Management of Phantom Limb Pain

This chapter provides a comprehensive overview of the management of chronic phantom limb pain (PLP) as it relates to the patient in the prosthesis clinic. The chapter begins with phantom pain assessment. Pharmacological therapies commonly used in the treatment of PLP will be discussed, with a review of the literature relating to success or otherwise of these medications. The side-effects of the drugs are highlighted, and the necessary advice to be given to patients is provided. What follows is a review of non-pharmacological therapies, beginning with Neuromodulation (TENS, spinal cord and deep brain stimulation). Psychological aspects of treatment are identified – how to recognise psychological distress; how to know when to refer on for psychological treatment and useful psychological interventions. The chapter concludes with suggestions for the holistic management of patients suffering from PLP. The role of mental imagery is highlighted.

[1]  Richard Schulz,et al.  Social and psychological factors in adjustment to limb amputation. , 1994 .

[2]  Toby Howard,et al.  The treatment of phantom limb pain using immersive virtual reality: Three case studies , 2007, Disability and rehabilitation.

[3]  M. Merzenich,et al.  Functional reorganization of primary somatosensory cortex in adult owl monkeys after behaviorally controlled tactile stimulation. , 1990, Journal of neurophysiology.

[4]  B. Mccarberg,et al.  Key Patient Assessment Tools and Treatment Strategies for Pain Management , 2008, Pain practice : the official journal of World Institute of Pain.

[5]  V. Ramachandran,et al.  The perception of phantom limbs. The D. O. Hebb lecture. , 1998, Brain : a journal of neurology.

[6]  P. Wall,et al.  A controlled pilot study of the utility of mirror visual feedback in the treatment of complex regional pain syndrome (type 1). , 2003, Rheumatology.

[7]  Charles Spence,et al.  Is mirror therapy all it is cracked up to be? Current evidence and future directions , 2008, PAIN.

[8]  G. Moseley,et al.  Graded motor imagery for pathologic pain , 2006, Neurology.

[9]  A Hill,et al.  Phantom limb pain: a review of the literature on attributes and potential mechanisms. , 1999, Journal of pain and symptom management.

[10]  R. Snaith,et al.  The Hospital Anxiety and Depression Scale , 1983 .

[11]  S. Wonderlich,et al.  Psychological Response to Amputation as a Function of Age and Time Since Amputation , 1984, British Journal of Psychiatry.

[12]  K Sathian,et al.  Visual cortical activity during tactile perception in the sighted and the visually deprived. , 2005, Developmental psychobiology.

[13]  N. Birbaumer,et al.  Painful and nonpainful phantom and stump sensations in acute traumatic amputees. , 2008, The Journal of trauma.

[14]  L. Göeken,et al.  Factors related to successful job reintegration of people with a lower limb amputation. , 2001, Archives of physical medicine and rehabilitation.

[15]  R. Sherman,et al.  Psychological factors influencing chronic phantom limb pain: An analysis of the literature , 1987, Pain.

[16]  P. Dijkstra,et al.  Phantom pain and phantom sensations in upper limb amputees: an epidemiological study , 2000, Pain.

[17]  M. Maclachlan,et al.  Phantom limb pain and residual limb pain following lower limb amputation: a descriptive analysis. , 2001, Disability and rehabilitation.

[18]  Bengt Linderoth,et al.  Mode of action of spinal cord stimulation in neuropathic pain. , 2006, Journal of pain and symptom management.

[19]  Todd Kuiken,et al.  Biofeedback in the Treatment of Phantom Limb Pain: A Time-Series Analysis , 2005, Applied psychophysiology and biofeedback.

[20]  V. Ramachandran,et al.  Synaesthesia in phantom limbs induced with mirrors , 1996, Proceedings of the Royal Society of London. Series B: Biological Sciences.

[21]  A Comparison of Psychosocial Functioning and Personality in Amputee and Chronic Pain Populations , 1992, The Clinical journal of pain.

[22]  S. Bhatnagar,et al.  Incidence and Management of Phantom Limb Pain According to World Health Organization Analgesic Ladder in Amputees of Malignant Origin , 2008, The American journal of hospice & palliative care.

[23]  M. Cynader,et al.  Somatosensory cortical map changes following digit amputation in adult monkeys , 1984, The Journal of comparative neurology.

[24]  Herta Flor,et al.  Phantom-limb pain: characteristics, causes, and treatment , 2002, The Lancet Neurology.

[25]  V. Andrew Stenger,et al.  Cerebral activation during hypnotically induced and imagined pain , 2004, NeuroImage.

[26]  Ann K Ketz,et al.  The experience of phantom limb pain in patients with combat-related traumatic amputations. , 2008, Archives of physical medicine and rehabilitation.

[27]  M. Backonja.  Use of anticonvulsants for treatment of neuropathic pain , 2002, Neurology.

[28]  Catherine Lido,et al.  Reflexology treatment for patients with lower limb amputations and phantom limb pain--an exploratory pilot study. , 2008, Complementary therapies in clinical practice.

[29]  T. Jensen,et al.  Phantom limb pain. , 2001, British journal of anaesthesia.

[30]  J. Farrar,et al.  Pharmacologic management of neuropathic pain: Evidence-based recommendations , 2007, PAIN.

[31]  J. Rothwell.  Principles of Neural Science , 1982 .

