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Keywords: Phantom limb /Pain assessment// Nursing Practice Amputation Practice review ●This article has been double-blind peer reviewed Nurses must conduct holistic assessments to manage this condition appropriately Dealing with phantom limb pain after amputation

In this article... associated with the physiological mecha- nisms of neuropathic pain (Flor, 2002). The mechanism of phantom limb pain Neuropathic pain is associated with a pri- The barriers to accurate pain assessment mary lesion or dysfunctions in the nervous system (IASP, 2010). Box 2 outlines possible Why patients may not report pain causes of PLP. What pain assessment tools are available Assessment of phantom limb pain Nurses have an important role in manag- Authors Dawn Fieldsen is staff nurse What is pain? ing pain control because they have more orthopaedics and trauma, Huddersfield Pain is an individual experience, which is contact with patients who are experienc- Royal Infirmary; Sharon Wood is lecturer not caused solely by a painful stimulus ing pain than any other healthcare profes- in nursing at University of Leeds. (Mann et al, 2009). The of pain sional (Mann et al, 2009). Using pain can be affected by numerous factors, in- assessment tools improves communica- Abstract Fieldsen D, Wood S (2011) cluding memory of previous pain, the tion and makes it easier to select the appro- Dealing with phantom limb pain after cause of the pain, the type and intensity of priate treatment (Mann et al, 2009). amputation. Nursing Times; 107, 1: 21-23. preoperative pain and cultural perspec- The Department of Health (2010) Patients usually experience phantom limb tives of pain (Mann et al, 2009). suggests assessment should include an pain after amputation but it may also occur The International Association for the evidence based tool that is appropriate to following resection of other parts of the Study of Pain (2010) defines pain as “an un- the individual's needs and health problem. body, such as the breast and internal pleasant sensory and emotional experi- Assessment should consider the physical, organs like the rectum. The causes are ence associated with actual or potential psychological, social and spiritual aspects complex and patients require careful tissue damage, or described in terms of of the pain experience (DH, 2010). The Clin- assessment to ensure they receive such damage”. This suggests pain is not ical Resource Efficiency Support Team appropriate care. This article describes the only a physiological process, but an expe- (2008) and the National Institute for Health causes of phantom limb pain and discusses rience that people interpret individually, and Clinical Excellence (2010) offer guid- assessment strategies. regardless of whether there is actual injury ance on the pharmacological management to the body. This may help to explain why and treatment of neuropathic pain. This hantom limb pain (PLP) is report- patients experience PLP. type of pain is often an element of PLP but ed in 60–80% of patients after a guidance does not specifically mention it. limb amputation, with up to 10% The pain response Preporting severe pain (Nikolajsen A response to noxious stimuli occurs after Pain assessment tools et al, 2006). It is defined as a painful phe- amputation surgery, resulting in patients Common pain assessment tools include: nomenon at the site of limb amputation, experiencing nociceptive pain. The noci- » The four-point verbal rating scale (VRS), which gives the sensation that the limb ceptive pain pathway includes transduc- which is used to describe increasing may still be there (Australian and New Zea- tion, transmission, perception and modu- pain intensity: 0 (no pain); 1 (mild pain); land College of Anaesthetists, 2010; Niko- lation (McCaffrey et al, 1999). These are 3 (moderate pain); 4 (severe pain); lajsen et al, 2006). Table 1 lists descriptions outlined in Box 1. » The 10-point numerical rating scale of after amputation. Normal nociceptive pain will be experi- (NRS), which is represented as a line Phantom pain has also been reported af- enced after surgery, but the exact physiol- with numbers: 0 (no pain) to 10 (most ter amputation and removal of other body ogy of PLP is unknown (Houser, 2002). It pain possible) on which patients parts, including the breast, rectum, tongue may be experienced in missing limbs and indicate their level of pain. and/or teeth and genitalia. Reasons for am- stumps, and a range of symptoms that are Measuring pain intensity is an important putation include vascular disease (includ- different to those associated with nocicep- part of assessment (Turk et al, 2001) and ing neuropathy caused by diabetes), trau- tive pain will be present (see Table 1). benefits of these tools include ease of use ma, infection and abnormal tissue growth There may be no physical reason for (Jensen et al, 2001). (Limb Loss Information Centre, 2010). PLP (McCaffrey et al, 1999) but it can be Research has demonstrated that the VRS

