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Phantom Limb Pain

Moon Suk Bang, MD, PhD, and Se Hee Jung, MD, MS

104

Synonyms
Painful phantom sensation Phantom pain Phantom limb syndrome

permanent disability in more than 40% of amputees. Phantom limb pain persisting more than 6 months is exceedingly difcult to treat. Phantom limb pain has been reported to be signicantly related to residual limb pain,16 physical activity,17 severity and duration of preamputation pain,14,18 noxious intraoperative inputs (such as pain brought about by cutting of tissues), acute postoperative pain,19 bilateral amputation, and lower limb amputation.9

ICD-9 Codes
353.6 729.2 905.9 Phantom limb (syndrome) Neuralgia, neuritis, and radiculitis, unspecied Late effect of traumatic amputation (injury classiable to 885-887 and 895-897) 997.60 Stump (surgical) (post-traumatic), abnormal, painful, or with complication (late)

SYMPTOMS
The pain is most prominent immediately after the operation. Phantom limb pain is not static in nature but changes in quality over the years. Phantom limb pain is usually intermittent, but some patients report constant pain with superimposed exacerbations. The duration of an attack ranges from seconds or minutes to hours or days.20,21 Phantom limb pain is usually localized in distal parts of the absent limb, usually in the foot or hand.14 The pain can be described as tingling, throbbing, aching, pins and needles, squeezing, stabbing, shooting, pinching, or cramping. In some cases, patients report that the amputated limb is positioned in a painful posture, or they sense spasms in the limb. The intensity as well as the quality of the pain varies greatly between patients from mild to severe. Phantom limb pain is triggered or worsened by physical (e.g., rainy weather, low temperature, prosthetic use, urination, defecation, reduced blood ow, and muscle tension), psychosocial (e.g., attention), and emotional (e.g., anxiety and stress) stimuli.18,22 Phantom limb pain is not relieved with position.

DEFINITION
Phantom pain refers to painful sensation perceived in a body part that is no longer present subsequent to surgical or traumatic removal. It is most common after the amputation of a limb, (i.e., phantom limb pain), but it has also been reported after the surgical removal of other body parts, such as breast, rectum, penis, testicles, eye, tooth, tongue, or lesion of peripheral or central nervous system. Phantom limb pain is distinguished from stump pain, which is pain in the residual limb or stump, and phantom limb sensation, which is nonpainful sensation of the absent part. Peripheral, spinal segmental, central, and psychological mechanisms are considered factors for the development of phantom limb pain.1-4 Although phantom limb pain is generally initiated within the rst few days after the amputation, it can take several months or years to emerge. The reported prevalence of phantom limb pain differs considerably, ranging from about 40% to 80%.5-11 However, phantom limb pain is less frequent in congenital amputation and loss of a limb early in childhood. The occurrence of phantom limb pain is independent of gender, age (in adults), level or side of amputation, dominance, and etiology of amputation.12,13 In several reports, the incidence and intensity of pain remained constant but both the frequency and duration of pain attacks decreased signicantly over time.14,15 A small percentage of patients experienced a reduction in intensity of pain over time. Phantom limb pain leads to

PHYSICAL EXAMINATION
Physical examination is generally unrevealing. However, patients can sometimes identify specic points on the residual limb that trigger phantom limb pain. Therefore, the residual limb should be assessed for any sources of pain or trigger areas. The residual limb is examined for neuromas, cysts, bursae, bone spurs, or sites of excessive pressure. Other precipitating factors should be searched for, such as an ill-tting prosthesis or mechanical stimulation.

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Local problems, such as a herniated disc or spinal disease emitting sensations into the phantom limb or neuroma, can cause neuropathic pain. A comprehensive physical evaluation with particular attention to the neurologic examination, including strength, range of motion, muscle stretch reexes, and muscle tone, should be done to rule out any concomitant central or peripheral neuropathic pain.

TABLE 104-1 Treatments Commonly Used for Phantom Limb Pain

Pharmacologic Conventional analgesics Opioids Anticonvulsants Antidepressants NMDA receptor antagonists Neuroleptics Ketamine Barbiturates Blockers Muscle relaxants Rehabilitation Physiotherapy Prosthesis training Transcutaneous electrical nerve stimulation Ultrasound Manipulation Electromyographic biofeedback Thermal biofeedback Sensory discrimination training Psychological Cognitive-behavioral pain management Sensory discrimination training Relaxation technique Stress management Distraction Hypnosis

FUNCTIONAL LIMITATIONS
Functional complications of phantom limb pain include sleep disorders, interference with prosthesis training and use, reduction in walking ability, inability to return to work, and limitation of participation in social activities. Patients with phantom limb pain experience a greater degree of despair, more symptoms of depression, less satisfaction with social relations, and poorer quality of life than amputees without it.

