Covers types of phantom phenomena, pathophysiologic mechanisms of phantom limb phenomena, residual limb pain; evaluation and evidence-based management

1. Post-amputation Pain
Dr. Darendrajit Longjam MD, FIPM
Department of Physical Medicine and Rehabilitation
AIIMS Bhubaneswar

2. DON’T
DECIDE A
BOOK BY ITS
COVER
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3. NOMENCLATURE
• Phantom Limb Sensations (PLS)
• Phantom Limb Pain (PLP)
• Residual Limb Pain (RLP)
• Phantom Complex (aka Phantom Limb Syndrome)
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5. PHANTOM SENSATIONS
• Nonpainful perceptions that occur in the region of the missing body
part
• Common after limb amputation surgery, with an incidence of 90%
during the first 6 months
• One third of patients experience phantom sensations within 24 hours
after their surgery
• Excision of a body part: not essential for phantom sensations
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7. PHANTOM SENSATIONS
• Kinetic sensations: perception of movements
• Kinesthetic: distorted representations in size or position
• Exteroceptive perceptions: paresthesias, tingling, touch, pressure,
itching, heat, cold, and wetness
• Commonly experienced in the distal portion:
hands and feet
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9. TELESCOPING
• Perception of progressive shortening of the
phantom body part resulting in the sensation
that the distal part of the limb is becoming more
proximal
• Common, occurring in up to two thirds of limb
amputees
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10. PHANTOM PAIN
• aka Phantom Limb Pain (PLP)
• Perception of dysesthesias, or unpleasant sensations, in the
distribution of the missing or deafferentated body part
• Occur in up to 79% of postamputation patients 6 months after
surgery
• with about 60% of patients still reporting significant PLP 2 years after surgery
A. 10-20% B. 30-50% C. 50-80% D. 90%
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11. PHANTOM PAIN
• Vary in character, duration, frequency, and intensity
• Sharp, dull, burning, squeezing, cramping, shooting, or as a shocklike
electrical sensation
• Occasionally complain of intermittent tremors or painful muscle spasms in
the stump associated with paroxysms of PLP
• Exteroceptive-like pain (knifelike or sticking) localized in the entire limb or
at least involving proximal parts of the lost limb to a mainly proprioceptive
type of pain (squeezing or burning) localized in the distal parts of the
amputated limb
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12. PHANTOM PAIN
• PLP persisting longer than 6 months is extremely difficult to treat
• Incidence: independent of age, sex, previous health status, and cause
of amputation
• One factor that appears to increase its incidence after amputation is
the presence of pain in the limb before the amputation
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13. RESIDUAL LIMB PAIN
• “stump pain”
• Pain localized to the residual body part following amputation
• Incidence of 56%–74%
• Often secondary to local pathologic processes
• Infection
• Lesions of the skin, soft tissue, or bone
• Heterotopic ossification (>50% in traumatic amputations)
• Local ischemia
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14. RESIDUAL LIMB PAIN
These processes can generally be classified into the following
categories:
• Postsurgical nociceptive
• Neurogenic
• Prosthogenic
• Arthrogenic
• Ischemic
• Referred (usually from the spine or joints)
• Sympathetically maintained
• Abnormal residual limb tissue (e.g., adhesive scar tissue)
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15. RLP vs PLP
• RLP: classically provoked or exacerbated by traction or pressure
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16. PHANTOM PHENOMENA AFTER
MASTECTOMY
• Phantom sensations are felt by 14%-48% of patients
• Most of these phantom sensations are felt intermittently, occurring once
every 2 or 4 weeks
• Sensation often appears within 3–6 months
of surgery and begins to dissipate after 1 yr
• Phantom pain incidence: 0%-23%
• Pain usually localizes to the entire breast
or around the nipple
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17. PATHOPHYSIOLOGY AND MECHANISMS OF
POSTAMPUTATION PAIN
• Result of interactions between altered peripheral, spinal and
supraspinal mechanisms
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18. Supraspinal mechanisms
• Reorganization of the somatosensory cortex following amputation
• Sensations in the phantom limb could be elicited by brushing the face
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19. Spinal mechanisms
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20. Spinal mechanisms
• Functional changes in the
dorsal horn of the spinal cord
following a deafferentation
injury
• Increased autonomous activity
of dorsal horn neurons, in
effect becoming “sensory
