Phantom Limb Pain (nyeri phantom) anes..

Phantom limb

1. Phantom limb pain

2. Phantom Limb Pain Severe injury leading to amputation Pain sensations experienced not necessarily cease after amputation Most (in excess of two-thirds) experienced by patients who have lost a limb at least occasionally

3. Classification 1. Phantom pain: painful sensation referred to the phantom limb 2. Phantom sensation: any sensation, other than pain, in the phantom limb 3. Stump pain: pain localized to the stump

4. Incidence The incidence of phantom pain is 60-80% among amputees. Independent of adult age, gender or location or side of amputation (less common in children or congenital amputees)

5. Onset and Duration Several studies have shown that 75% of patients with PLP develop pain within the first few days after amputation. One study of 58 amputees found incidence of PLP to be 72%, 65% and 59% after 1 week, 6 months and 2 years. (Jensen, et al 1985) Another study of 56 amputees showed that although the incidence and intensity of pain remained constant, the frequency and duration of pain attacks decreased significantly. (Nikolajsen, et al 1997)

6. Character and association Phantom pain is usually intermittent; only few patient’s are in constant pain. Aggravted by stress. Pain is primarily located in distal parts of the missing limb. Few case reports suggest that pre-amputation pain may persist as PLP, but this is not the case in most patients. Phantom pain is more frequent in patients with long-term stump pain, and decreases with resolution of stump-end pathology Average Vas score is 5.3

7. Common descriptions of phantom pain

8. Predictive factor Prior experience with pain prior to amputation Climatic conditions: changes in air pressure and tempreture Stress . Inactivity Periodic illness - Colds, flu, infections

9. Sympathetic nervous system role Application of norepinephrine or activation of post-ganglionic sympathetic fibers excites and sensitizes damaged (not normal) nerve fibers. (Devor, et al 1994) Sympatholytic block can abolish neuropathic pain, but pain can be rekindled by injection of norepinephrine under the skin. (Torebjork et al 1995)

10. Cerebral reorganization One study of adult monkeys revealed cortical reorganization in which the mouth and chin invade cortices corresponding to arm and digits. (Dotrovsky, et al 1999) In humans, similar reorganization has been observed using magnetoencephalographic techniques and there was a linear relationship between pain and degree of reorganization (flor, et al 1998)

11. Treatment Multidisciplinary Approach TENS Acupuncture Bio-feedback Hypnosis Massage Ultrasound ECT Nerve blocks Neurectomy Stump revision Rhizotomy Cordotomy Lobectomy Sympathectomy Spinal cord stim Brain stimulation TCA Anticonvulsants Lidocaine Opioids NMDA antagonists clonidine

12. Medical management TCA Anticonvulsants Lidocaine Opioids NMDA antagonists clonidine

13. Adjuvant therapies TENS Acupuncture Bio-feedback Hypnosis Massage Ultrasound ECT Exercise

14. Transcutaneous electrical nerve stimulation (TENS):  uses low current at a low-frequency oscillation to stimulate the nerves and provide pain relief.  The amputee feels a gentle tingling without increased muscle tension.  TENS can cause arrhythmia, it should not be used by people with advanced heart disease or a pacemaker.

15. Treatment-exercise Increases circulation Stimulates the production of endorphins (chemicals naturally produced in the brain that kill pain). Many amputees find that moderate and frequent exercise can help to reduce phantom pain. Flexing and relaxing the muscles on the residual limb also helps some amputees.

16. Classic mirror box treatment If the patient gets visual feedback that the phantom is obeying the brain’s commands, the learned paralysis is sometimes unlearned. Mirror imaging of limbs using a mirror box

17. Immersive Virtual Reality (IVR)

18. Intervention Neurectomy Stump revision Rhizotomy Sympathectomy Spinal cord stim Brain stimulation Cordotomy Lobectomy

19. SCORE Description Implication/ Recommend 1A+ Effectiveness demonstrated by various RCT of good quality. The benefits clearly outweigh risk and burdens. Positive Recommendation 1B+ One RCT or more RCTs with methodologic weakness, demonstrate effectiveness. The benefits clearly outweigh risk and burdens. 2B+ One RCT or more RCT s with methodologic weakness, demonstrates effectiveness. Benefits closely balanced with risk and burdens.

20. SCORE Description Implication/ Recommend 2B+/- Multiple RCTs with methodological weakness yield contradictory result better or worse than the control treatment. Benefits closely balanced with risk and burdens or uncertainty in the estimates of benefits risks and burdens Considered, preferably study related 2C+ Effectiveness only demonstrated in observational studies given that there is no conclusive evidence of the effect, benefits closely balanced with risk and burdens.

21. SCORE Description Implication/ Recommend There is no literature or there are case reports available, but these are insufficient to suggest effectiveness and/or safety. The treatment should only be applied in relation to studies. Only study related

22. SCORE Description Implication/ Recommend 2C- Observational studies indicates no or too short lived effectiveness. Given that there is no positive clinical effect, risk and burdens outweigh the benefit. Negative Recommendation 2B- One /more RCTs with methodologic weakness or large observational studies that do not indicate any superiority to the control treatment. Given that there is no positive clinical effect, risks and burdens outweigh the benefit. 2A- RCT s of good quality which does not exhibit any clinical effect. Given that there is not positive clinical effect, risk and burdens outweigh the benefit

23. Evidence for Interventional Management of Phantom Pain Technique Evaluation Pulsed radiofrequency treatment of the 0 stump neuroma Pulsed radiofrequency treatment adjacent 0 to the spinal ganglion (DRG) Spinal cord stimulation 0

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