[32]  T. Nurmikko,et al.  Phantom limb pain, cortical reorganization and the therapeutic effect of mental imagery , 2008, Brain : a journal of neurology.

[33]  S. Wonderlich,et al.  Depression among amputees. , 1983, The Journal of clinical psychiatry.

[34]  S. Derbyshire,et al.  Fibromyalgia pain and its modulation by hypnotic and non‐hypnotic suggestion: An fMRI analysis , 2009, European journal of pain.

[35]  A S Whyte,et al.  Psychological distress in amputees with phantom limb pain. , 2001, Journal of pain and symptom management.

[36]  M. Mishkin,et al.  Massive cortical reorganization after sensory deafferentation in adult macaques. , 1991, Science.

[37]  Y. Katayama,et al.  Motor Cortex Stimulation for Phantom Limb Pain: Comprehensive Therapy with Spinal Cord and Thalamic Stimulation , 2002, Stereotactic and Functional Neurosurgery.

[38]  D. Bradbrook.  Acupuncture Treatment of Phantom Limb Pain and Phantom Limb Sensation in Amputees , 2004, Acupuncture in medicine : journal of the British Medical Acupuncture Society.

[39]  A. Whyte,et al.  A preliminary examination of the relationship between employment, pain and disability in an amputee population , 2002, Disability and rehabilitation.

[40]  Malcolm MacLachlan,et al.  Affective distress and amputation-related pain among older men with long-term, traumatic limb amputations. , 2006, Journal of pain and symptom management.

[41]  S. Miyauchi,et al.  Mirror visual feedback alleviates deafferentation pain, depending on qualitative aspects of the pain: a preliminary report. , 2008, Rheumatology.

[42]  Sherman Ra,et al.  Prevalence and characteristics of chronic phantom limb pain among American veterans. Results of a trial survey. , 1983, American journal of physical medicine.

[43]  K. Robinson,et al.  The Self-Directed Physiatric Education Program (SDPEP) 2004 , 2004 .

[44]  P. Schwenkreis,et al.  Efficacy of the NMDA-receptor antagonist memantine in patients with chronic phantom limb pain – results of a randomized double-blinded, placebo-controlled trial , 2003, Pain.

[45]  G. Williamson.  The central role of restricted normal activities in adjustment to illness and disability: A model of depressed affect. , 1998 .

[46]  R. Melzack,et al.  Pain assessment in adult patients , 2006 .

[47]  M. Bone,et al.  Gabapentin in Postamputation Phantom Limb Pain: A Randomized, Double-Blind, Placebo-Controlled, Cross-Over Study , 2002, Regional Anesthesia & Pain Medicine.

[48]  A review of amputation, phantom pain and nursing responsibilities. , 2002, British journal of nursing.

[49]  H. Flor,et al.  Phantom movements and pain. An fMRI study in upper limb amputees. , 2001, Brain : a journal of neurology.

[50]  Clement Hamani,et al.  Deep brain stimulation for chronic neuropathic pain: Long-term outcome and the incidence of insertional effect , 2006, Pain.

[51]  J. Czerniecki,et al.  Trial of amitriptyline for relief of pain in amputees: results of a randomized controlled study. , 2004, Archives of physical medicine and rehabilitation.

[52]  H. Flor,et al.  Effect of sensory discrimination training on cortical reorganisation and phantom limb pain , 2001, The Lancet.

[53]  Niels Birbaumer,et al.  The effect of opioids on phantom limb pain and cortical reorganization , 2001, Pain.

[54]  I. Cameron,et al.  Evidence for the Optimal Management of Acute and Chronic Phantom Pain: A Systematic Review , 2002, The Clinical journal of pain.

[55]  Kenneth M Heilman,et al.  Mirror therapy for phantom limb pain. , 2007, The New England journal of medicine.

[56]  E. Brodie,et al.  Analgesia through the looking‐glass? A randomized controlled trial investigating the effect of viewing a ‘virtual’ limb upon phantom limb pain, sensation and movement , 2007, European journal of pain.

[57]  Stephen T Wegener,et al.  Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. , 2005, Archives of physical medicine and rehabilitation.

[58]  E. Leskowitz.  Phantom limb pain treated with therapeutic touch: a case report. , 2000, Archives of physical medicine and rehabilitation.

[59]  A. Jadad,et al.  Anticonvulsant drugs for acute and chronic pain. , 2005, The Cochrane database of systematic reviews.

[60]  T. Aziz,et al.  Deep brain stimulation for phantom limb pain , 2005, Journal of Clinical Neuroscience.

[61]  P. Haggard,et al.  Noninformative vision improves the spatial resolution of touch in humans , 2001, Current Biology.

[62]  G. Montgomery,et al.  A meta-analysis of hypnotically induced analgesia: How effective is hypnosis? , 2000, The International journal of clinical and experimental hypnosis.

[63]  L. Radbruch,et al.  Assessment and treatment of neuropathic cancer pain following WHO guidelines , 1999, Pain.

[64]  P. Halligan,et al.  Hypnotic imagery as a treatment for phantom limb pain: two case reports and a review , 2002, Clinical rehabilitation.

[65]  V. Ramachandran,et al.  Perceptual correlates of massive cortical reorganization. , 1992, Neuroreport.

[66]  Richard A. Sherman,et al.  Chronic phantom and stump pain among american veterans: results of a survey , 1984, Pain.