epileptic discharges”
• Spinal reorganization
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21. Spinal mechanisms
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22. Peripheral mechanisms
• Neuroma formation
• Afferent fibers in a neuroma may develop ectopic activity, mechanical
sensitivity, and chemosensitivity to catecholamines
• Upregulation of voltage-sensitive sodium channels
• Downregulation of potassium channels
• Expression of novel receptors in the neuroma
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23. Potential mechanisms of postamputation pain
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24. EVALUATION
• First step: Attempt to identify a specific etiology that can be the
target for developing a treatment strategy
• Inspection and palpation
 Skin breakdown
 Pressure sores
 Infection
 Bony abnormalities (e.g., spurs, heterotopic ossification)
 Ischemia (e.g., choke syndrome, changes in color or temperature)
 Masses
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25. EVALUATION
• Imaging: X-rays, CT, MRI, Ultrasound
• Laboratory testing: CBC, ESR, CRP
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26. TREATMENT
• Individualized and interdisciplinary approach
Pharmacotherapy
Physiotherapy and modalities
Complementary and alternative therapies
Psychological therapies
Interventional therapies
Surgery
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27. PHARMACOTHERAPY
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28. PHARMACOTHERAPY
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29. PHARMACOTHERAPY
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30. PHARMACOTHERAPY
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31. PREVENTIVE ANALGESIA
• Preoperative epidural anesthesia with bupivacaine and morphine,
administered 72 hours preoperatively, was reported to decrease the
incidence of phantom pain for up to a year following lower extremity
amputation
Bach S, Noreng MF, Tjellden NU: Phantom limb pain in amputees during the first 12 months
following limb amputation, after preoperative lumbar epidural blockade. Pain 33(3):297–301,
1988.
• Similar results reported when epidural infusions of bupivacaine,
diamorphine, and clonidine were started 24-48 hours before a lower
limb amputation and continued for 72 hours postoperatively reduced
the incidence of phantom pain for up to 1 year
Jahangiri M, Jayatunga AP, Bradley JW, Dark CH: Prevention of phantom pain after major lower
limb amputation by epidural infusion of diamorphine, clonidine and bupivacaine. Ann R Coll
Surg Engl 76(5):324–326, 1994.
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32. PREVENTIVE ANALGESIA
• Collectively, the studies on perioperative analgesia suggest that
timing may be critical for any preventive effect on PLP
• Anesthesia instituted over 24 hours in advance of amputation are
more likely to yield positive results
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33. PREVENTIVE ANALGESIA
• Perineural anesthesia
 Limited evidence of its preemptive effects
 Perineural anesthesia reduced postoperative opioid consumption
but did not improve postoperative pain scores, in-hospital
mortality, PLP, or RLP
Bosanquet DC, Glasbey JC, Stimpson A, Williams IM, Twine CP: Systematic review and meta-
analysis of the efficacy of perineural local anaesthetic catheters after major lower limb
amputation. Eur J Vasc Endovasc Surg 50(2):241–249, 2015.
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34. PREVENTIVE ANALGESIA
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35. PHYSIATRY, PHYSICAL AND OCCUPATIONAL
THERAPY, PROSTHETIST
• creates a foundation for functional restoration and prevention of
complications, including pain
• Ideally, the educated patient will develop self-treatment strategies
 Compression garments for the residual limb to control edema
 ROM exercises to prevent joint contractures
 Adaptation strategies to perform ADLs
• Myoelectric prosthesis reduces cortical reorganization for UL
amputation
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36. COMPLEMENTARY AND ALTERNATIVE
MEDICINE THERAPIES AND MODALITIES
• TENS
• Acupuncture
• Mirror therapy
• Mental imagery and phantom exercises
• Neurostimulation methods: rTMS, tDCS
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37. PSYCHOLOGICAL THERAPIES
• Cognitive and behavioral therapies
• Hypnosis
• Biofeedback
• Support groups
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38. INTERVENTIONAL THERAPIES
• To be considered when conservative measures fail
• Local injection therapy is commonly used for diagnostic and potentially
therapeutic benefit for PAP
• Regional nerve blocks or injections of a LA may provide immediate pain
relief, but the effects are often temporary
• Patients with PAP received onabotulinumtoxin A (250–300 units) or
lidocaine with depomedrol into areas of tenderness in the residual limb.
