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

33. National Institute for Health and Clinical Excellence. Neuropathic Pain: The Pharmacological Management of Neuropathic Pain in Adults in Non-Specialist Settings. National Institute for Health and Clinical Excellence, London, 2010. Available at http://www.guideline.gov/content.aspx?id=24108 . Accessed Sept. 24, 2013.

34. Kuiken TA, Schechtman L, Harden RN. Phantom limb pain treatment with mirtazapine: a case series. Pain Pract. 2005; 5(4):356-360.

35. Huse E, Larbig W, Flor H, Birbaumer N. The effect of opioids on phantom limb pain and cortical reorganization. Pain. 2001; 90(1-2):47-55.

36. Wilder-Smith CH, Hill LT, Laurent S. Postamputation pain and sensory changes in treatment-naïve patients: characteristics and responses to treatment with tramadol, amitriptyline, and placebo. Anesthesiology. 2005; 103(3):619-628.

37. Nicholson B. Evaluation and treatment of central pain syndromes. Neurology. 2004; 62(2):S30-S36.

38. Rasmussen MR, Kitaoka HB, Patzer GL. Nonoperative treatment of plantar interdigital neuroma with a single corticosteroid injection. Clin Orthop. 1996; 326:188-193.

39. Mexiletine. Lexicomp Online [subscription required]. http://online.lexi.com . Accessed April 2013.

40. Casale R, Ceccherelli F, Labeeb AA, Biella GE. Phantom limb pain relief by contralateral myofascial injection with local anesthetic in a placebo-controlled study: preliminary results. J Rehabil Med. 2009; 41(6):418-422.

41. Bennett GJ. Update on the neurophysiology of pain transmission and modulation: focus on the NMDA-receptor. J Pain Symptom Manage. 2000; 19(suppl 1):S2-S6.

42. Nikolajsen L, Hansen C, Nielsen J et al. The effect of ketamine on phantom pain: a central neuropathic disorder maintained by peripheral input. Pain. 1996; 67(1):69-77.

43. Hackworth RJ, Tokarz KA, Fowler IM, et al. Profound pain reduction after induction of memantine treatment in two patients with severe phantom limb pain. Anesth Analg. 2008; 107(4):1377-1379.

44. Maier C, Dertwinkel R, Mansourian N, et al. Efficacy of the NMDA-receptor antagonist memantine in patients with chronic phantom limb pain—results of a randomized double-blinded, placebo-controlled trial. Pain. 2003; 103(3):277-283.

45. Nikolajsen L, Gottrup H, Kristensen AG, Jensen TS. Memantine (a N-methyl-D-aspartate receptor antagonist) in the treatment of neuropathic pain after amputation or surgery: a randomized, double-blinded, cross-over study. Anesth Analg. 2000; 91(4):960-966.

46. Hanley MA, Ehde DM, Campbell KM, et al. Self-reported treatments used for lower-limb phantom pain: descriptive findings. Arch Phys Med Rehabil. 2006; 87(2):270-277.

47. Casale R, Alaa L, Mallick M, Ring H. Phantom limb related phenomena and their rehabilitation after lower limb amputation. Eur J Phys Rehabil Med. 2009; 45(4):559-566.

48. Jaeger H, Maier C. Calcitonin in phantom limb pain: a double-blind study. Pain. 1992; 48(1):21-27.

49. Chan BL, Witt R, Charrow AP, et al. Mirror therapy for phantom limb pain. N Engl J Med. 2007; 357(21):2206-2207.

50. Ramachandran VS, Rogers-Ramachandran D. Synaesthesia in phantom limbs induced with mirrors. Proc Biol Sci. 1996; 263(1369):377-86.

51. Weinstein SM. Phantom limb pain and related disorders. Neurol Clin. 1998; 16(4):919-936.

52. Louis ED, York GK. Weir Mitchell’s observations on sensory localization and their influence on Jacksonian neurology. Neurology 2006; 66(8):1241-1244.

53. Davies MK, Hollman A. René Henri Marie Leriche (1879-1955). Heart. 1997; 77(2):98.

54. Liebeskind JC. History of pain collection - phantom limb and causalgia. History & Special Collections, UCLA Louise M. Darling Biomedical Library, 1998. Accessed April 2013.

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.