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Phantom Limb Pain

Phantom limb pain was first observed in Civil War amputees. In an 1871 study, surgeon Silas Mitchell coined the term to describe the sensation or pain perceived by soldiers in a leg or arm that had been removed. [1] Nowadays the definition of phantom limb pain has broadened and can refer to sensation continuously felt in any part of the body that has been removed (organ, breast etc.), or even in limbs that have been paralyzed. Roughly 85% of amputees will experience phantom limb pain within the first three weeks of surgery. [2]

Patients can have non-painful and painful phantom sensations. Non-painful sensations include the perception the missing organ is still attached and functioning normally with the rest of the body as it did before. These patients can feel the movement of amputated arms or the extension of toes or fingers. In some cases, patients even report being able to feel the presence of an accessory they were accustomed to wearing on the phantom limb, such as a wristwatch or wedding ring. [3]

Painful phantom sensations can be initially mild: a feeling of heat or wetness, pressure, pins-and-needles, itching. In more severe cases patients will experience intolerable stabbing, cramping, burning, squeezing or throbbing pain in the missing body part. Intermittent tremors and painful muscle spasms have also been reported. [4]

Phantom limb pain is still not yet well understood and there is a need for more data from large controlled trials. The good news is that, in the meantime, patients have shown great responses to a combination of behavioral therapies, medications, and minimally invasive procedures. The doctors at the Ainsworth Institute of Pain Management are experts in state-of-the-art treatment combinations for phantom limb pain.

What is Phantom Limb Pain?

As mentioned above, phantom limb pain refers to pain felt in a missing (or paralyzed) body part. The pain might be triggered by certain bodily positions or movements. The pain can also be brought on or exacerbated by changes in the weather, or, in the case of amputation, pressure on the residual part of the limb. Psychological factors such as chronic stress and anxiety have been implicated in triggering pain as well. [5]

Post Amputation Pain Post Amputee Pain Phantom Limb PainThe phantom usually feels the same size and shape of the missing body part immediately after removal. [6] Over time the perception of the size of the phantom as opposed to it’s original size can become distorted. In cases of limb amputation, patients can sometimes feel as if the nonexistent hand or foot at the end of the removed limb has become twisted or sprained. Also, patients with amputated arms or legs have reported feeling the phantom grow smaller until the eventually only feel the digits of the hand or toes of the foot at the amputation site (stump). This phenomenon is called telescoping. [7]

The pain itself can also change quality over time. Studies have shown that patients who experienced a sharp stabbing pain immediately after surgery have had it change in presentation to a squeezing or burning after 6 months. [8] Pain usually decreased overall in the first 6 months as well. Phantom pain persisting longer than 6 months becomes increasingly difficult to treat. [9]

Phantom limb pain strikes males and females in similar numbers. It also seems to show no preference for age, reason for body part removal, or health status. [9] Pain in the body part previous to the amputation, however, seems to increase the likelihood of phantom pain after removal.

What's the Difference Between Phantom Limb Pain & Post-Amputee Pain?

Post-amputation pain is a catch-all term that applies to many things including phantom limb pain. Post-amputation pain can refer to the general pain of the amputation itself, or it can also refer to pain in the distal part of the residual limb after the amputation. This is an area of the body that actually still exists i.e. the stump. This pain can be felt as itching, aching or burning. These patients can also experience involuntary muscle movement in the residual limb at the amputation site. [10]

Phantom Limb Pain Post Amputation Pain Post Amputee PainThe phantom limb pain discussed on this page can fall under the category of post-amputation pain as many patients of amputated limbs will experience it. However, not all patients experiencing phantom limb sensation or pain have had an amputation/limb removed. As mentioned above, the diagnosis of phantom limb pain has evolved to encompass those who have had body parts removed other than limbs. This phenomena has been reported after removal of the bladder, tongue and breasts to name a few.

Phantom pain can also occur in people who have become paralyzed. Patients have reported feeling their paralyzed limbs moving freely and uncontrollably, or feeling as they were permanently stuck in a painful or awkward position despite visual evidence to the contrary. [11] Lastly, phantom limb pain can even occur in people who were born without limbs.

