Pain Management of the Amputee: Difference between revisions

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'''Original Editor '''- [[User:Peter Le Feuvre|Peter Le Feuvre]] as part of the [[WCPT Network for Amputee Rehabilitation Project]]  
'''Original Editor '''- [[User:Peter Le Feuvre|Peter Le Feuvre]] as part of the [[World Physiotherapy Network for Amputee Rehabilitation Project]]  


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;  
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;  
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== Introduction  ==
== Introduction  ==


Pain is an inevitable consequence of amputation, and for many, pain will not just result from the trauma of the surgery, but will also include a neuropathic presentation known as phantom limb pain (PLP). When amputation has resulted from a traumatic incident, such as in a disaster setting, this can be complicated by co-existing injury to the same limb or other parts of the body. For the physiotherapists involved in the early and post acute stages of rehabilitation, the challenge is determining the nociceptive and neuropathic causes which require attention in order to manage the patient and so enable effective rehabilitation to occur.<br>
Pain is an inevitable consequence of amputation. There are several types of sensations following an amputation that should be discussed when referring to pain following amputation. Some of them are extremely painful and terribly unpleasant; some are simply weird or disconcerting. In one form or another they are experienced by most people following an amputation.  


#'''Post-Amputation Pain''': Post-amputation pain at the wound site should be distinguished from pain in the residual limb and the phantom limb. After amputation, all three may occur together<ref name="Kooijmana">CM, Kooijmana Dijkstra PU, Geertzena JHB, et al. Phantom pain and phantom sensations in upper limb amputees: an epidemiological study. Pain 2000;87:33–41</ref>
== Why Does Pain Occur? ==
#'''Residual Limb Pain (RLP)''': Patients can often feel pain or sensations in the areas adjacent to the amputated body part. This is known as residual limb (RLP) or stump pain. &nbsp;It is often confused with and its intensity is often positively correlated with PLP<ref name="MacIver">MacIver K, Lloyd DM, Kelly S, et al. Phantom limb pain, cortical reorganization and the therapeutic effect of mental imagery. Brain 2008;131:2181–91.</ref>.&nbsp;
 
#'''Phantom Limb Sensation''': This is a normal experience for the majority of amputees, but it is '''not''' a noxious sensation, which might be described by the patient as unpleasant. Often it can be described as a light tingling sensation, or in such cases re-assurance is the key<ref name="Le Feuvre">Le Feuvre P, Aldington D. Know Pain Know Gain: proposing a treatment approach for phantom limb pain. J R Army Med Corps 2014; 160(1):16-21</ref>.  
'''Peripheral neuropathic mechanisms:'''  
#'''Phantom Limb Pain (PLP)''': Classified as neuropathic pain, whereas RLP and post-amputation pain are classified as nociceptive pain. PLP is often more intense in the distal portion of the phantom limb and can be exacerbated or elicited by physical factors (pressure on the residual limb, time of day, weather) and psychological factors, such as emotional stress. Commonly used descriptors include sharp, cramping, burning, electric, jumping, crushing and cramping.
 
*Immediate nerve injury discharge.
*Local nociceptive substances.
*Deafferentation.
*Ectopic firing.
*Neuromas.
*Ephatic transmission b/w sensory and sympathetic fibres.
 
'''Spinal cord:'''  
 
*Expansion of receptive fields.
*Low-threshold inputs when high-threshold inputs lost.
*Disinhibition.
 
'''Brain:'''  
 
*Cortical engram generates pain in absence of stimuli.
*Cortical reorganisation.
 
'''Non-neurological factors:'''  
 
*Skin blood flow.
*Stump temperature.
*Muscle tension.
 
