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Management of Phantom Limb Pain

  • Kate MacIver
  • Donna Lloyd
Chapter

Abstract

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.

Keywords

Neuropathic Pain Deep Brain Stimulation Motor Imagery Complex Regional Pain Syndrome Spinal Cord Stimulation 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. Backonja M-M (2002) Use of anticonvulsants for treatment of neuropathic pain. Neurology 59:S14–S17Google Scholar
  2. Bittar RG, Otero S, Carter H, Aziz TZ (2005) Deep brain stimulation for phantom limb pain. J Clin Neurosci 12:399–404PubMedCrossRefGoogle Scholar
  3. Bone M, Critchley P, Buggy DJ (2002) Gabapentin in post-amputation phantom limb pain: A randomised, double-blind, placebo-controlled, cross-over study. Reg Anesth Pain Med 27:481–486PubMedGoogle Scholar
  4. Bradbrook D (2004) Acupuncture treatment of phantom limb pain and phantom limb sensation in amputees. Acupunct Med 22:93–97PubMedCrossRefGoogle Scholar
  5. British National Formulary (2008) http://www.bnf.org. Visited 02/02/2009
  6. Brodie EE, Whyte A, Niven CA (2007) Analgesia through the looking-glass? A randomized controlled trial investigating the effect of viewing a “virtual” limb upon phantom limb pain, sensation and movement. Eur J Pain 11:428–436PubMedCrossRefGoogle Scholar
  7. Brown CA, Lido C (2008) Reflexology treatment for patients with lower limb amputations and phantom limb pain – an exploratory pilot study. Complement Ther Clin Pract 14:124–131PubMedCrossRefGoogle Scholar
  8. Chan BL, Witt R, Charrow AP et al (2007) Mirror therapy for phantom limb pain. N Engl J Med 357:2206–2207PubMedCrossRefGoogle Scholar
  9. Derbyshire SW, Whalley MG, Stenger VA, Oakley DA (2004) Cerebral activation during hypnotically induced and imagined pain. Neuroimage 23:392–401PubMedCrossRefGoogle Scholar
  10. Derbyshire SW, Whalley MG, Oakley DA (2008) Fibromyalgia pain and its modulation by hypnotic and non-hypnotic suggestion: An fMRI analysis. Eur J Pain Doi:10.1016/j.e.pain.2008.06.010Google Scholar
  11. Desmond DM, MacLachlan M (2006) Affective distress and amputation-related pain among older men with long-term, traumatic limb amputations. J Pain Symptom Manage 31:362–368PubMedCrossRefGoogle Scholar
  12. Dworkin RH, O’Connor AB, Backonja M, Farrar JT, Finnerup NB, Jensen TS, Kalso EA, Loeser JT, Miaskowski C, Nurmikko TJ, Portenoy RK, Rive ASC, Stacey BR, Treede RD, Turk DC, Wallace MS (2007) Pharmacological management of neuropathic pain: Evidence-based recommendations. Pain 132:237–251PubMedCrossRefGoogle Scholar
  13. Ellis K (2002) A review of amputation, phantom pain and nursing responsibilities. Br J Nurs 11:155–163PubMedGoogle Scholar
  14. Ephraim PL, Wegener ST, MacKenzie EJ, Dillingham TR, Pezzin LE (2005) Phantom pain, residual limb pain, and back pain in amputees: Results of a national survey. Arch Phys Med Rehabil 86:1910–1919PubMedCrossRefGoogle Scholar
  15. Flor H (2002) Phantom limb pain: Characteristics, causes and treatment. Lancet 1:181–189Google Scholar
  16. Flor H, Denke C, Schaefer M, Grusser S (2001) Effect of sensory discrimination training on cortical reorganisation and phantom limb pain. Lancet 357:1763–1764PubMedCrossRefGoogle Scholar
  17. Frank RG, Kashani JH, Kashani SR, Wonderlich SA, Umlauf RL, Ashkanazi GS (1984) Psychological response to amputation as a function of age and time since amputation. Br J Psychiatry 144:493–497PubMedCrossRefGoogle Scholar