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does not provide sensitive data (Williamson learning et al, 2005) and its reliability may be affect- pointS ed by the intervals between the predeter- mined levels of pain (Jensen et al, 2001). The Reflect on an occasion when more levels a tool has to gauge pain, the eas- you assessed a patient who ier it is to identify a change in intensity was reporting pain after an (Williamson et al, 2005). The 10 point NRS amputation: could be considered more responsive to the ● What pain assessment tool change in pain intensity than the four-point did you use? VRS, but the advantage of the VRS is that it ● Was this effective in uses words to describe pain intensity. assessing the patient's pain? Using the VRS or NRS may enhance a ● Did you reassess the pain systematic and effective assessment of the to establish whether the pain and evaluation of the effectiveness of analgesia you administered treatments for PLP. However, assessing was effective in reducing the PLP intensity may fail to identify other fac- levels of pain? tors such as reduced quality of sleep and ● What could you have done function, and depression (Turk et al, 2001). Nociceptive pain may be experienced in missing limbs and stumps to improve pain manage- Pain should be individually assessed ment for this patient? and tools appropriate to the patient should include dimensions such as intensity, sen- sation, mood and function. 5 key Table 1. Types of phantom limb pain Multidimensional assessment tools facts Type of pain Symptoms Some multidimensional pain assessment Phantom limb Phantom pain Burning, tingling, stinging, cramping, shooting, tools are specifically designed to diagnose 1pain (PLP) is twisting. Often stronger versions of phantom neuropathic pain. As PLP appears to be reported in sensations considered within the umbrella term of 60–80% of patients Phantom sensations of position, temperature, itching, discomfort neuropathic pain, CREST (2008) suggests following a limb Stump pain Localised pain in the area of amputation, often using The Leeds Assessment of Neuro- amputation acute postoperative pain pathic Symptoms and Signs – Self-report (Nikolajsen et al, Adapted from Australian and New Zealand College of Anaesthetists (2005) tool (S-LANSS). 2006) This tool has encouraged accurate diag- ● This does not There may be Box 1. Perception: noses of neuropathic-related pain – in- 2no physical originate from one distinct cluding PLP – in 75% of people studied and reason for PLP Nociceptive area of the , which has demonstrates high levels of sensitivity (McCaffrey et al, pain pathwayS led to the neuromatrix theory (Bennett et al, 2005). This suggests the S- 1999) (Brooks et al, 2005). Melzack LANSS provides a more accurate and sen- Pain assess- ● Transduction: Initial (1989) proposed this theory sitive assessment of PLP when compared 3ment should stimulation of the primary to describe the mechanism of with the unidimensional VRS and NRS. consider the afferent neurons occurs as a phantom limb pain, suggest- Dworkin et al (2001) argued the assess- physical, psycho- result of thermal, mechanical ing a network of neurons ment of neuropathic-related pain, such as logical, social and or chemical stimuli from continuously communicated PLP should include more than one tool in spiritual aspects of amputation surgery and the information about pain order to consider wider aspects of the pain the pain experi- inflammatory response sensation through various experience. The S-LANSS tool diagnoses ence (DH, 2010) (Caterina et al, 2005). This circuits in the brain. the presence and type of pain and, com- There is a lack causes the release of ● Modulation: This describes bined with an intensity score – for exam- 4of guidance on excitatory regulating