A Closer Look At Evolving Treatments For Phantom Limb Pain

Start Page:

A Primer On The Early Research Into Phantom Limb Pain

Ambroise Paré was a 16th-century French barber, a surgeon who served in the military. Paré documented the pain experienced by amputees who perceived sensation in the “phantom” amputated limb.51 Paré believed that phantom pains occur in the brain and not in the remnants of the limbs.

In 1872, American neurologist S. Weir Mitchell, MD, described a bizarre symptom complex resulting from wounds to peripheral nerves in his book, Injuries of Nerves and Their Consequences. Mitchell saw a large number of patients who had been wounded in the Civil War and suffered from a chronic affliction he called causalgia and coined the term “phantom limb pain,” recording an incidence as high as 90 percent.8,52 The common treatment for causalgia associated with peripheral nerve injury was amputation.

In 1937, Leriche wrote his classic work La Chirurgie de la Douleur, in which he detailed his work on causalgia and phantom limbs.53,54 He acknowledged Mitchell's contribution and looked for ways to solve the problem of pain. Leriche's opportunity to study phantom limb pain came during World War I when he saw many soldiers with peripheral nerve damage.54 He observed vasomotor changes, which suggested to him an abnormality of vascular stimulation. In 1916, he attempted to alleviate the pain through periarterial sympathectomy.54 Leriche also saw patients with painful stumps and phantom limb pain.

W.K. Livingston, MD, had learned at Harvard that pain was a specific response to an unpleasant stimulus, a warning of tissue damage. One of the problems that puzzled him early in his career was visceral pain. Patients might experience no apparent pain from tissue damage to certain internal organs but would report "referred pain" in another part of the body.54 He studied other pain phenomena, such as causalgia and phantom limb pain, which presented similar enigmas.54 During World War II, Livingston was assigned to the Oakland Naval Hospital, where he assumed responsibility for patients with peripheral nerve injury and other difficult pain problems, including causalgia cases.54 Livingston used periarterial sympathectomies, ganglionectomies and novocaine blocks to treat his patients, but he recorded several cases in which the relief was only temporary and the pain returned.54

Robert G. Smith, DPM, MSc, RPh, C.Ped

7. Owings MF, Kozak LJ. Ambulatory and inpatient procedures in the United States, 1996. Vital Health Stat 13. 1998; (139):1–119.

8. Subedi B, Grossberg GT. Phantom limb pain: mechanisms and treatment approaches. Pain Res Treat 2011; 2011:864605. doi: 10.1155/2011/864605. Epub 2011 Aug 14.

9. Hsu E, Cohen SP. Postamputation pain: epidemiology, mechanisms, and treatment. J Pain Res. 2013; 6:121-136.

10. Ramachandran VS, Rogers-Ramachandran D, Stewart M. Perceptual correlates of massive cortical reorganization. Science. 1992; 258(5085):1159-1160.

11. Iacono RP, Linford J, Sandyk R. Pain management after lower extremity amputation. Neurosurgery. 1987; 20(3):496-500.

12. Davis RW. Phantom sensation, phantom pain, and stump pain. Arch Phys Med Rehabil. 1993; 74(1):79-91.

13. Jensen TS, Krebs B, Nielsen J, et al. Immediate and long-term phantom limb pain in amputees, incidence, clinical characteristics and relationship to pre-amputation limb pain. Pain. 1985; 21(3):267-278.

14. Kroner K, Krebs B, Skov J et al. Immediate and long-term phantom breast syndrome after mastectomy, incidence, clinical characteristics and relationship to pre-mastectomy breast pain. Pain. 1989; 36(3):327-334.

15. Ramachandran VS, Brang D, McGeoch PD. Dynamic reorganization of referred sensations by movements of phantom limbs. NeuroReport. 2010; 21(10):727-730.

16. Flor H, Nikolajsen L, Jensen TS. Phantom limb pain: a case of maladaptive CNS plasticity? Nature Reviews Neuroscience. 2006; 7(11):873-881.

17. Dickinson BD, Head CA, Gitlow S, et al. Maldynia: pathophysiology and management of neuropathic and maladqaptive pain-a report of the AMA council on science and public health. Pain Medicine. 2010; 11(11):1635-1653.

