Phantom Limb Pain—A Complication of Lower Extremity Wound Management

Treating intractable phantom limb pain with ambulatory continuous peripheral nerve blocks: a pilot study

BACKGROUND

There is currently no reliable treatment for phantom limb pain (PLP). Chronic PLP and associated cortical abnormalities may be maintained from abnormal peripheral input, raising the possibility that a continuous peripheral nerve block (CPNB) of extended duration may permanently reorganize cortical pain mapping, thus providing lasting relief.

METHODS

Three men with below-the-knee (2) or -elbow (1) amputations and intractable PLP received femoral/sciatic or infraclavicular perineural catheter(s), respectively. Subjects were randomized in a double-masked fashion to receive perineural ropivacaine (0.5%) or normal saline for over 6 days as outpatients using portable electronic infusion pumps. Four months later, subjects returned for repeated perineural catheter insertion and received an ambulatory infusion with the alternate solution ("crossover"). Subjects were followed for up to 1 year.

RESULTS

By chance, all three subjects received saline during their initial infusion and reported little change in their PLP. One subject did not receive crossover treatment, but the remaining two subjects reported complete resolution of their PLP during and immediately following treatment with ropivacaine. One subject experienced no PLP recurrence through the 52-week follow-up period and the other reported mild PLP occurring once each week of just a small fraction of his original pain (pretreatment: continuous PLP rated 10/10; posttreatment: no PLP at baseline with average of one PLP episode each week rated 2/10) for 12 weeks (lost to follow-up thereafter).

CONCLUSIONS

A prolonged ambulatory CPNB may be a reliable treatment for intractable PLP. The results of this pilot study suggest that a large, randomized clinical trial is warranted.

From pleasure to pain: The role of the MPQ in the language of phantom limb pain

In opposition to the argument that pain is private, personal and unsharable, I propose that the intersubjectivity of pain is fundamental to it. Using the case of phantom limb, I show how a specific language of pain emerged and became concretized in the US circa 1975 with the advent of the McGill Pain Questionnaire (MPQ). Through widespread use of the MPQ, a language of pain materialized, one that was commonly used to describe the qualitative dimensions of phantom limb. After 1975, the terminology used within the medical literature was overwhelmingly consonant with the set of descriptors advanced by the MPQ. The utilization of a pain questionnaire to assess the qualitative dimensions of phantom limb effectively accentuated pain, and by 1980, what was once considered relatively rare became a common sequela of phantom manifestation.

Treatment of phantom limb pain with botulinum toxin type A

INTRODUCTION

Phantom limb pain and sensations are common in amputees. The pathophysiology remains unclear and the treatment difficult and often unsuccessful. Opioids are frequently used when non-narcotics have failed, but are not effective in many cases. We report on three phantom and stump pain patients, refractive to previous treatments, who were successfully treated with botulinum toxin A (BoNT-A).

METHODS

Three patients who had previously undergone amputation of their leg due to accident (N = 2) or injury by a landmine (N = 1) were treated with BoNT-A (Dysport). We injected a total dose of up to 500 units (U) BoNT-A under EMG-control. Global clinical improvement was based on a 0-3 scale (0 = no effect; 3 = marked improvement) and on a questionnaire rating pain intensity (based on the visual analog scale), intake of pain medication and phantom limb sensations.

RESULTS

All three patients evaluated the clinical global improvement with 3 (marked improvement). The pain intensity and pain medication was reduced significantly in all three cases. No side effects were reported. The duration of response lasted up to 11 weeks.

DISCUSSION

These three successfully treated phantom and stump pain patients show that therapy with BoNT-A may be worth studying as an effective and safe treatment option for this kind of pain.

The pathophysiology of the chronic pain cycle

The diagnosis and treatment of chronic pain is an area in which the field of medicine is failing to offer the best possible care to patients. This article presents a clinically driven view of the condition with an emphasis on active recognition and intervention. Defining aspects of chronic pain, including the emotional and psychologic components, are introduced with regard to recognition and diagnosis. The pathophysiologic mechanisms that underlie the transition from acute pain to chronic pain are reviewed from the standpoint of treatment intervention. Finally, specific chronic pain states that affect the lower extremities are considered.