  18. Gallagher P, Allen D, MacLachlan M (2001) Phantom limb pain and residual limb pain following lower limb amputation: A descriptive analysis. Disabil Rehabil 23:522–530PubMedCrossRefGoogle Scholar
  19. Grond S, Radbruch L, Meuser T, Sabatowski R, Loick G, Lehmann KA (1999) Assessment and treatment of neuropathic cancer pain following WHO guidelines. Pain 79:15–20PubMedCrossRefGoogle Scholar
  20. Halbert J, Crotty M, Cameron ID (2002) Evidence for the optimal management of acute and chronic phantom pain: A systematic review. Clin J Pain 18:84–92PubMedCrossRefGoogle Scholar
  21. Hamani C, Schwalb JM, Rezai AR, Dostrovsky JO, Davis KD, Lozano AM (2006) Deep brain stimulation for chronic neuropathic pain: Long-term outcome and the incidence of insertional effect. Pain 125:188–196PubMedCrossRefGoogle Scholar
  22. Harden RN, Houle TT, Green S et al (2005) Biofeedback in the treatment of phantom limb pain: a time-series analysis. Appl Psychophysiol Biofeedback 30:83–93PubMedCrossRefGoogle Scholar
  23. Hill A (1999) Phantom limb pain: A review of the literature on attributes and potential mechanisms. J Pain Symptom Manage 17:125–142PubMedCrossRefGoogle Scholar
  24. Huse E, Larbig W, Flor H, Birbaumer N (2001) The effect of opioids on phantom limb pain and cortical reorganisation. Pain 90:47–55PubMedCrossRefGoogle Scholar
  25. Jenkins WM, Merzenich MM, Ochs MT, Allard T, Guic-Robles E (1990) Functional reorganization of primary somatosensory cortex in adult owl monkeys after behaviorally controlled tactile stimulation. J Neurophysiol 63:82–104PubMedGoogle Scholar
  26. Kandel ER, Schwartz JH, Jessel TM (eds) (2000) Principles of neural science. McGraw-Hill, New YorkGoogle Scholar
  27. Kashani JH, Frank RG, Kashani SR, Wonderlich SA, Reid JC (1983) Depression among amputees. J Clin Psychiatry 44:256–258PubMedGoogle Scholar
  28. Katayama Y, Yamamoto T, Kobayashi K, Kasai M, Oshima H, Fukaya C (2001) Motor cortex stimulation for phantom limb pain: comprehensive therapy with spinal cord and thalamic stimulation. Stereotact Funct Surg 77:159–162CrossRefGoogle Scholar
  29. Kennett S, Taylor-Clarke M, Haggard P (2001) Noninformative vision improves the spatial resolution of touch in humans. Curr Biol 11:1188–1191PubMedCrossRefGoogle Scholar
  30. Ketz AK (2008) The experience of phantom limb pain in patients with combat-related traumatic amputations. Arch Phys Med Rehabil 89:1127–1132PubMedCrossRefGoogle Scholar
  31. Kooijman CM, Dijkstra PU, Geertzen JHB, Elzinga A, van der Schans CP (2000) Phantom pain and phantom sensations in upper limb amputees: An epidemiological study. Pain 87:33–41PubMedCrossRefGoogle Scholar
  32. Leskowitz ED (2000) Phantom limb pain treated with therapeutic touch: A case report. Arch Phys Med Rehabil 81:522–524PubMedCrossRefGoogle Scholar
  33. Lotze M, Flor H, Grodd W, Larbig W, Birbaumer N (2001) Phantom movements and pain. An fMRI study in upper limb amputees. Brain 124:2268–2277PubMedCrossRefGoogle Scholar
  34. MacIver K, Lloyd DM, Kelly S, Roberts N, Nurmikko T (2008) Phantom limb pain, cortical reorganisation and the therapeutic effect of mental imagery. Brain 31:2181–2191CrossRefGoogle Scholar
  35. Maier C, Dertwinkle R, Mansourian N, Hosbach I, Schwenkreis P, Senne I, Skipka G, Zenz M, Tegenthoff M (2003) Efficacy of NMDA-receptor antagonist memantime in patients with chronic phantom limb pain – results of a randomized double-blinded, placebo-controlled trial. Pain 103:277–283PubMedCrossRefGoogle Scholar