'''Psychological factors:'''  


== Assessment  ==
*Stressors/ depression/anxiety
*Not personality types


Assessment sould seek to establish the type of pain present.
== Intrinsic pain ==


In addition to completing a pain chart, measurement of pain intensity is objectively helpful. The [[Brief Pain Inventory - Short Form|brief pain inventory]] (BPI) is one method of charting the intensity of symptoms, however it takes time to administer. The [[Visual Analogue Scale|0-3 VAS]] is an easy to administer scale which highlights when intervention is required. It is also easy to fit it with the WHO pain ladder (Figure 1). In short, scores of 0 and 1 (nil to mild pain) require no intervention, 2 and 3 (moderate to severe) requires immediate action<ref name="Le Feuvre" /><ref name="Looker">Looker J, Aldington D, ‘Pain Scores - As Easy as Counting to Three.’ J R Army Med Corps 2009;155:1 42-43</ref>.  
* Post amputation pain can be isolated to the residual limb or can occur as phantom pain. For many, pain will not just result from the trauma of the surgery, but will also include a neuropathic presentation known as '''[[Phantom Limb Pain]]''' (PLP).
* When amputation has resulted from a traumatic incident, such as in a disaster setting, this can be complicated by co-existing injury to the same limb or other parts of the body. For the physiotherapists involved in the early and post acute stages of rehabilitation, the challenge is determining the nociceptive and neuropathic causes which require attention in order to manage the patient and so enable effective rehabilitation to occur.
#'''Post-Amputation Pain''': Post-amputation pain at the wound site should be distinguished from pain in the residual limb and the phantom limb. After amputation, all three may occur together<ref name="Kooijmana">CM, Kooijmana Dijkstra PU, Geertzena JHB, et al. Phantom pain and phantom sensations in upper limb amputees: an epidemiological study. Pain 2000;87:33–41</ref>
#'''Residual Limb Pain (RLP)''': Patients can often feel pain or sensations in the areas adjacent to the amputated body part. This is known as residual limb (RLP) or stump pain. It is often confused with and its intensity is often positively correlated with PLP<ref name="MacIver">MacIver K, Lloyd DM, Kelly S, et al. Phantom limb pain, cortical reorganization and the therapeutic effect of mental imagery. Brain 2008;131:2181–91.</ref>.
#'''Phantom Limb Sensation''': This is a normal experience for the majority of amputees, but it is '''not''' a noxious sensation, which might be described by the patient as unpleasant. Often it can be described as a light tingling sensation, or in such cases re-assurance is the key<ref name="Le Feuvre">Le Feuvre P, Aldington D. Know Pain Know Gain: proposing a treatment approach for phantom limb pain. J R Army Med Corps 2014; 160(1):16-21 http://jramc.bmj.com/content/160/1/16.full.pdf+html</ref>.
#'''Phantom Limb Pain (PLP)''': Classified as '''''neuropathic pain,''''' whereas RLP and post-amputation pain are classified as '''''nociceptive pain'''''. PLP is often more intense in the distal portion of the phantom limb and can be exacerbated or elicited by physical factors (pressure on the residual limb, time of day, weather) and psychological factors, such as emotional stress. Commonly used descriptors include sharp, cramping, burning, electric, jumping, crushing and cramping.


<br> [[Image:Pain-scale-and-who-pain-ladder.png|thumb|center|400px|Pain scale and WHO pain ladder]]  
In addition to these 4 pain types that can be experienced following amputation, clinicians should also be aware of pain that may be caused by [[Pathology leading to amputation|co-existing pathology]]:


<br>
#'''Vascular pain''' - such as exercise induced claudication or pain caused by vascular disease
#'''Musculoskeletal pain''' - pain from other injuries suffered during a traumatic amputation, musculoskeletal pain caused by abnormal gait patterns pain caused by normal ageing processes, or excessive wear and tear on the joints and soft tissue of the residual limb.
#'''Neuromas''' - localized pain, sharp/shooting/paraesthesia reproduced by local palpation and Tinel's sign, relieved by LA injection.