18. Karanikolas M, Aretha D, Tsolakis I, et al. Optimized perioperative analgesia reduces chronic phantom limb pain intensity, prevalence, and frequency: a prospective, randomized, clinical trial. Anesthesiology. 2011; 114(5):1144-1154.

19. Borghi B, D’Addabbo M, White PF, et al. The use of prolonged peripheral neural blockade after lower extremity amputation: the effect on symptoms associated with phantom limb syndrome. Anesthesia and Analgesia. 2010; 111(5):1308-1315.

20. Baron R. Mechanisms of disease: neuropathic pain-a clinical perspective. Nat Clin Pract Neurol. 2006; 2(2):95-106.

21. Berger IH, Bacon DR. Historical notes on amputation and phantom limb pain: “All quiet on the Western Front?” Gundersen Lutheran Medical Journal. 2009; 6(1):26-29.

22. Anderson-Barnes VC, McAuliffe C, Swanberg KM, et al. Phantom limb pain-a phenomenon of proprioceptive memory. Med Hypotheses 2009; 73(4):555-558

23. Gabapentin. Lexicomp Online [subscription required]. http://online.lexi.com . Accessed May 2013.

24. Bone M, Critchley P, Buggy DJ. Gabapentin in postamputation phantom limb pain: a randomized, double-blind, placebo-controlled, cross-over study. Reg Anesth Pain Med. 2002; 27(5):481-486.

25. Smith DG, Ehde DM, Hanley MA, et al. Efficacy of gabapentin in treating chronic phantom limb and residual limb pain. J Rehabil Res Dev. 2005; 42(5):645-654.

26. Neurontin (gabapentin) product information. Pfizer, New York, December 2012.

27. Elliott F, Little A, Milbrandt W. Carbamazepine for phantom-limb phenomena. N Engl J Med. 1976; 295(12):678.

28. Gilron I, Watson PN, Cahill CM, Moulin DE. Neuropathic pain: a practical guide for the clinician. CMAJ. 2006; 175(3):265-275.

29. Finnerup NB, Otto M, McQuay HJ, et al. Algorithm for neuropathic pain treatment: an evidence based proposal. Pain. 2005; 118(3):289-305.

30. Weeks SR, Anderson-Barnes VC, Tsao JW. Phantom limb pain: theories and therapies. Neurologist. 2010; 16(5):277-286.

31. Robinson L, Czerniecki J, Ehde D, et al. Trial of amitriptyline relief of pain in amputees: results of a randomized controlled study. Arch Phys Med Rehabil. 2004; 85(1):1-6.

32. Pertovaara A. Noradrenergic pain modulation. Prog Neurobiol. 2006; 80(2):53-83.

image description image description

Bob Smithsays: October 5, 2013 at 10:59 pm

My deep gratitude to Podiatry Today and its staff for publishing this manuscript while I am away.

Reply to this comment »
DrDpmsays: October 30, 2013 at 1:13 pm

This is an excellent article on the topic of peripheral neuropathy! Phantom limb pain syndrome and residual limb pain syndrome are both variant examples of peripheral neuropathy in the distal lower extremities.

I disagree with this article that stated that people with peripheral neuropathy cannot feel the pain sensations from phantom or residual pain syndromes. Let me elaborate. There are two types of pain: nociceptive pain and neuropathic pain. A patient with diabetic neuropathy and residual pain syndrome (from an amputated toe) will not feel nociceptive pain but will feel neuropathic pain emanating from that amputated toe. Although the patient may feel "numbness," neuropathic pain is still present because the nerve is damaged from resection due to amputation.

I had a patient with diabetic neuropathy in the feet who experiences debilitating lancinating pain from an amputated toe. That agonizing pain flareup is the neuropathic pain, not nociceptive pain.

When it comes to the medical topic of peripheral neuropathy, all physicians, including podiatrists, must distinguish nociceptive pain mechanisms from neuropathic pain mechanisms. This can help improve diagnosis and treatment management.

Reply to this comment »

Post new comment

  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.

More information about formatting options

Enter the characters shown in the image.