Both treatments significantly improved RLP but not PLP at 6-month
Wu H, Sultana R, Taylor KB, Szabo A: A prospective randomized doubleblinded pilot study to
examine the effect of botulinum toxin type A injection versus Lidocaine/Depomedrol injection on
residual and phantom limb pain: initial report. Clin J Pain 28(2):108–112, 2012
• Perineuromal inj of etanercept effective in patients with RLP of less than 1
year in duration28-Jul-20 38

39. INTERVENTIONAL THERAPIES
• Sympathetic block
• Cohen SP performed sympathetic blocks on 17 amputees
• 50% of patients experienced significant pain relief postprocedure,
suggesting that SMP plays a role in PLP and to a lesser extent RLP, but
long-term benefits uncommon
Cohen SP, Gambel JM, Raja SN, Galvagno S: The contribution of sympathetic mechanisms to
postamputation phantom and residual limb pain: a pilot study. J Pain 12(8):859–867, 2011
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40. INTERVENTIONAL THERAPIES
• Pulsed radiofrequency (PRF)
• A case series described four patients with upper or lower extremity RLP and
PLP that improved significantly with PRF (following successful diagnostic local
anesthetic blocks), including average pain, medication requirements, and
mobility/prosthesis use
West M, Wu H: Pulsed radiofrequency ablation for residual and phantom limb pain: a case
series. Pain Pract 10(5):485–491, 2010.
• Cryoneurolysis
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41. INTERVENTIONAL THERAPIES
• Spinal cord stimulators
 Broggi et al. reported that 23 of 26 patients were satisfied with
SCS for the treatment of PAP
 In 2001, a series of 19 patients reported 80% improvement in PLP
postimplant, although only 6 patients obtained satisfactory long-
term results
• Peripheral nerve stimulation
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42. SURGERY
• Typically, surgical therapies are indicated only when a specific
rectifiable pathology is identified
• Indications: Protruding bone, bony exostosis, wound infection, poorly
healed wounds
• Neuroma under constant pressure or near a joint resulting in
repeated traction may be treated by excision of the neuroma and
repositioning the nerve endings in bone or muscle
• Surgical treatment of heterotopic ossification
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43. SURGERY
• Targeted muscle reinnervation (TMR)
 Proximal healthy ends of amputated nerves are connected to
other muscles that can be repurposed to allow for control of a
myoelectric prosthesis
 14 of 15 patients with RLP had resolution of symptoms after
surgery
Souza JM, Cheesborough JE, Ko JH, Cho MS, Kuiken TA, Dumanian GA: Targeted muscle
reinnervation: a novel approach to postamputation neuroma pain. Clin Orthop Relat Res
472(10):2984–2990, 2014.
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44. SURGERY
• Deep brain stimulation (DBS) of the sensory thalamus or
periaqueductal and periventricular gray matter has demonstrated
some benefit in PAP
• A meta-analysis noted that patients with peripheral neuropathy or
PLP experienced 60%–75% pain relief with DBS
Bittar RG, Kar-Purkayastha I, Owen SL, et al.: Deep brain stimulation for pain relief: a meta-
analysis. J Clin Neurosci 12(5):515–519, 2005.
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47. EBM/Grading strength of recommendations and
quality of evidence in clinical guidelines
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48. Summary of evidence for interventional
management of phantom pain
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49. KEY POINTS
• The most common sources of PAP are phantom pain and RLP
• Phantom phenomena are not fully understood but are thought to
result from a combination of reorganization of the somatosensory
cortex following amputation (supraspinal mechanisms), functional
changes in the dorsal horn of the spinal cord after deafferentation
(spinal mechanisms), and spontaneous neuronal activity at the ends
of cut nerves (peripheral mechanisms)
• Results of randomized controlled trials show mixed results for the
pharmacologic management of PAP
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50. KEY POINTS
• Studies on perioperative analgesia suggest that timing may be critical
for any preventive effect on phantom pain, with those starting
treatment more than 24 hours prior to amputation showing the most
benefit
• Complementary therapies such as mirror therapy, mental imagery,
and noninvasive MCS may be beneficial for PAP
• Psychological therapies are known to be helpful in the management
of chronic pain but are not well studied for PAP
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51. KEY POINTS
• Interventional treatments such as neuroma injections,
radiofrequency, cryoneurolysis, PNS, and spinal cord stimulation are
reportedly beneficial for PAP, but evidence is limited to case series
• Surgical therapies for PAP may include intracranial neurostimulation,
peripheral neuromodulation therapies, or resection of neuromas and
heterotopic ossification
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52. Thank You
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