pain management in the amputee

8/6/2019 Pain Management in the Amputee

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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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References: Weeks SR, et al: Phantom limb pain: theories and therapies. Neurologist. 2010 Sep: 16(5): 277-86. Hanley MA, Ehde DM, Jensen M, Czerniecki J, Smith DG, Robinson LR. Chronic pain associated with upper-limb loss. Am J Phys

Med Rehabil. 2009 Sep;88(9):742-51

Kooijman CM, Dijkstra PU, Geertzen JH, Elzinga A, van der Schans CP. Phantom pain and phantom sensations in upper limbamputees: an epidemiological study. Pain. 2000 Jul;87(1):33-41 Mulvey MR, et al: Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in

adults. Cochrane Database Sys Rev. 2010 May 12; 5. Atkinson GJ, et al: Heterotopic ossification in the residual lower limb in an adult nontraumatic amputee patient. Am J Phys Med

Rehab. 2010 Mar: 89(3): 245-8. Shanthanna, H, et al: Early and effective use of ketamine for treatment of phantom limb pain. Indian J Anaesth. 2010 Mar;54(2):

157-9. Wilder-Smith, CH, et al: Postamputation pain and sensory changes in treatment-nave patients: characteristics and responses to

treament with tramadol, amitriptyline, and placebo. Anesthesiology. 2005 Sep; 103(3): 619-28.

Charrow A, et al: Intradermal botulinum toxin type A injection effectively reduces residual limb hyperhidrosis in amputees: a caseseries. Arch Phys Med Rehab. 2008 Jul:89(7): 1407-9. Ketz AK: The experience of phantom limb pain in patients with combat-related traumatic amputations. Arch Phys Med Rehab. 2008

Jun: 89(6): 1127-32. Bosmans JC, et al: Factors associated with phantom limb pain: a 3 year prospective study. Clin Rehab. 2010 May; 24(5): 444-53. Diers M, et al: Mirrored, imagined and executed movements differentially activate sensorimotor cortex in amputees with and without

phantom limb pain. Pain. 2010 May: 149(2): 296-304. West M, Wu H: Pulsed Radiofrequency ablation for residual and phantom limb pain: A case series. Pain Pract. 2010 Mar 3. Borghi B, et al: The use of prolonged peripheral neural blockade after lower extremity amputation: The effect on symptoms

associated with phantom limb syndrome. Anesth Analg. 2010 Sep 29. Namba Y, et al: Phantom erectile penis after sex reassignment surgery. Acta Med Okayama. 2008 Jun;62(3):213-6. Schley MT, Wilms P, Toepfner S, Schaller HP, Schmelz M, Konrad CJ, Birbaumer N. Painful and nonpainful phantom and stump

sensations in acute traumatic amputees. J Trauma. 2008 Oct;65(4):858-64. Ephraim PL, Wegener ST, MacKenzie EJ, Dillingham TR, Pezzin LE. Phantom pain, residual limb pain, and back pain in amputees:

results of a national survey. Arch Phys Med Rehabil. 2005 Oct;86(10):1910-9. Ehde DM, Czerniecki JM, Smith DG, Campbell KM, Edwards WT, Jensen MP, Robinson LR. Chronic phantom sensations, phantom

pain, residual limb pain, and other regional pain after lower limb amputation. Arch Phys Med Rehabil. 2000 Aug;81(8):1039-44. Kern U, Busch V, Rockland M, Kohl M, Birklein F. [Prevalence and risk factors of phantom limb pain and phantom limb sensations in

Germany. A nationwide field survey]. Schmerz. 2009 Oct;23(5):479-88 Ehde DM, Czerniecki JM, Smith DG, Campbell KM, Edwards WT, Jensen MP, Robinson LR. Chronic phantom sensations, phantom

pain, residual limb pain, and other regional pain after lower limb amputation. Arch Phys Med Rehabil. 2000 Aug;81(8):1039-44.


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References (contd): Ziegler-Graham K et al. Estimating the Prevalence of Limb Loss in the United States - 2005 to 2050. Archives of Physical Medicine

and Rehabilitation 89 (2008): 422-429. Adams PF, et al, Current Estimates from the National Health Interview Survey, 1996. Vital and Health Statistics 10:200 (1999).

Flor H. Phantom-limb pain: characteristics, causes, and treatment. Lancet Neurol. 2002 Jul;1(3):182-9. Nikolajsen L, et al: A randomized study of the effects of gabapentin on postamputation pain. Anesthesiology. 2006 Nov;105(5): 1008-

15. Roullet S, et al: Preoperative opioid consumption increases morphine requirement after leg amputation. Can J Anaesth. 2009 Dec:

56(12): 908-13. Finger, Stanley, Hustwit, Meredith P. Five Early Accounts of Phantom Limb in Context: Pare, Descartes, Lemos, Bell, and Mitchell.

Neurosurgery. 52(3):675-686, March 2003. Nikolajsen L, Jesnon TS. Phantom Limb Pain. British Journal Anaesthesiology. 2001; 87:107-116. Hill A. Phantom Limb Pain: A review the literature on attributes and potential mechanisms. Journal of Pain Symptom Management.

1999;17:125-142 Soroush M, Modirian E, Soroush M, Masoumi M. Neuroma in bilateral upper limb amputation. Orthopedics. 2008 Dec;31(12). O'Neal ML, Bahner R, Ganey TM, Ogden JA. Osseous overgrowth after amputation in adolescents and children. J Pediatr Orthop.