== Phantom Limb Pain ==
== Pathophysiological mechanisms of Acute and Chronic Phantom Limb Pain ==


When PLP is present it is important to establish the principle driver(s). These may be centrally driven adaptation, peripheral sensitisation, mental state or social concerns, and musculoskeletal factors. Treatment should target these drivers.  
=== '''Acute PLP'''<ref name=":0">Ahuja V,Thapa D,Ghai B.Strategies for prevention of lower limb post-amputation pain:a clinical narrative review.J Anaesthesiol Clin Pharmacol.2018;34(4):439-449.</ref> ===
'''Amputation site:'''


{| width="100%" border="1" cellpadding="1" cellspacing="1"
* Tissue and Neuronal injury.
|+ '''Potential drivers of PLP and treatment options (please note this is not a conclusive list, but the table should stimulate ideas)'''
* Hyperexcitability.
!
* Spontaneous discharge.
!Treatment options
!Drivers
|- valign="top"
| width="30%" | '''Central Adaptation'''
| width="30%" |
Mental imagery (also included within GMI)<br>Graded Motor Imagery (GMI) (inc mirror therapy)<br>Anti-neuropathic medication / opioids<br>Physical exercise / limb mobility<br>Prosthetic use<br>Acupuncture / TENS Machine'''Irritant management<br>Self massage<br>Education'''


| width="40%" |
'''Brain:'''
PLP appears to coexist with a reorganisation of the cortical map. For example, in upper limb amputees, the greater the shift of the mouth and face representation into the deafferented hand and arm amputation zone, the greater the PLP. Stimulation of facial muscles, including mastication or eye movements, will then elicit PLP. In lower limb amputations this phenomenon can manifest in the migration of the representation areas for the bladder, bowel and genitals into the amputation zone. Again, stimulation of these organs will elicit PLP.


|- valign="top"
* Increased neuronal activity.
| '''Peripheral Sensitisation'''  
* Hyperexcitability.
|
* Loss of descending inhibitory pain pathway.
Irritant management with attention to excluding differential diagnosis, poor wound dressings, stump oedema.<br>Pharmacology: Follow the pain ladder<br>Stump sock / juzo / relax sock <br>Education <br>Prosthetic (if applicable): Ensure good alignment and fitting.<br>Scar management<br>Self massage / desensitisation<br>Acupuncture / TENS Machine<br>Sleep hygiene
* Expansion of neuronal receptive field.
 
'''Spinal cord:'''


|
* Increased NMDA Receptor activity mediated by substance P tachvkinin and neurakinins.
Nociceptive input from the residual limb appears to correlate with the level of PLP. The dorsal root ganglion can amplify discharge from the residual limb or cross-excite neighbouring neurons. Increased circulating epinephrine resulting from sympathetic discharge will also trigger or exacerbate neuronal activity. Such sympathetic discharge can result from emotional distress, and may also be due to temperature or inflammation. Continued nociceptive stimulation will cause the peripheral nervous system to become more efficient at transmitting these signals and in turn contribute to neuropathic excitation.  
* Non-pain neurons sprout into dorsal horn.


|- valign="top"
=== Chronic PLP<ref name=":0" /> ===
| '''Psychological and Social Factors'''  
'''Amputation site:'''
|
Education<br>Sleep hygiene<br>Acupuncture<br>Physical exercise<br>Relaxation techniques<br>CBT<br>Referral for formal mental health / social support


|
* Stump and neuroma formation.
Is pain influenced by memory of the incident, memory of pain proceeding the amputation, mood state, social concerns or sleep pattern? Circulating epinephrine resulting from emotional distress can contribute to the sensitisation of the peripheral nervous system.  
* Deafferentation pain.


|- valign="top"
'''Brain:'''
| '''Musculoskeletal (MSK) Factors'''  
|
Joint ROM / muscular <br>Maintenance of control and function of the limb by working segmental stabilisers as well as global mobilisers.<br>Trigger points / myofascial release<br>Neural mobilisation


|
* Cortical reorganisation.
Joint dysfunction and MSK referral can contribute to the presence of PLP. In addition, prosthetic use significantly aids resolution of PLP, especially with the upper limb. Preparatory work to ensure the maintenance of joint range, normal symmetrical movement and proximal stabilisation will aid prosthetic fitting and successful use, This will potentially enhance the beneficial effect of limb wearing upon PLP.  
* Cortical motor-sensory dissociation.
* Abnormal neuromatrix and neurosignature.


|}
'''Spinal cord:'''


<br>
* Spinal cord sensitisation.
* Wind up phenomena.