  36. Mailis-Gagnon A, Furlan AD, Sandoval JA, Taylor R (2004) Spinal cord stimulation for chronic pain (Cochrane Review). In: The Cochrane Library, Issue 3. John Wiley and Sons Ltd., Chichester, UKGoogle Scholar
  37. Marshall M, Helmes E, Deathe AB (1992) A comparison of psychosocial functioning and personality in amputee and chronic pain populations. Clin J Pain 8:351–357PubMedCrossRefGoogle Scholar
  38. McCabe CS, Haigh RC, Ring EF, Halligan PW, Wall PD, Blake DR (2003) A controlled pilot study of the utility of mirror visual feedback in the treatment of complex regional pain syndrome (type 1). Rheumatology (Oxford) 42:97–101CrossRefGoogle Scholar
  39. McCarberg B, Stanos S (2008) Key assessment tools and treatment strategies for pain management. Pain Pract 8:423–432PubMedCrossRefGoogle Scholar
  40. Melzack R, Katz J (2006) Pain assessment in adult patients. In: McMahon SB, Koltzenburg M (eds) Textbook of pain, 5th edn. Elsevier Churchill Livingstone, LondonGoogle Scholar
  41. Merzenich MM, Nelson RJ, Stryker MP, Cynader MS, Schoppmann A, Zook JM (1984) Somatosensory cortical map changes following digit amputation in adult monkeys. J Comp Neurol 224:591–605PubMedCrossRefGoogle Scholar
  42. Meyerson BA, Linderoth B (2006) Mode of action of spinal cord stimulation in neuropathic pain. J Pain Symptom Manage 31:S6–S12PubMedCrossRefGoogle Scholar
  43. Mishra S, Bhatnager S, Gupta D, Diwedi A (2008) Incidence and management of phantom limb pain according to World Health Organisation analgesic ladder in amputees of malignant origin. Am J Hosp Palliat Med 24:455–462CrossRefGoogle Scholar
  44. Montgomery GH, DuHamel KN, Redd WH (2000) A meta-analysis of hypnotically induced analgesia: how effective is hypnosis? Int J Clin Exp Hypn 48:138–153PubMedCrossRefGoogle Scholar
  45. Moseley GL (2006) Graded motor imagery for pathologic pain. Neurology 67:1–6CrossRefGoogle Scholar
  46. Moseley GL, Gallace A, Spence C (2008) Is mirror therapy all it is cracked up to be? Current evidence and future directions. Pain 138:7–10PubMedCrossRefGoogle Scholar
  47. Murray CD, Pettifer S, Howard T et al (2007) The treatment of phantom limb pain using immersive virtual reality: Three case studies. Disabil Rehabil 29:1465–1469PubMedCrossRefGoogle Scholar
  48. Nikolajsen L, Jensen TS (2001) Phantom limb pain. Br J Anaesth 87:107–116PubMedCrossRefGoogle Scholar
  49. Nikolajsen L, Jensen TS (2006) Phantom limb. In: McMahon SB, Koltzenburg M (eds) Textbook of pain, 5th edn. Elsevier Churchill Livingstone, LondonGoogle Scholar
  50. Nnoaham KE, Kumbang J (2007) Transcutaneous electrical nerve stimulation (TENS) for chronic pain. Cochrane Database Syst Rev (3) Art No. D003222. DOI:  10.1002/14651858.CD003222.pub2
  51. Oakley DA, Whitman LG, Halligan PW (2002) Hypnotic imagery as a treatment for phantom limb pain: two case reports and a review. Clin Rehabil 16:368–377PubMedCrossRefGoogle Scholar
  52. Pons TP, Garraghty PE, Ommaya AK, Kaas JH, Taub E, Mishkin M (1991) Massive cortical reorganization after sensory deafferentation in adult macaques. Science 252:1857–1860PubMedCrossRefGoogle Scholar
  53. Ramachandran VS, Hirstein W (1998) The perception of phantom limbs. The D.O. Hebb lecture. Brain 121(9):1603–1630PubMedCrossRefGoogle Scholar
  54. Ramachandran VS, Rogers-Ramachandran D (1996) Synaesthesia in phantom limbs induced with mirrors. Proc R Soc Lond B Biol Sci 263:377–386CrossRefGoogle Scholar