DIAGNOSTIC STUDIES
The diagnosis of phantom limb pain is generally made clinically on the basis of history and physical examination. Plain radiography and ultrasonography are performed for the diagnosis of underlying conditions, such as neuroma, abscess, bursitis, bone spur or fragment, or nerve entrapment. Magnetic resonance imaging, electrodiagnostic tests, or laboratory tests may be indicated if other diagnoses are suspected. Nerve block may be attempted as a diagnostic tool to identify candidates for specic procedures. Various pain scales and psychometric questionnaires are used to assess severity, treatment effect, and disability.

Differential Diagnosis
Nonpainful phantom sensation Stump pain (residual limb pain) Chronic postsurgical pain Radicular pain Neuralgia Anginal pain

Anesthetic Local anesthesia Nerve blocks Sympathetic block Epidural blockade Surgical Stump revision Neurectomy Sympathectomy Dorsal root entry zone ablation Dorsal rhizotomy Cordotomy Thalamotomy Spinal cord stimulation Deep brain stimulation Cortical resection of brain

TREATMENT
The treatments commonly used for phantom limb pain are listed in Table 104-1.

Initial
Patients should be taught (if possible, before amputation) that phantom limb pain is not a complication but a normal side effect of some amputations. Education about
Other Acupuncture

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phantom limb pain reduces anxiety and distress of patients. The expected course of symptoms after amputation and during the prosthetic tting process should be carefully reviewed with the patient. Preemptive analgesia, which is attempted to prevent phantom limb pain by epidural or general routes during the preoperative and initial postoperative period, has not been shown to be effective.1,3,14,23 Tricyclic antidepressants and anticonvulsants have long been considered to be the drugs of choice. Controlled studies, however, showed conicting data on the effect of tricyclic antidepressants in phantom limb pain conditions.24,25 Anticonvulsants such as carbamazepine, gabapentin, topiramate,26 and lamotrigine are effective in phantom limb pain. Randomized controlled studies demonstrated that opioids have analgesic efcacy for phantom limb pain and suggested an effect on cortical reorganization.27-29 Tramadol is an analgesic with both monoaminergic and opioid activity that is effective in long-standing phantom limb pain.25 In controlled studies, intravenous calcitonin30,31 and intravenous ketamine demonstrated reduction of phantom limb pain.32 N-Methyl-D-aspartate (NMDA) receptor antagonists, such as dextromethorphan33,34 and memantine,35-37 showed efcacy in controlling phantom limb pain in several studies. Other pharmacologic interventions, such as blockers, topical capsaicin, nonsteroidal anti-inammatory drugs, nonopioid analgesics, and botulinum toxin,38,39 have been suggested, but well-controlled trials have not been published.

provide relief, although very few studies on phantom limb pain were conducted.

Procedures
Regional anesthesia with local anesthetics, including plexus or nerve block, sympathetic block, and epidural block, can be applied to intractable phantom limb pain with pharmacologic measures.

Surgery
Surgery is generally not indicated for phantom limb pain. Stump revision, such as neuroma resection, is indicated in selected patients with stump pain due to neuroma. The purpose of neuroma resection is relief of stump pain, not of phantom limb pain. Spinal cord stimulation, dorsal root entry zone ablation, neurectomy, sympathectomy, dorsal rhizotomy, cordotomy, thalamotomy, and cortical resection of brain have been used in a few cases of intractable pain.

POTENTIAL DISEASE COMPLICATIONS

Phantom limb pain reportedly causes signicant disability. It keeps amputees from their usual activities and causes considerable interference with their daily, social, recreational, and work activities.8 The health-related quality of life of amputees with phantom limb pain is poorer than that of amputees without phantom limb pain.52

POTENTIAL TREATMENT COMPLICATIONS

Side effects of pharmacologic treatment are well documented. Complications of regional anesthesia are systemic effects of local anesthetics, physiologic effects of the procedure (e.g., hypotension, inadvertent injection or block), and damage to adjacent structures. Spinal cord stimulation has few serious complications. Complications of surgical ablation techniques include Horner syndrome, dysesthesia, sudomotor paralysis, weakness, urinary complications, and respiratory problems. Selection of appropriate patients is important to successful surgical ablation.

Rehabilitation
Transcutaneous electrical nerve stimulation has long been considered an effective treatment modality40-42; it can begin early in the postoperative period without signicant side effects. Compression stockings or stump shrinkers during the early postoperative period and heat and cold, manipulation, vibration, massage, and acupuncture can all be tried in an attempt to provide relief of phantom limb pain. Several prior studies have reported positive results of biofeedback, including electromyographic biofeedback, thermal biofeedback, and muscle relaxation procedures.1,26,42-45 Frequent use of a myoelectric prosthesis that provides sensory, visual, and motor feedback reportedly reduces phantom limb pain.46 Sensory discrimination training47 or tactile stimulation48 has also been reported to reduce phantom limb pain with a reversal of cortical reorganization. Virtual reality and mirror treatment with use of a mirror box or virtual reality box to offer visual input on phantom sensations have been suggested as potential treatment.49-51 Psychological treatments such as relaxation technique, stress management, distraction, and hypnosis can also

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