The image below shows an assessment approach which may help clinicians to determine the correct course of action required with a patient with PLP. The assessment must commence by accurately identifying that PLP is indeed the issue. A knowledge of the different characteristics of each pain presentation will help the clinician to establish this from an assessment of their history:
== Extrinsic causes of pain ==


<br>
'''Prosthetic pain''' is also a concern and may be caused by:


[[Image:Assessment-and-treatment-for-phantom-limb-pain.png|thumb|center|800px|Summary of assessment process and treatments for PLP]]
#Ill-fitting socket : lack of distal contact, insufficient bony relief, too tight, too loose, pistoning causing friction / blisters
#Incorrect alignment and pressure distribution
#Incorrectly donned prosthesis, including the number / thickness of socks
#Excessive sweating / skin breakdown
#Verrucous hyperplasia


<br>
== Assessment  ==


== An aid to clinical reasoning in phantom limb pain<ref name="Le Feuvre" />  ==
Assessment should seek to establish the type of pain present.


Simply discriminating between RLP and PLP is more complex than it appears. Both often coexist and RLP may provoke PLP. Eliminating the causes of RLP is therefore the priority as this will resolve or lessen PLP which is respondent to peripheral aggravators. It also shows the degree to which central factors may have an ongoing influence.  
In addition to completing a '''pain chart''', measurement of pain intensity is objectively helpful.  


Immediate post-amputation management demands early effective analgesia and adjunctive measures include managing oedema using elastic stump socks, semi-rigid dressings and rigid plaster casts. Post-acute management requires attention to both intrinsic and extrinsic causes of RLP.  
* '''The [[Brief Pain Inventory - Short Form|brief pain inventory]] (BPI):''' is one method of charting the intensity of symptoms, however it takes time to administer.  
* '''The [[Visual Analogue Scale|0-3 VAS]]:''' is an easy to administer scale which highlights when intervention is required.
* '''WHO pain ladder''' (Figure 1).  


Extrinsic RLP will result from complications of wound healing and so infection must be excluded. Tissue load and sheering forces placed on the limb due to a poor prosthetic fit will also evoke pain. A prosthetic review will improve fit and enable sensitised structures to be offloaded. Scar formation can also cause pain, particularly where there is nerve entrapment, or adhesions reducing the mobility of soft tissues. In either case, scar management using soft tissue massage and moisturiser is recommended; silicone treatment can also be added if required. Besides improving tissue mobility, massage can be used to desensitise the residual limb. Intrinsic causes of RLP can include ischaemia, joint dysfunction proximal to the residual limb, stress fracture, osteomyelitis and wound dehiscence. Occasionally where the bone has been improperly trimmed or formation of bone in extraskeletal soft tissue has occurred (HO), then pain may result in high-pressure areas. Investigations will be required and revision surgery may be considered; alternatively, prosthetic adjustment can be used to unload pressure areas.
Scores of: 


Neuroma is the most common cause of intrinsic RLP. Ectopic discharge may evoke a neuropathic response causing PLP. Neuroma formation after amputation is normal, but when it becomes sensitised to mechanical or chemical stimuli, often exacerbated by entrapment, then problems ensue<ref name="Flor">Flor H. Phantom-limb pain: characteristics, causes and treatment. Lancet 2002;1:182–9.</ref><ref name="Flor2">Flor H. Cortical reorganisation and chronic pain; implications for rehabilitation. J Rehabil Med 2003;41:66–72.</ref>. Pain is intermittent and variable, but diagnosis is confirmed by a specific site of tenderness on palpation, which can be confirmed with an injection of local anaesthetic into the site. Surgical referral can be considered, but massage, vibration, acupuncture and transcutaneous electrical nerve stimulation (TENS) may also effectively desensitise the area<ref name="Black">Black LM, Persons RK, Jamieson MLS. What is the best way to manage phantom limb pain? J fam practice 2009;58:155–8.</ref><ref name="Bradbrook">Bradbrook D. Acupuncture treatment of phantom limb pain and phantom limb sensation in amputees. Acupunct Med 2004;22:93–7.</ref>. It is also work excluding muscle tension / spasm as a cause by assessing local and trigger points within the soft tissue.
* '''0 and 1''' (nil to mild pain)- require no intervention
* '''2 and 3''' (moderate to severe)- requires immediate action<ref name="Le Feuvre" /><ref name="Looker">Looker J, Aldington D, ‘Pain Scores - As Easy as Counting to Three.’ J R Army Med Corps 2009;155:1 42-43</ref>.  


