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Phantom limb pain

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Phantom limb pain

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Phantom pain is pain caused by elimination or interruption of sensory nerve impulses by destroying or injuring the sensory nerve fibers after amputation or deafferentation

Phantom pain is pain caused by elimination or interruption of sensory nerve impulses by destroying or injuring the sensory nerve fibers after amputation or deafferentation

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Phantom limb pain

  1. 1. Phantom Limb Pain DR MOHSEN ABAD Pain specialist
  2. 2. overveiw •History •Definition •INTENSITY AND FREQUENCY •MECHANISMS OF PHANTOM PAIN •PREVENTION •TREATMENT PHANTHOM LIMB PAIN
  3. 3. History • first medical descriptions at the 16th century • Silas Weir Mitchell (1829-1914) is credited with coining the term phantom limb, and more than anyone else
  4. 4. History • over the past several decades, wars and land mine explosions in many parts of the world have been responsible for numerous cases of traumatic amputation • In Western countries, the main reasons for amputation are diabetes and peripheral vascular disease in elderly people
  5. 5. History • after the war between Iraq and Iran, 64% of 200 soldiers who had lost limbs during this war suffered from phantom pain, 32% from phantom movement pain, while 24% suffered from stump pain.
  6. 6. Definition • Phantom pain is pain caused by elimination or interruption of sensory nerve impulses by destroying or injuring the sensory nerve fibers after amputation or deafferentation. • Phantom phenomena may also occur following the amputation of other body parts, such as the breast and rectum
  7. 7. Category
  8. 8. PREVALENCE • most recent studies agree that 60% to 80% • The prevalence is probably not influenced by age in adults, gender, side, or level and cause (civilian versus traumatic) of the amputation • Phantom pain is less frequent in very young children and congenital amputees
  9. 9. TIME COURSE • usually within the first week after amputation • The appearance of phantom pain may, however, be delayed for months or even years
  10. 10. INTENSITY AND FREQUENCY • phantom pain is present in 60% to 80% • severe pain is substantially smaller and in the range of 5% to 15%. • the mean intensity of pain 6 months after amputation was 22 (range, 3 to 82) on a visual analog scale (VAS, 0 to 100). • The pain is usually intermittent and only a few patients are in constant pain • Episodes of pain attacks are most often reported to occur daily or at daily or weekly intervals
  11. 11. LOCALIZATION AND CHARACTER • Phantom pain is primarily localized to the distal parts of the missing limb • In upper limb amputees, pain is normally felt in the fingers and palm of the hand • in lower limb amputees, it is generally experienced in the toes, foot, or ankle
  12. 12. Common descriptions of phantom pain • Phantom pain is often described as shooting, pricking, and burning, pins and needles, tingling, throbbing, cramping, crushing – a hammer is slammed at my calf – Ants are crawling around inside my foot
  13. 13. PHANTOM SENSATIONS • more frequent than phantom pain • experienced by nearly all amputees • do not usually pose a major clinical problem • 30% of amputees may find these sensations moderately to severely • appear within the first days after amputation • Immediately after amputation, the phantom limb often resembles the preamputation limb in shape, length, and volume • Over time, the phantom fades, with sensation of the distal parts of the limb disappearing.
  14. 14. Telescoping • shrinkage of the phantom is reported to occur in about a third of patients. • The phantom gradually approaches the amputation stump and eventually becomes attached to it
  15. 15. STUMP PAIN • Stump pain is common in the early postamputation period. • all patients experienced some stump pain in the first week after amputation, with a median intensity of 15.5 • prevalence of chronic stump pain varies in the literature, • severe pain is probably seen in only 5% to 10% • Stump pain may be described as pressing, throbbing, burning, squeezing, or stabbing • hypoesthesia, hyperalgesia, or allodynia • Stump pain and phantom limb pain are strongly correlated.
  16. 16. MECHANISMS OF PHANTOM PAIN • Not completely understood • it is now clear that nerve injury is followed by a number of morphologic, physiologic , and chemical changes in both the peripheral and central nervous system and that all these changes • Divided to : peripheral, spinal, and supraspinal mechanisms
  17. 17. PERIPHERAL MECHANISMS • The ectopic and increased spontaneous and evoked activity from the periphery is assumed to be the result of an increased and also de novo expression of sodium channels • increased activity in afferent C fibers • Stump neuromas induces stump and phantom pain. • It has been claimed that surgical removal of a neuroma abolishes phantom pain
  18. 18. PERIPHERAL MECHANISMS • DRG cells exhibit dramatic changes in the expression of different sodium channels following axonal transection. • The sympathetic nervous system may also play an important role • Sympatholytic blocks can abolish or reduce phantom pain, • pain can be rekindled by injection of noradrenaline into the skin
  19. 19. SPINAL MECHANISMS • Phantom limb pain may appear or disappear following spinal cord neoplasia. • After nerve injury there is an increase in the general excitability of spinal cord neurons, where C fibers and Aδ afferents gain access to secondary pain-signaling neurons. • Sensitization of dorsal horn neurons is mediated by release of glutamate and neurokinins • reduced flexion reflex thresholds in response to noxious mechanical