What are the Symptoms?

Phantom limb pain can have multiple non-painful and painful symptoms. Non-painful symptoms can still interfere with a patient’s quality of life.

Non-Painful Symptoms
Post Amputee Pain Post Amputation Pain Phantom Limb Pain New York New York City Phantom Limb Pain Treatment  Feeling of limb/body part still existing after it has been removed
 Perception of movement or normal function in the removed limb/body part
 Distorted representation of size or position in the removed limb/body part
 Itching
 Pins and needles
 Feeling of pressure
 Feeling of heat/cold/wetness

Painful Symptoms
 Sharp knife-like or stabbing pain
 Feeling something is sticking in the limb
 Squeezing or burning in the furthest part of the original limb i.e. hand or foot
 Electrical shock
 Cramping
 Burning
 Feeling of tremor or muscle spasm in removed body part

Learn About Our Clinical Trials on Amputee Pain

What are the Causes?

Phantom pain is thought to be the result of the complex interaction between the brain, spinal cord, and peripheral nervous system. [10] Although the exact causes are not yet fully understood, three prominent theories include:

 Maladaptive plasticity – The primary sensory cortex of the brain did not adapt properly after amputation or removal of the body part.
 Proprioception vs. vision – A conflict emerges between the perceived signals sent from the removed body part and gathering of visual information which influences motor commands.
 Simply remembering limb positions vividly after amputation. [12]

Recent theories have countered this though and postulated phantom limb pain is generated primarily in the peripheral nervous system. Studies have shown good results in reducing or eliminating phantom pain in leg amputees by injecting anesthetic into the lower back. [12]

What are my Treatment Options?

Treatment for Phantom Limb Pain Treatment for Post Amputee PainThere is no one test to diagnose phantom pain. The doctor will want to ascertain a full medical and surgical history, as well as collect all the information he/she can about your symptoms and circumstances or trauma surrounding the onset of your pain. Additionally, it is also useful to know of any issues you had with the body part or limb prior to removal.

Treating phantom limb pain can potentially be difficult. At this point your doctor will typically employ a multidisciplinary approach including medication and behavioral interventions before moving on to non-invasive or minimally invasive procedures.

Interventional Pain Management Treatments

At the Ainsworth Institute of Pain Management, our physicians can offer treatments for Phantom Limb Pain that are not available anywhere else in New York City. Some of these include:

Sympathetic Nerve Blocks – These injections have been utilized as both a diagnostic and therapeutic tool. Your physician will insert a thin needle under radiographic guidance, through the skin, targeting the Sympathetic Nervous System (SNS). The nerves of the SNS are then “blocked” with small amount of local anesthetic. The pain relief from these injections can dramatic. Procedures that focus on facial and upper extremity neuropathy include the Stellate Ganglion Block. Lumbar Sympathetic Blocks are typically performed for lower extremity neuropathic pain.

Neurolysis & Ablation – In cases where an injection provides only temporary relief, neurolysis or neuroablation can be utilized to increase the duration. There are several different methods that can be used:

  • Radiofrequency Ablation (RFA) – Radio waves are applied to a nerve or plexus, preventing the transmission of pain.
  • Cryoablation – Similar to RFA, however cold temperatures are applied to the area instead of radio waves.
  • Chemodenervation – The premise is the same as cryoablation and RFA in that the goal is to prevent a nerve or plexus from transmitting pain; rather than applying mechanical stress to the nerve through radiowaves or cold temperatures, small amounts of either alcohol or phenol are injected to block the nerve’s ability to transmit a signal.

IV Infusion Therapy – An increasingly popular procedure for treating a variety pain syndromes, as well as depression and anxiety. Patients are hooked up to an IV and special medications are administered intravenously. The infusions can take as little as 30 minutes to complete.