Combining physical and occupational therapy with a cognitive understanding of the condition will amplify the effects of treatment<ref name="Butler">Butler D, Moseley GL. Explain pain. Noigroup Publications, 2010</ref><ref name="Moseley" />. We should aim to equip and empower the patient, informing them about their condition and how they can take control while seeking to alter destructive or erroneous beliefs and actions. Common self-treatment strategies can include wearing an elastic stump sock to minimise volume changes in the residual limb, stump massage, mental imagery of the phantom limb and taking physical exercise.
See the image below for the proposed taxonomy for post-amputation pain.<ref>Collin Clarke, MD, David R. Lindsay, MD,Srinivas Pyati, MD, and Thomas Buchheit, MD, 2013, Residual A Proposed Algorithm to Classify Postamputation Pain, Clin J Pain 2013;29:551–562</ref>  


Visualisation of limb movement and prosthetic use can reduce PLP, this is especially the case with upper limb amputees<ref name="Flor" /><ref name="Kooijmana" />. Joint dysfunction proximal to the residual limb and prosthetic fit will however undermine this effect. Good prosthetic use is vital. Normalising the gait pattern is, in part, due to prosthetic fit and alignment. It is also dependent on good proprioception, correct motor patterning and symmetrical movement control enabling dissociation of movement between trunk and limb. In turn, the residual limb(s), trunk and spinal segments must have sufficient range and control of movement to achieve a symmetrical gait pattern. Where limb wearing is not possible, the therapist should engage their creativity to seek ways of simulating visual and even motor stimuli in order to mimic the use of the limb.
<gallery widths="350px" heights="350px">
File: Pain-scale-and-who-pain-ladder.png|Pain scale and WHO pain ladder
File: Proposed-taxonomy-postamputation-pain.png|Clarke et al 2013 have proposed a taxonomy of postamputation pain
</gallery>


== Mirror&nbsp;therapy ==
== Treatments  ==


[[Mirror_Therapy|Mirror therapy]] is a therapeutic intervention which has been shown to affect motor and sensory processes through the relative dominance of the visual input it provides. The effect is created by viewing a reflection of the intact limb through a mirror placed where the amputated limb would have existed. Most of the evidence for this intervention comes from case studies and anecdotal data with only a couple of well controlled studies<ref name="Moseley2" />. Moseley argued that while mirrored movements may expose the cortex to sensory and motor input, the therapeutic effect is magnified if cortical networks are gradually activated using limb recognition, motor imagery and finally, mirrored movement. This sequence of cortical exposure has become known as graded motor imagery<ref name="Moseley">Moseley GL. Graded motor imagery for pathologic pain: a randomized controlled trial. Neurology 2006;67:2129–34.</ref><ref name="Moseley2">Moseley GL, Gallace A, Spence C. Is mirror therapy all it is cracked up to be? Current evidence and future directions. Pain 2008;138:1387–10.</ref>. Clinicians wishing to add this programme to their treatment repertoire can find resources at [http://www.noigroup.com/en/Home NOIGroup]
A large variety of medical/surgical and non-medical methods exist for the treatment of post-amputation pain:  