the response to the ple, from the VRS or NRS – may help nurses assessing and including prostaglandins, perceived pain (Jagger, 2005). provide the most appropriate treatment or managing PLP and . Melzack and Wall (1965) early referral to specialist services. It may Other aspects ● Transmission: Impulses are suggested inhibitory neurons also be necessary to use additional tools 5of pain may generated along the afferent in the dorsal horn can control that assess the different aspects of the include reduced neurons to the dorsal horn of incoming sensory information effect of PLP on the patient, for example, quality of sleep the . Through before transmission to the mood, behaviour and functions. Further and depression excitatory neurotransmitters, brain. Stimulation by research is required to identify a tool that the impulse can continue and touch can release will facilitate a holistic assessment of PLP. across the synaptic cleft, up inhibitory neurotransmitters, The DH (2010) describes pain as the fifth the spinal cord, through the including endogenous opioids vital sign and confirms that assessment of ascending pathways to the and aiding pain relief it and management strategies should be brain stem and (Mann et al, 2009; Mitchinson ongoing and regularly observed along with (Wood, 2008; McCaffrey et et al, 2007; McCaffrey et al, other vital physiological measurements. al, 1999). 1999). This can be done with a unidimensional

Alamy VRS or NRS but may be more problematic ➜

22 Nursing Times 11.01.11 / Vol 107 No 1 / www.nursingtimes.net For a Nursing Times Learning unit Nursing on neuropathic pain, go to Times.net nursingtimes.net/neuropathic

➜ with a tool like the S-LANSS as the data pharmacological treatment should be tai- References obtained is more difficult to represent on lored to the individual patient by identify- Australian and New Zealand College of Anaesthe- tists (2005) (ANZCA) Acute Pain Management: vital sign documents. Adapting documen- ing the medication that delivers the great- Scientific Evidence. www.anzca.edu.au tation to include a multidimensional and est pain relief with the least number of side Bennett MI et al (2005) The S-LANSS score for pain intensity assessment tool for people effects. This is why individualised pain identifying pain of predominantly neuropathic origin: validation for use in clinical and postal with PLP would make it more likely that assessment is important. CREST (2008) research. Journal of Pain; 6: 3, 149-158. pain would be treated as the fifth vital. and NICE (2010) have recommended Brooks J et al (2005) From nociception to pain prompt referral to specialist pain services. perception: imaging the spinal and supraspinal Assessment barriers pathways. Journal of Anatomy; 207: 1, 19-33. Caterina MJ et al (2005) Molecular biology of Difficulties are often encountered in clini- Conclusion . In: Hunt S, Koltzenburg M (eds) The cal practice when assessing PLP. The com- Nurses should be aware of PLP and how it Neurobiology of Pain. Oxford: Oxford University monly reported symptoms outlined in can differ from other types of pain to ensure Press. Clinical Resource Efficiency Support Team (2008) Table 1 are difficult to understand – as the patients receive holistic care. Nurses should Guidelines on the Management of Neuropathic source of the pain has been amputated, the obtain information about pain from the pa- Pain. tinyurl.com/crest-pain assessment must rely purely on the tient as part of their care plan and use the Department of Health (2010) Benchmarks for patient’s description of it. McCaffrey et al tools available in their clinical area. It may Prevention and Management of Pain. London: DH. tinyurl.com/essence-pain (1999) acknowledged that healthcare also be possible for nurses to access the Dworkin RH et al (2007) Pharmacologic professionals are more likely to treat pain specialist knowledge of pain nurses, who management of neuropathic pain: Evidence-based when the cause is clear. are there to support both nurses and pa- recommendations. Pain; 132: 3, 237-251. Dworkin RH et al (2001) Assessment of It is vital that nurses remain non-judge- tients through the management of pain. NT neuropathic pain. In: Turk DC, Melzack R (eds). mental and administer analgesia accord- HandBook of Pain Assessment. New York: The ing to the pain being expressed. Pain Guilford Press. assessment can be affected by healthcare Box 2. Causes