Spinal Cord Stimulation (SCS) – This is a commonly performed procedure utilizing technology similar to that of cardiac pacemakers. This method involves placing small electrodes into the epidural space near the spinal cord. These electrodes produce a small electrical current over the spinal cord that your brain will interpret as a gentle massage or a “champagne bubble” feeling. This will inhibit pain transmission and provide relief to areas affected by neuropathy.

DRG Stimulation – DRG Stimulation (aka Dorsal Root Ganglion Stimulation) is THE most cutting-edge treatment for pain available in the United States.  The clinical trial (ACCURATE Study) recorded unprecedented improvements in pain and overall successes that have never before been seen.  The procedure is almost identical to traditional Spinal Cord Stimulation, except a special system called Axium™ (available exclusively through St. Jude Medical™) provides isolated stimulation to only the DRG.  Even if you have failed traditional Spinal Cord Stimulation in the past, statistics suggest DRG Stimulation will still work! 

Peripheral Nerve Stimulation – This is very similar to spinal cord stimulation, except the electrodes are placed adjacent to the affected nerves in the extremity.

Intrathecal Pumps – A small catheter is placed in the subarachnoid space (just below the epidural space) and extremely small amounts of medication are slowly delivered directly over the spinal cord. This enables your physician to provide the same medications you might take orally to manage the pain but at a fraction of the dose – thus decreasing the side effects.

Other Treatment Options

Medication Management & Pharmacologic Therapy: One of the most studied classes of medication for neuropathy are antidepressants – more specifically, tricyclic antidepressants (TCAs), serotonin-norepinephrine reuptake inhibitors (SNRIs) and selective serotonin reuptake inhibitors (SSRIs).[13] Anticonvulsants, like gabapentin and Lyrica, are considered by most to be the “first-line” medications in treating neuropathic pain.

Physical Therapy & Conservative Measures: Also rarely effective when used alone. Includes TENS, relaxation exercises, biofeedback, massage therapy, and acupuncture.

The Ainsworth Institute is Here to Help

The doctors at the Ainsworth Institute of Pain Management specialize in managing and treating Phantom Limb Pain. Dramatic improvements in pain and quality of life are a single phone call away. Schedule an appointment today with one of our board certified pain management experts to discuss what options for treatment may best suit your needs.

References

[1] Mitchell SW. Injuries of Nerves and Their Consequences. London: Smith Elder; 1872.

[2] Parkes CM. Factors determining the persistance of phantom pain in the amputee. J Psychosom Res 1973; 17; 97-108.

[3] Katz J, Melzack R. Pain memories in phantom limbs: review and clinical observation. Pain. 1990; 43:319-336.

[4] Bartels K, Cohen SP, Raja SN: Postamputation pain. In: Benzon HT, ed. Essentials of Pain Medicine. 3Rd ed. Philadelphia, PA: Saunders; 2011: 365-368.

[5] Flor H. Phantom-limb pain: characteristics, causes, and treatment. Lancet Neurology 2002;1:182-189.

[6] Melzack R, Wall P. The Challenge of Pain. London: Penguin; 1984.

[7] Montoya P, Larbig W, Grulke N, et al. The relationship of phantom limb pain to other phantom limb phenomena in upper extremity amputees. Pain 1997;72:87-93.

[8] Jensen TS, et al.: Immediate and long-term phantom limb pain in amputees. incidence, clinical characteristics and relationship to pre-amputation limb pain Pain. 21:267-278 1985

[9] Davis RW: Phantom sensation, phantom pain, and stump pain. Arch Phys Med Rehabil. 74:79-91 1993

[10] HS Smith, I Lalaini, CE Argoff: Phantom Pain. In: Bonica JJ: The Management of Pain. 4Th ed. Philadelphia, Lea & Febiger; 2009: 331-338.

[11] Melzack, R. 1992. Phantom limbs. Scientific American 90–96.

[12] Elizabeth A. Franz1. “Bimanual coupling in amputees with phantom limb.” Nature Neuroscience.

[13] Sindrup SH, Otto M, Finnerup NB, et al.: Antidepressants in the treatment of neuropathic pain. Basic Clin Pharmacol Toxicol. 2005; 96:399-409.

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