== A note on medication ==
*Adequate post-op analgesia.
UK military pain management system encourages the use of antineurppathic medication such as pregabalin and amitriptyline as early as possible. First-line treatment is a trial of up to 300 mg twice daily of pregabalin and up to 150 mg of amitriptyline at night. If pregabalin is insufficient, or depression is a problem, duloxetine may be used. Opioids are of variable help. It may be that tapentadol will prove to be beneficial, but it is too early to say clearly. While pharmacological agents can be of use, the way they are used is even more important. Pharmacological agents are not going to remove all pain. What really matters is that the agents enable the patient to ‘do more’. In this way they can be likened to the old confectionary advertisement that suggested it allows you to ‘work, rest and play’; the point being if the pharmacological agents do not have this action there is no point taking them. Often a good starting point is to enable good sleep. '''You can always have a good night after a bad day, but never a good day after a bad night'''.
*Patient education.
*Limit oedema.
*Prevent contractures.
*Address musculoskeletal weakness and imbalances.
*Desensitisation - massage/bandaging.
*Get patient moving, distraction helps.
*Early prosthetic training.Below Peter Le Feurve, a physiotherapist with an interest in pain talks about pain management in amputees:
{| width="100%" border="0" align="center" cellpadding="1" cellspacing="1"
|-
|
| {{#ev:youtube|k1tehDquTRA}}
|}


<br>  
== Virtual Reality (VR) ==
[[Virtual Reality|Virtual reality]](VR) is a new technology being investigated as a possible treatment for PLP. VR produces a simulated world in which a person can be immersed in a different reality. VR can assist persons with PLP in visualising and controlling their missing limb. VR is an exciting new therapy option for PLP. It is a non-invasive and safe treatment that can help patients with this ailment enhance their quality of life. More research is needed to validate the effectiveness of VR for PLP, however the findings of previous trials are encouraging.<ref>Paxton, G. (2023). ''The potential of virtual reality to improve the quality of life for people with phantom limb pain (NON-THESIS)''. Concordia University St. Paul.</ref>  


== Resources  ==
== Resources  ==


<br>
*[[Phantom limb pain|Phantom Limb Pain]]
*[[Mirror Therapy]]
*[http://www.austpar.com/portals/acute_care/pain_management.php Pain management]. Australian Physiotherapists in Amputee Rehabilitation..
*[http://www.amputee-coalition.org/fact_sheets/painmgmt.html Pain management for patients]. National Limb loss information center.
*{{pdf|Cochrane2010.amputeeTENS.pdf|Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults (Review). Mulvey MR, Bagnall AM, Johnson MI, Marchant PR, Cochrane Library, 2010, Issue 5.}}
*{{pdf|TENS.Cochrane2014.pdf|Transcutaneous electrical nerve stimulation (TENS) for chronic pain (Review). Nnoaham KE, Kumbang J. Cochrane collaboration, 2014, Issue 7}}
*{{pdf|Phantomlimb.pdf|Phantom Limb Pain.  L. Nikolajsen and T.S. Jensen. Br J Anaesth, 2001, 87(1):107-16}}
*{{pdf|TENS.AMputee.2012.pdf|Transcutaneous Electrical Nerve Stimulation for Phantom Pain and Stump Pain in Adult Amputees Matthew R. Mulvey, Helen E. Radford, Helen J. Fawkner, ynn Hirst, Vera Neumann, Mark I. Johnson. Pain Practice, 2013, 13(4):289–296}}
*Privitera R, Birch R, Sinisi M, Mihaylov IR, Leech R, Anand P. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5516883/ Capsaicin 8% patch treatment for amputation stump and phantom limb pain:] a clinical and functional MRI study. Journal of pain research. 2017;10:1623.


== References  ==
== References  ==
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<references />  
<references />  


[[Category:Amputees]] [[Category:WCPT_Amputee_Project]]
[[Category:Interventions]]
[[Category:Amputees]]  
[[Category:Pain]]
[[Category:World Physiotherapy Amputee Project]]

Latest revision as of 09:57, 6 October 2023

Original Editor - Peter Le Feuvre as part of the World Physiotherapy Network for Amputee Rehabilitation Project

Top Contributors - Admin, Kim Jackson, Aicha Benyaich, Tarina van der Stockt, Melissa Coetsee, Tony Lowe, Kirenga Bamurange Liliane, Evan Thomas, Aya Alhindi and Bruno Serra  

Introduction[edit | edit source]

Pain is an inevitable consequence of amputation. There are several types of sensations following an amputation that should be discussed when referring to pain following amputation. Some of them are extremely painful and terribly unpleasant; some are simply weird or disconcerting. In one form or another they are experienced by most people following an amputation.