Flor H (2002) Phantom-limb pain: characteristics, of phantom causes, and treatment. The Lancet ; 1: professionals' beliefs that people who 182-189. report PLP construct it in their minds limb pain Houser SA (2002) Phantom limb pain. In: Warfield (Flor, 2002). This can lead to inaccurate CA, Fausett HJ (eds). Manual of Pain Manage- ment. Philadelphia: Lipincott Williams and Wilkins. ● assessment by nurses and non-reporting : Pain evoked by International Association for the Study of Pain of pain by patients. stimuli that would not usually (2010) IASP Pain Terminology. tinyurl.com/ Other barriers to the overall assessment be considered painful (Jensen iasp-terminology (2005) Overview of pain pathways. In: et al, 2001). Nerve fibres may Jagger SI of pain that are commonly experienced in Holdcroft A, Jagger S (eds). Core Topics in Pain. clinical practice can include heavy work- lose their ability to desensitise Cambridge: Cambridge University Press. load, constant interruptions and problems the pain sensation and instead Jensen MP et al (2001) Self-report scales and with prescriptions. Barriers to effective evoke pain impulses (Mann et procedures for assessing pain in adults. In: Turk DC, Melzack R (eds). Handbook of Pain Assess- pain management may also include staff al, 2009). Touching or ment. New York: The Guilford Press. shortages, nurses not asking patients what massaging an amputated area Limb Loss Information Centre (2010) FAQs: Limb levels of pain they are experiencing and may cause more pain. Loss? tinyurl.com/limbloss-FAQ ● Mann EM et al (2009) Pain: Creative Approaches relying on non-verbal behaviour to assess : Increased to Effective Management. London: Palgrave pain (Mann et al, 2009; Schafheutle et al, response to painful stimuli and Macmillan. 2000). Patients may also be reluctant to lowered pain threshold McCaffrey M et al (1999) Pain: Clinical Manual. (Jensen et al, 2001). St Louis: Mosby. express their pain experience to nurses Mitchinson AR et al (2007) Acute postoperative due to psychological barriers, such as ● Central sensitisation: Can pain management using massage as an adjuvant of the meaning of the pain, of injections, occur in the dorsal horn of the therapy. Archives of Surgery; 142: 12, 158-1167. of becoming addicted to pain killers, of spinal cord due to the National Institute for Health and Clinical Excellence (2010) Neuropathic Pain: The Pharmacological becoming an unpopular patient or being increased number or intensity Management of Neuropathic Pain in Adults in disbelieved, or resignation to the pain. of the impulses generated. Non-specialist Settings. www.nice.org.uk/CG96 This demonstrates why pain assessment This results in permanent Nikolajsen L et al (2006) Phantom limb. In: McMahon SB, Koltzenburg M (eds). Wall and changes to the dorsal horn undertaken by nurses may be seen as inad- Melzack’s Textbook of Pain. Edinburgh: Churchill equate (Sloman et al, 2005). neurons (Flor, 2002). Livingstone. ● Neuromas: Commonly form Schafheutle EI et al (2000) Why is pain Treatment of neuropathic and after nerves are cut and can management suboptimal on surgical wards? Journal of Advanced Nursing; 33: 6, 728-737. phantom limb pain lead to spontaneous activity Sloman RG et al (2005) Nurses' assessment of Recommendations for the treatment of and increased sensitivity to pain in surgical patients. Journal of Advanced neuropathic pain and PLP suggest that stimulation (Wood, 2008; Nursing; 52: 2, 25-132. Todd DD et al (2006) Neuroanatomical substrates opioids, such as morphine, and the tricy- Nikolajsen et al, 2006). of spinal nociception. In: McMahon SB, Koltzen- clic antidepressant, amitriptyline, should ● Regenerative sprouting: burg M (eds). Wall and Melzack’s Textbook of be used (NICE, 2010; CREST, 2008). Gabap- Occurs at the site of nerve Pain. Edinburgh: Chuchill Livingstone. injury, which can lead to an Turk DC et al (2001) The measurement of pain entin and other anticonvulsant drugs are and the assessment of people experiencing pain. often used to treat PLP but the evidence increase in pain impulses In: Turk DC, Melzack R (eds). Handbook of Pain base on their efficacy is small (Smith et al, (Wood, 2008). Assessment. New York: The Guilford Press. 2005). These are commonly used in clinical Williamson A et al (2005) Pain: a review of three commonly used pain rating scales. 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