  55. Ramachandran VS, Rogers-Ramachandran D, Stewart M (1992) Perceptual correlates of massive cortical reorganization. Science 258:1159–1160PubMedCrossRefGoogle Scholar
  56. Robinson LR, Czerniecki JM, Ehde DM, Edwards WT, Judish DA, Goldberg ML, Campbell KM, Smith DG (2004) Trial of amitriptyline for relief of pain in amputees: Results of a randomised controlled study. Arch Phys Med Rehab 85:1–6Google Scholar
  57. Saarto T, Wiffen PJ (2007) Antidepressants for neuropathic pain. Cochrane Database of Systematic Reviews, Issue 4. Art. No. CD005454. DOI:  10.1002/14651858.CD005454pub2
  58. Sathian K (2005) Visual cortical activity during tactile perception in the sighted and the visually deprived. Dev Psychobiol 46:279–286PubMedCrossRefGoogle Scholar
  59. Schley MT, Wilms P, Toepfner S, Schaller HP, Schmelz M, Konrad CJ, Birbaumer N (2008) Painful and non-painful phantom and stump sensations in acute traumatic amputees. J Trauma Injury Infect Crit Care 65:858–864CrossRefGoogle Scholar
  60. Schoppen T, Boonstra A, Groothoff JW, Van SE, Goeken LN, Eisma WH (2001) Factors related to successful job reintegration of people with a lower limb amputation. Arch Phys Med Rehabil 82:1425–1431PubMedCrossRefGoogle Scholar
  61. Sherman RA, Sherman CJ (1983) Prevalence and characteristics of chronic phantom limb pain among American veterans: Results of a trial survey. Am J Phys Med 62:227–238PubMedGoogle Scholar
  62. Sherman RA, Sherman CJ, Bruno GM (1981) Psychological factors influencing chronic phantom limb pain: An analysis of the literature. Pain 28:285–295CrossRefGoogle Scholar
  63. Sherman RA, Sherman CJ, Parker L (1984) Prevalence and characteristics of chronic phantom limb pain among American veterans: Results of a survey. Pain 18:83–95PubMedCrossRefGoogle Scholar
  64. Sumitani M, Miyauchi S, McCabe CS et al (2008) Mirror visual feedback alleviates deafferentation pain, depending on qualitative aspects of the pain: A preliminary report. Rheumatology (Oxford) 47:1038–1043CrossRefGoogle Scholar
  65. Whyte AS, Carroll LJ (2002) A preliminary examination of the relationship between employment, pain and disability in an amputee population. Disabil Rehabil 24:462–470PubMedCrossRefGoogle Scholar
  66. Whyte AS, Niven CA (2001) Psychological distress in amputees with phantom limb pain. J Pain Symptom Manage 22:938–946PubMedCrossRefGoogle Scholar
  67. Wiffen PJ, Collins S, McQuay HJ, Carroll D, Jadad A, Moore RA (2005) Anticonvulsant drugs for acute and chronic pain. Cochrane Database Syst Rev (3) Art No. CD001133. DOI:  10.1002/14651858.CD001133.pub2
  68. Williamson GM (1998) The central role of restricted normal activities in adjustment to illness and disability: A model of depressed affect. Rehabil Psychol 43:327–347CrossRefGoogle Scholar
  69. Williamson GM, Schulz R, Bridges MW, Behan AM (1994) Social and psychological-factors in adjustment to limb amputation. J Soc Behav Pers 9:249–268Google Scholar
  70. World Health Organisation (1996) WHO guidelines: Cancer pain relief, 2nd edn. World Health Organisation Geneva, SwitzerlandGoogle Scholar
  71. Zigmond AS, Snaith RP (1983) The hospital anxiety and depression scale. Acta Psychiatr Scand 67:361–370PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  1. 1.Pain Research Institute in LiverpoolLiverpoolUK

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