Why Does Pain Occur?[edit | edit source]

Peripheral neuropathic mechanisms:

  • Immediate nerve injury discharge.
  • Local nociceptive substances.
  • Deafferentation.
  • Ectopic firing.
  • Neuromas.
  • Ephatic transmission b/w sensory and sympathetic fibres.

Spinal cord:

  • Expansion of receptive fields.
  • Low-threshold inputs when high-threshold inputs lost.
  • Disinhibition.

Brain:

  • Cortical engram generates pain in absence of stimuli.
  • Cortical reorganisation.

Non-neurological factors:

  • Skin blood flow.
  • Stump temperature.
  • Muscle tension.

Psychological factors:

  • Stressors/ depression/anxiety
  • Not personality types

Intrinsic pain[edit | edit source]

  • Post amputation pain can be isolated to the residual limb or can occur as phantom pain. For many, pain will not just result from the trauma of the surgery, but will also include a neuropathic presentation known as Phantom Limb Pain (PLP).
  • When amputation has resulted from a traumatic incident, such as in a disaster setting, this can be complicated by co-existing injury to the same limb or other parts of the body. For the physiotherapists involved in the early and post acute stages of rehabilitation, the challenge is determining the nociceptive and neuropathic causes which require attention in order to manage the patient and so enable effective rehabilitation to occur.
  1. Post-Amputation Pain: Post-amputation pain at the wound site should be distinguished from pain in the residual limb and the phantom limb. After amputation, all three may occur together[1]
  2. Residual Limb Pain (RLP): Patients can often feel pain or sensations in the areas adjacent to the amputated body part. This is known as residual limb (RLP) or stump pain. It is often confused with and its intensity is often positively correlated with PLP[2].
  3. Phantom Limb Sensation: This is a normal experience for the majority of amputees, but it is not a noxious sensation, which might be described by the patient as unpleasant. Often it can be described as a light tingling sensation, or in such cases re-assurance is the key[3].
  4. Phantom Limb Pain (PLP): Classified as neuropathic pain, whereas RLP and post-amputation pain are classified as nociceptive pain. PLP is often more intense in the distal portion of the phantom limb and can be exacerbated or elicited by physical factors (pressure on the residual limb, time of day, weather) and psychological factors, such as emotional stress. Commonly used descriptors include sharp, cramping, burning, electric, jumping, crushing and cramping.

In addition to these 4 pain types that can be experienced following amputation, clinicians should also be aware of pain that may be caused by co-existing pathology:

  1. Vascular pain - such as exercise induced claudication or pain caused by vascular disease
  2. Musculoskeletal pain - pain from other injuries suffered during a traumatic amputation, musculoskeletal pain caused by abnormal gait patterns pain caused by normal ageing processes, or excessive wear and tear on the joints and soft tissue of the residual limb.
  3. Neuromas - localized pain, sharp/shooting/paraesthesia reproduced by local palpation and Tinel's sign, relieved by LA injection.

Pathophysiological mechanisms of Acute and Chronic Phantom Limb Pain[edit | edit source]

Acute PLP[4][edit | edit source]

Amputation site:

  • Tissue and Neuronal injury.
  • Hyperexcitability.
  • Spontaneous discharge.

Brain:

  • Increased neuronal activity.
  • Hyperexcitability.
  • Loss of descending inhibitory pain pathway.
  • Expansion of neuronal receptive field.

Spinal cord:

  • Increased NMDA Receptor activity mediated by substance P tachvkinin and neurakinins.
  • Non-pain neurons sprout into dorsal horn.

Chronic PLP[4][edit | edit source]

Amputation site:

  • Stump and neuroma formation.
  • Deafferentation pain.

