Phantom limb pain

Phantom Limb Pain
DR MOHSEN ABAD
Pain specialist

overveiw
•History
•Definition
•INTENSITY AND FREQUENCY
•MECHANISMS OF PHANTOM PAIN
•PREVENTION
•TREATMENT
PHANTHOM LIMB
PAIN

History
• first medical descriptions at the 16th
century
• Silas Weir Mitchell (1829-1914) is
credited with coining the term phantom
limb, and more than anyone else

History
• over the past several decades, wars
and land mine explosions in many parts
of the world have been responsible for
numerous cases of traumatic
amputation
• In Western countries, the main reasons
for amputation are diabetes and
peripheral vascular disease in elderly
people

History
• after the war between Iraq and Iran,
64% of 200 soldiers who had lost limbs
during this war suffered from phantom
pain, 32% from phantom movement
pain, while 24% suffered from stump
pain.

Definition
• Phantom pain is pain caused by
elimination or interruption of sensory
nerve impulses by destroying or injuring
the sensory nerve fibers after
amputation or deafferentation.
• Phantom phenomena may also occur
following the amputation of other body
parts, such as the breast and rectum

PREVALENCE
• most recent studies agree that 60% to
80%
• The prevalence is probably not
influenced by age in adults, gender,
side, or level and cause (civilian versus
traumatic) of the amputation
• Phantom pain is less frequent in very
young children and congenital
amputees

TIME COURSE
• usually within the first week after
amputation
• The appearance of phantom pain may,
however, be delayed for months or even
years

INTENSITY AND FREQUENCY
• phantom pain is present in 60% to 80%
• severe pain is substantially smaller and in the
range of 5% to 15%.
• the mean intensity of pain 6 months after
amputation was 22 (range, 3 to 82) on a visual
analog scale (VAS, 0 to 100).
• The pain is usually intermittent and only a few
patients are in constant pain
• Episodes of pain attacks are most often reported
to occur daily or at daily or weekly intervals

LOCALIZATION AND CHARACTER
• Phantom pain is primarily
localized to the distal parts
of the missing limb
• In upper limb amputees,
pain is normally felt in the
fingers and palm of the
hand
• in lower limb amputees, it is
generally experienced in
the toes, foot, or ankle

Common descriptions of phantom pain
• Phantom pain is often
described as shooting,
pricking, and burning, pins
and needles, tingling,
throbbing, cramping,
crushing
– a hammer is slammed at my
calf
– Ants are crawling around
inside my foot

PHANTOM SENSATIONS
• more frequent than phantom pain
• experienced by nearly all amputees
• do not usually pose a major clinical problem
• 30% of amputees may find these sensations
moderately to severely
• appear within the first days after amputation
• Immediately after amputation, the phantom limb
often resembles the preamputation limb in
shape, length, and volume
• Over time, the phantom fades, with sensation of
the distal parts of the limb disappearing.

Telescoping
• shrinkage of the
phantom is reported
to occur in about a
third of patients.
• The phantom
gradually
approaches the
amputation stump
and eventually
becomes attached to
it

STUMP PAIN
• Stump pain is common in the early postamputation
period.
• all patients experienced some stump pain in the first
week after amputation, with a median intensity of 15.5
• prevalence of chronic stump pain varies in the
literature,
• severe pain is probably seen in only 5% to 10%
• Stump pain may be described as pressing, throbbing,
burning, squeezing, or stabbing
• hypoesthesia, hyperalgesia, or allodynia
• Stump pain and phantom limb pain are strongly
correlated.

MECHANISMS OF PHANTOM PAIN
• Not completely understood
• it is now clear that nerve injury is followed
by a number of morphologic, physiologic ,
and chemical changes in both the
peripheral and central nervous system and
that all these changes
• Divided to : peripheral, spinal, and
supraspinal mechanisms

PERIPHERAL MECHANISMS
• The ectopic and increased spontaneous and
evoked activity from the periphery is
assumed to be the result of an increased and
also de novo expression of sodium channels
• increased activity in afferent C fibers
• Stump neuromas induces stump and
phantom pain.
• It has been claimed that surgical removal of a
neuroma abolishes phantom pain

PERIPHERAL MECHANISMS
• DRG cells exhibit dramatic changes in the
expression of different sodium channels
following axonal transection.
• The sympathetic nervous system may also
play an important role
• Sympatholytic blocks can abolish or reduce
phantom pain,
• pain can be rekindled by injection of
noradrenaline into the skin

SPINAL MECHANISMS
• Phantom limb pain may appear or disappear
following spinal cord neoplasia.
• After nerve injury there is an increase in the
general excitability of spinal cord neurons,
where C fibers and Aδ afferents gain access
to secondary pain-signaling neurons.
• Sensitization of dorsal horn neurons is
mediated by release of glutamate and
neurokinins
• reduced flexion reflex thresholds in response
to noxious mechanical

SPINAL MECHANISMS
• increased persistent neuronal discharges with
prolonged pain after stimulation (wind-up
phenomena)
• expansion of peripheral receptive ﬁelds
• increased activity in N-methyl-d-aspartate
(NMDA) receptor–operated systems