1996 Jan-Feb;16(1):78-84. Dudek NL, DeHaan MN, Marks MB. Bone overgrowth in the adult traumatic amputee. Am J Phys Med Rehabil. 2003

Nov;82(11):897-900. Potter BK, Burns TC, Lacap AP, Granville RR, Gajewski DA. Heterotopic ossification following traumatic and combat-related

amputations. Prevalence, risk factors, and preliminary results of excision. J Bone Joint Surg Am. 2007 Mar;89(3):476-86. Stitik TP, Foye PM. The prevalence of knee pain and symptomatic knee osteoarthritis among veteran traumatic amputees and

nonamputees. Arch Phys Med Rehabil. 2005 Mar;86(3):487-93. Esquenazi A, Meier RH. Rehabilitation in limb deficiency. Limb Amputation. Archives of Physical Medicine and Rehabilitation. 1996;

77:S18-S28 Hill A. Phantom limb pain: a review of the literature on attributes and potential mechanisms. J Pain Symptom Management

1999;17:125-42. Halbert J, Crotty M, Camerson ID. Evidence for the optimal management of acute and chronic phantom pain: a systematic review.

Clinical Journal of Pain 2002;18:84-92. Smith DG, Ehde DM, Hanley MA, Campbell KM, Jensen MP, Hoffman AJ, Awan AB, Czerniecki JM, Robinson LR. Efficacy of

gabapentin in treating chronic phantom limb and residual limb pain. J Rehabil Res Dev. 2005 Sep-Oct;42(5):645-54. Bone M, et al. 2002: Gabapentin in post-amputation phantom limb pain: a randomized, double-blind, placebo-controlled, cross-over

study. Reg Anesth Pain Med. 2002 Sep-Oct;27(5):481-6. Rasmussin KG, Rummans TA. Electroconvulsive Therapy for phantom limb pain. Pain. 200 Mar 85(1-2): 301-2.


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References (contd): Robinson LR, et al. 2004: Trial of amitriptyline for relief of pain in amputees: results of a randomized controlled study. Arch Phys Med

Rehabil. 2004 Jan;85(1):1-6. Jin L, Kollewe K, Krampfl K, Dengler R, Mohammadi B. Treatment of phantom limb pain with botulinum toxin type A. J Pain Med.

2009 Mar;10(2):300-3. Kern U, et al. 2003: Treatment of phantom limb pain with botulinum-toxin A: a pilot study. Schmerz. 2003 Apr;17(2):117-24. Mishra S, Bhatnagar S, Gupta D, Diwedi A. Incidence and management of phantom limb pain according to World Health

Organization analgesic ladder in amputees of malignant origin. Am J Hosp Palliat Care. 2007 Dec-2008 Jan;24(6):455-62. Wu CL, et al. 2008: Morphine versus mexiletine for treatment of post-amputation pain: a randomized, placebo-controlled, cross-over

trial. Anesthesiology. 2008 Aug;109(2):289-96. Maier C, et al. 2002. Efficacy of the NMDA-receptor antogonist memantine in patients with chronic phantom limb pain: results of a

randomized double-blinded, placebo-controlled trial. Pain. 2003 Jun;103(3):277-83. Hayes C, et al. 2004: Perioperative intravenous ketamine infusion for the prevention of persistent post-amputation pain: a

randomized, controlled trial. Anaesth Intensive Care. 2004 Jun;32(3):330-8. Hackworth RJ, et al. 2008: Profound pain reduction after induction of memantine treatment in two patients with severe phantom limb

pain. Anesth Analg. 2008 Oct;107(4):1377-9. Bittar RG, Otero S, Carter H, Aziz TZ. Deep brain stimulation for phantom limb pain. J Clin Neurosci. 2005 May;12(4):399-404. Smith E, Ryall N. Residual limb osteomyelitis: A case series from a national prosthetic centre. Disabil Rehabil. 2009 May 21:1-5. Katayama Y, et al. 2001: Motor cortex stimulation (MCS) for phantom limb pain: comprehensive therapy with spinal cord (SCS) and

thalamic stimulation (DBS). Stereotact Funct Neurosurg. 2001;77(1-4):159-62. Bradbrook D. Acupuncture treatment of phantom limb pain and phantom limb sensation in amputees. Acupunct Med. 2004

Jun;22(2):93-7. Flor, et al. 1995. Phantom-limb pain as a perceptual correlate of cortical reorganization following arm amputation. Nature. 1995 Jun

8;375(6531):482-4. Wiech K, et al. 2004: A placebo-controlled randomized cross-over trial of the N-methyl-D-aspartic acid (NMDA) receptor antagonist

memantine in patients with chronic phantom limb pain. Anesth Analg. 2004 Feb;98(2):408-13 Mercier C, Sirigu A. Training with virtual visual feedback to alleviate phantom limb pain. Neurorehabil Neural Repair. 2009 Jul-

Aug;23(6):587-94 Cole J, et al. 2009: Exploratory findings with virtual reality for phantom limb pain; from stump motion to agency and analgesia. Disabil

Rehabil. 2009;31(10):846-54. Ramachandran VS, Altschuler EL. The use of visual feedback, in particular mirror visual feedback, in restoring brain function. Brain

2009 132(7):1693-1710 Weiss T, et al. 1999: Decrease in phantom limb pain associated with prosthesis-induced increased use of an amputation stump in

humans. Neurosci Lett. 1999 Sep 10;272(2):131-4. Lotze M, et al. 1999. Does use of a myoelectric prosthesis prevent cortical reorganization and phantom limb pain? Nat Neurosci.

1999 Jun;2(6):501-2. Casale, et al: Phantom limb related phenomena after lower limb amputation. Eur J Phys Rehabil Med. 2009 Dec;45(4):559-66.


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pain management in the amputee

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