Brain:

  • Cortical reorganisation.
  • Cortical motor-sensory dissociation.
  • Abnormal neuromatrix and neurosignature.

Spinal cord:

  • Spinal cord sensitisation.
  • Wind up phenomena.

Extrinsic causes of pain[edit | edit source]

Prosthetic pain is also a concern and may be caused by:

  1. Ill-fitting socket : lack of distal contact, insufficient bony relief, too tight, too loose, pistoning causing friction / blisters
  2. Incorrect alignment and pressure distribution
  3. Incorrectly donned prosthesis, including the number / thickness of socks
  4. Excessive sweating / skin breakdown
  5. Verrucous hyperplasia

Assessment[edit | edit source]

Assessment should seek to establish the type of pain present.

In addition to completing a pain chart, measurement of pain intensity is objectively helpful.

  • The brief pain inventory (BPI): is one method of charting the intensity of symptoms, however it takes time to administer.
  • The 0-3 VAS: is an easy to administer scale which highlights when intervention is required.
  • WHO pain ladder (Figure 1).

Scores of:

  • 0 and 1 (nil to mild pain)- require no intervention
  • 2 and 3 (moderate to severe)- requires immediate action[3][5].

See the image below for the proposed taxonomy for post-amputation pain.[6]

  • Pain scale and WHO pain ladder

    Pain scale and WHO pain ladder

  • Clarke et al 2013 have proposed a taxonomy of postamputation pain

    Clarke et al 2013 have proposed a taxonomy of postamputation pain

Treatments[edit | edit source]

A large variety of medical/surgical and non-medical methods exist for the treatment of post-amputation pain:

  • Adequate post-op analgesia.
  • Patient education.
  • Limit oedema.
  • Prevent contractures.
  • Address musculoskeletal weakness and imbalances.
  • Desensitisation - massage/bandaging.
  • Get patient moving, distraction helps.
  • Early prosthetic training.Below Peter Le Feurve, a physiotherapist with an interest in pain talks about pain management in amputees:

Virtual Reality (VR)[edit | edit source]

Virtual reality(VR) is a new technology being investigated as a possible treatment for PLP. VR produces a simulated world in which a person can be immersed in a different reality. VR can assist persons with PLP in visualising and controlling their missing limb. VR is an exciting new therapy option for PLP. It is a non-invasive and safe treatment that can help patients with this ailment enhance their quality of life. More research is needed to validate the effectiveness of VR for PLP, however the findings of previous trials are encouraging.[7]

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ CM, Kooijmana Dijkstra PU, Geertzena JHB, et al. Phantom pain and phantom sensations in upper limb amputees: an epidemiological study. Pain 2000;87:33–41
  2. ↑ MacIver K, Lloyd DM, Kelly S, et al. Phantom limb pain, cortical reorganization and the therapeutic effect of mental imagery. Brain 2008;131:2181–91.
  3. ↑ 3.0 3.1 Le Feuvre P, Aldington D. Know Pain Know Gain: proposing a treatment approach for phantom limb pain. J R Army Med Corps 2014; 160(1):16-21 http://jramc.bmj.com/content/160/1/16.full.pdf+html
  4. ↑ 4.0 4.1 Ahuja V,Thapa D,Ghai B.Strategies for prevention of lower limb post-amputation pain:a clinical narrative review.J Anaesthesiol Clin Pharmacol.2018;34(4):439-449.
  5. ↑ Looker J, Aldington D, ‘Pain Scores - As Easy as Counting to Three.’ J R Army Med Corps 2009;155:1 42-43
  6. ↑ Collin Clarke, MD, David R. Lindsay, MD,Srinivas Pyati, MD, and Thomas Buchheit, MD, 2013, Residual A Proposed Algorithm to Classify Postamputation Pain, Clin J Pain 2013;29:551–562
  7. ↑ Paxton, G. (2023). The potential of virtual reality to improve the quality of life for people with phantom limb pain (NON-THESIS). Concordia University St. Paul.
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