SUPRASPINAL MECHANISMS
• alter neuronal activity in cortical and subcortical
structures
• complex perceptual qualities and its modification by
various internal stimuli (e.g., attention, distraction, or
stress) shows the phantom image to be a product of
the brain.
• cortical reorganization after amputation
• Changes have also been observed at subcortical
levels
• was shown that thalamic neurons, which do not
normally respond to stimulation, begin to respond
and show enlarged somatotopic maps in amputees

PREVENTION
1. phantom pain is in some cases a replicate of the pain
experienced before the amputation
2. pain before the amputation increases the risk for
postamputation phantom pain

EPIDURAL INTERVENTIONS
1. phantom pain was lower in patients who had
received the preoperative epidural blockade
2. The intensity of stump and phantom pain and
consumption of opioids were also similar in the two
groups at all four postoperative interviews
• no difference was found in the incidence of
phantom pain 24 months after the amputation in
those who had received epidural, spinal, or general
anesthesia for the amputation

PERIPHERAL REGIONAL ANESTHESIA
• Studies have found negative and positive effects,
• One study : a catheter into the transected nerve
sheath at the time of amputation and infused
bupivacaine for 72 hours. Phantom pain did not
develop in any patients during a 12-month follow-up
• incidence of phantom pain was similar in the two
groups after 3 days and 6 and 12 months

SYSTEMIC INTERVENTIONS
• intravenous ketamine infused intraoperatively
and for 72 hours: no effect of a treatment
• oral memantine: reduced phantom pain after 4
weeks and 6 months, but not after 12 months
• oral gabapentin: 300 mg - 2400 mg/day : early
and prolonged treatment with gabapentin did not
seem to reduce the incidence of phantom pain

conclusion
• In conclusion, perioperative interventions, such as
epidurals, other nerve blocks, and systemic treatments,
are effective in the treatment of immediate postoperative
stump pain
• further evaluate the potential for different perioperative
treatment regimens to reduce chronic phantom pain
• multimodal approach seems to generate better outcome
consist of: sychological counseling and treatment;
cognitive behavioral therapy and pharmacological
treatment

TREATMENT
• The authors’ conclusion was that data from the studies
included were not sufficient to support any particular
medication for established phantom limb pain.

MEDICAL TREATMENT
• Amitriptyline: dose of 125 mg/day: no effect of on
pain intensity or secondary outcome measures such
as satisfaction with life
• Both tramadol and amitriptyline had almost abolished
stump and phantom pain at the end of the treatment
period
• gabapentin : titrated in increments 300 to the
maximum dosage of 2400 mg/day:
– Gabapentin did not decrease the intensity of pain
significantly, but was better than placebo

MEDICAL TREATMENT
• oral morphine: a significant reduction in phantom pain
• Calcitonin alone had no effect on pain
• Memantine at doses of 20 or 30 mg/day failed to have
any effect on spontaneous pain, allodynia, and
hyperalgesia.
• A large number of other treatments, such as
dextromethorphan, topical application of capsaicin,
intrathecal opioids, various anesthetic blocks, injections
of botulinum toxin, and topiramate, have been claimed to
be effective in relieving phantom pain, but none of them
have proved to be effective in well-controlled trials with a
sufficient number of patients.

MEDICAL TREATMENT
• Sympathetic blocks may also reduce phantom pain, but
only for a limited time after the injection
• The inflammatory cytokine tumor necrosis factor alpha
(TNF - α ) plays an important role in neuropathic pain
conditions: perineural injections of etanercept, a TNF - α
antagonist, describes a significant improvement

NONMEDICAL TREATMENT
• Physical therapy involving
massage, manipulation, and
passive movements may
prevent trophic changes and
vascular congestion in the
stump.
• Transcutaneous electrical
nerve stimulation (TENS),
acupuncture, biofeedback, and
hypnosis, may in some cases
have a beneficial effect on
stump and phantom pain.

Mirror therapy
• It has been suggested that mirror
therapy can reduce phantom but
failed to find any significant effect of
mirror treatment (benzon 2014)
• sham controlled crossover trial
showed that mirror therapy is better
than mental visualization or
covered mirror therapy.
• The principle of this treatment is
based on the idea that the central
representation of the missing hand
of the phantom could be recovered.
This could relieve or eliminate the
phantom pain.

Interventional m anagement
• pulsed radiofrequency of the proximal and distal ends of
a sciatic neuroma with treatment at 42 ° C for 120
seconds under ultrasound guidance with VAS reduction
of 90%, 90%,
• PRF adjacent to the L4 – L5 ganglion spinale (dorsal
root ganglion, DRG)
• Spinal cord stimulation to be effective and may be used
for the treatment of phantom limb pain.
• deep brain stimulation
• stump injections

SURGICAL AND OTHER INVASIVE
TREATMENTS
• Today, stump revision is performed only in cases of
obvious stump pathology
• Surgery may produce short-term pain relief, but the
pain often reappears

Summary of evidence for interventional management of phantom pain.

Clinical practice algorithm for the treatment of phantom pain.

Phantom limb pain

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