  20. 20. SPINAL MECHANISMS • increased persistent neuronal discharges with prolonged pain after stimulation (wind-up phenomena) • expansion of peripheral receptive fields • increased activity in N-methyl-d-aspartate (NMDA) receptor–operated systems
  21. 21. Sussman (1995)
  22. 22. SUPRASPINAL MECHANISMS • alter neuronal activity in cortical and subcortical structures • complex perceptual qualities and its modification by various internal stimuli (e.g., attention, distraction, or stress) shows the phantom image to be a product of the brain. • cortical reorganization after amputation • Changes have also been observed at subcortical levels • was shown that thalamic neurons, which do not normally respond to stimulation, begin to respond and show enlarged somatotopic maps in amputees
  23. 23. PREVENTION 1. phantom pain is in some cases a replicate of the pain experienced before the amputation 2. pain before the amputation increases the risk for postamputation phantom pain
  24. 24. EPIDURAL INTERVENTIONS 1. phantom pain was lower in patients who had received the preoperative epidural blockade 2. The intensity of stump and phantom pain and consumption of opioids were also similar in the two groups at all four postoperative interviews • no difference was found in the incidence of phantom pain 24 months after the amputation in those who had received epidural, spinal, or general anesthesia for the amputation
  25. 25. PERIPHERAL REGIONAL ANESTHESIA • Studies have found negative and positive effects, • One study : a catheter into the transected nerve sheath at the time of amputation and infused bupivacaine for 72 hours. Phantom pain did not develop in any patients during a 12-month follow-up • incidence of phantom pain was similar in the two groups after 3 days and 6 and 12 months
  26. 26. SYSTEMIC INTERVENTIONS • intravenous ketamine infused intraoperatively and for 72 hours: no effect of a treatment • oral memantine: reduced phantom pain after 4 weeks and 6 months, but not after 12 months • oral gabapentin: 300 mg - 2400 mg/day : early and prolonged treatment with gabapentin did not seem to reduce the incidence of phantom pain
  27. 27. conclusion • In conclusion, perioperative interventions, such as epidurals, other nerve blocks, and systemic treatments, are effective in the treatment of immediate postoperative stump pain • further evaluate the potential for different perioperative treatment regimens to reduce chronic phantom pain • multimodal approach seems to generate better outcome consist of: sychological counseling and treatment; cognitive behavioral therapy and pharmacological treatment
  28. 28. TREATMENT • The authors’ conclusion was that data from the studies included were not sufficient to support any particular medication for established phantom limb pain.
  29. 29. MEDICAL TREATMENT • Amitriptyline: dose of 125 mg/day: no effect of on pain intensity or secondary outcome measures such as satisfaction with life • Both tramadol and amitriptyline had almost abolished stump and phantom pain at the end of the treatment period • gabapentin : titrated in increments 300 to the maximum dosage of 2400 mg/day: – Gabapentin did not decrease the intensity of pain significantly, but was better than placebo
  30. 30. MEDICAL TREATMENT • oral morphine: a significant reduction in phantom pain • Calcitonin alone had no effect on pain • Memantine at doses of 20 or 30 mg/day failed to have any effect on spontaneous pain, allodynia, and hyperalgesia. • A large number of other treatments, such as dextromethorphan, topical application of capsaicin, intrathecal opioids, various anesthetic blocks, injections of botulinum toxin, and topiramate, have been claimed to be effective in relieving phantom pain, but none of them have proved to be effective in well-controlled trials with a sufficient number of patients.
  31. 31. MEDICAL TREATMENT • Sympathetic blocks may also reduce phantom pain, but only for a limited time after the injection • The inflammatory cytokine tumor necrosis factor alpha (TNF - α ) plays an important role in neuropathic pain conditions: perineural injections of etanercept, a TNF - α antagonist, describes a significant improvement
  32. 32. NONMEDICAL TREATMENT • Physical therapy involving massage, manipulation, and passive movements may prevent trophic changes and vascular congestion in the stump. • Transcutaneous electrical nerve stimulation (TENS), acupuncture, biofeedback, and hypnosis, may in some cases have a beneficial effect on stump and phantom pain.
  33. 33. Mirror therapy • It has been suggested that mirror therapy can reduce phantom but failed to find any significant effect of mirror treatment (benzon 2014) • sham controlled crossover trial showed that mirror therapy is better than mental visualization or covered mirror therapy. • The principle of this treatment is based on the idea that the central representation of the missing hand of the phantom could be recovered. This could relieve or eliminate the phantom pain.
  34. 34. Interventional m anagement • pulsed radiofrequency of the proximal and distal ends of a sciatic neuroma with treatment at 42 ° C for 120 seconds under ultrasound guidance with VAS reduction of 90%, 90%, • PRF adjacent to the L4 – L5 ganglion spinale (dorsal root ganglion, DRG) • Spinal cord stimulation to be effective and may be used for the treatment of phantom limb pain. • deep brain stimulation • stump injections
  35. 35. SURGICAL AND OTHER INVASIVE TREATMENTS • Today, stump revision is performed only in cases of obvious stump pathology • Surgery may produce short-term pain relief, but the pain often reappears
  36. 36. Summary of evidence for interventional management of phantom pain.
  37. 37. Clinical practice algorithm for the treatment of phantom pain.
  38. 38. references • Evidence-Based Interventional Pain Medicine (2012) Third Edition (Third Edition) • PRACTICAL MANAGEMENT OF PAIN Copyright © 2014 by Mosby DR Mohsen Abad
  39. 39. THANK YOU FOR YOUR ATTENTION

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