ChiropracticChiropractic
ColdCold
Electrical StimulationElectrical Stimulation
ExerciseExercise
Hypnosis (huge!)Hypnosis (huge!)
When desired, the When desired, the mind can literally mind can literally affect what the body affect what the body does/perceives. does/perceives.
Proof?Proof? Visualize a lemonVisualize a lemon Smell the lemon – cut Smell the lemon – cut
the lemon- feel the the lemon- feel the juice – bite the lemon juice – bite the lemon – taste the lemon – taste the lemon
Did you salivate?Did you salivate?(I did)(I did)
It’s that simple It’s that simple and this was and this was the merest the merest exampleexample
Mirror TherapyMirror TherapyThe subconscious mind can The subconscious mind can
re-map perception re-map perception
Multi-disciplinary PM TeamMulti-disciplinary PM Team
Anesthesia/Pain Mgt. Anesthesia/Pain Mgt. PrimaryPrimary PT/OT/MassagePT/OT/Massage ProsthetistProsthetist Psych (ARNP, PhD, MD/DO)Psych (ARNP, PhD, MD/DO) Support group Support group
Survivors or “whine festival”Survivors or “whine festival”
Progress - but more to doProgress - but more to do
What’s in he pipeline?What’s in he pipeline?
Neuroplasticity as a Neuroplasticity as a treatment?treatment?
Osseointegrated pinsOsseointegrated pins
You can play an important role in You can play an important role in preventing unwanted neuroplastic preventing unwanted neuroplastic changes! changes!
You can be somebody’s hero!You can be somebody’s hero!
Thank You!Thank You!My family sleeps well & safe – because of themMy family sleeps well & safe – because of them
HistoryHistory
The Rig-Veda, an ancient sacred poem of The Rig-Veda, an ancient sacred poem of India, is said to be the first written record India, is said to be the first written record of a prosthesis. of a prosthesis.
Written in Sanskrit between 3500 and Written in Sanskrit between 3500 and 1800 B.C., it recounts the story of a 1800 B.C., it recounts the story of a warrior Queen Vishpla, who lost her leg in warrior Queen Vishpla, who lost her leg in battle, was fitted with an iron prosthesis, battle, was fitted with an iron prosthesis, and returned to battle.and returned to battle.
HistoryHistory
Herodotus wrote of a prisoner who Herodotus wrote of a prisoner who escapes his chains by cutting off his own escapes his chains by cutting off his own foot. He later fashioned a substitute from foot. He later fashioned a substitute from wood. wood.
The oldest known artificial limb, dating The oldest known artificial limb, dating from 300 BC was made from copper and from 300 BC was made from copper and wood - unearthed near Capri, Italy. wood - unearthed near Capri, Italy.
In FranceIn France
Parre, a French surgeon describes Parre, a French surgeon describes Phantom limb pain in 1551.Phantom limb pain in 1551.
Larry, Napoleon's surgeon, recorded in his Larry, Napoleon's surgeon, recorded in his memoirs that extremely cold weather memoirs that extremely cold weather (-19 (-19 ooF) allowed him to perform painless F) allowed him to perform painless amputations.amputations.
Revolutionary WarRevolutionary War ““If amputation was chosen, the patient was If amputation was chosen, the patient was laid out at table height, covered with double laid out at table height, covered with double blankets, and given pillows for his head. blankets, and given pillows for his head. Alcohol, if available, was used to help sedate Alcohol, if available, was used to help sedate the patient. The following procedure was then the patient. The following procedure was then performed by a surgeon.performed by a surgeon.A good surgeon cut fast, performing the A good surgeon cut fast, performing the procedure in about a minute. If the patient was procedure in about a minute. If the patient was lucky, he'd pass out before feeling the searing lucky, he'd pass out before feeling the searing pain.” pain.”
Civil WarCivil War
Chloroform came into use for anesthesia, Chloroform came into use for anesthesia, for PM. Opium and derivatives were widely for PM. Opium and derivatives were widely used. used.
Civil War veterans Civil War veterans commonly suffered commonly suffered in agony from war in agony from war wounds for the rest wounds for the rest of their livesof their lives