Pain & Sensation | amputeerehab

Pain and sensation

Stump pain

Pain localised in the stump is common early post-amputation, and improves with healing in most patients (Edhe et al., 2000). Stump pain may be related to pathologies such as wounds, infections, bone spurs, scar adhesions, and neuromas (Nikolajsen & Jensen, 2001). Additionally, stump pain may be associated with central pain sensitisation, reduction in pain thresholds (hyperalgesia), and triggering of pain by non-noxious stimuli (allodynia) (Nikolajsen & Jensen, 2001). Pain can be an issue for prosthetic training, as it may limit the patient’s ability to fully weight bear into the prosthesis, which will impact balance and gait (Hyland, 2009).

Phantom limb sensation

Phantom limb sensation includes any sensation felt in the absent limb, except for pain (Nikolajsen & Jensen, 2001). A sensation that the amputated body part is still present is common, and may include the shape, position, or movement of the limb, warm or cold sensations, or itching and tingling (Flor, 2002). Episodes of sensation may be constant or intermittent, lasting a few minutes to an hour (Edhe et al., 2000). Amputees commonly experience phantom sensations, however it is rarely an issue clinically and may be helpful during prosthetic training, as the sensations provide a reference for where they should be placing their prosthesis (Nikolajsen & Jensen, 2001). However, there is the risk of a patient forgetting that they have had the amputation, as they have phantom sensations, and thus falling when they try to stand up from bed.

Phantom limb pain

Phantom pain can be experienced in the amputated limb, and may be described as stabbing, squeezing, shooting, throbbing and burning (Nikolajsen & Jensen, 2001). Phantom pain may be constant or intermittent, and is primarily localised in the distal missing limb (Nikolajsen & Jensen, 2001). This pain is correlated with representational neuroplasticity changes in the somatosensory cortex, however peripheral and psychological factors may also contribute (Karl, Birbaumer, Liyzenberger, Cohen, & Flor, 2001). Phantom pain may be worsened by physical factors such as pressure on the residual limb and psychological factors such as stress (Flor, 2002).

Around 30% of amputees report the feeling of ‘telescoping’, where the distal part of the phantom limb sensation retracts towards the residual limb, and is associated with reductions in phantom limb pain (Flor, 2002).

Treatment

A number of therapies exist, however no guidelines have been developed as there is limited high-level evidence available on the treatment effects (Nikolajsen & Jensen, 2001). Treatment may be pharmacological, surgical, anaesthetic, psychological, or other non-invasive therapies such as TENS, mirror therapy, biofeedback and behavioural methods (Subedi & Grossberg, 2011). Surgical interventions are usually only used when other methods of treatment have been unsuccessful (Subedi & Grossberg, 2011).

References:

Ehde, D. M., Czerniecki, J. M., Smith, D. G., Campbell, K. M., Edwards, W. T., Jensen, M. P., & Robinson, L. R. (2000). Chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after lower limb amputation. Archives of physical medicine and rehabilitation, 81(8), 1039-1044. Retrieved from: http://dx.doi.org/10.1053/apmr.2000.7583

Flor, H. (2002). Phantom-limb pain: characteristics, causes, and treatment. The Lancet Neurology, 1(3), 182-189. Retrieved from: http://psych.unl.edu/mdodd/psy498/phantomlimb.pdf

Hyland, N. W. (2009). A comparative analysis of two gait training approaches for individuals with transtibial amputation. Seton Hall University. Retrieved from: https://search.proquest.com/openview/5a37ff53f099f36fa6d7a42866ed9fa1/1?pq-origsite=gscholar&cbl=18750&diss=y

Karl, A., Birbaumer, N., Lutzenberger, W., Cohen, L. G., & Flor, H. (2001). Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain. Journal of Neuroscience, 21(10), 3609-3618. Retrieved from: http://www.jneurosci.org/content/21/10/3609.full

Nikolajsen, L., & S. Jensen, T. (2001). Phantom limb pain. British journal of anaesthesia, 87(1), 107-116. Retrieved from: https://www.physio-pedia.com/images/a/a8/Phantomlimb.pdf

Subedi, B., & Grossberg, G. T. (2011). Phantom Limb Pain: Mechanisms and Treatment Approaches. Pain Research and Treatment, 864605. doi: 10.1155/2011/864605

Treatments for phantom-limb pain

(Flor, 2002; Subedi & Grossberg, 2011)

Pharmacological

Surgical

Anaesthetic

Psychological

Other

Conventional analgesics

Opioids

Beta-blockers

Neuroleptics

Anticonvulsants

NMDA-receptor antagonists

Ketamine

Memantine

Antidepressants

Barbiturate

Muscle relaxants

Neurectomy

Stump revision

Dorsal column stimulation

Deep brain stimulation

Sympathectomy

Rhizotomy

Cordotomy

Tractotomy

Nerve blocks

Sympathetic block

Local anaesthesia

Epidural blockage

Lidocaine

EMG feedback

Cognitive-behavioural pain management

Sensory discrimination training

Hypnosis

Temperature biofeedback

TENS

Acupuncture

Massage

Ultrasound

Prosthesis training

Mirror training