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What Is the Best Way to Manage Phantom Limb Pain?

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What Is the Best Way to Manage Phantom Limb Pain? View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by University of Missouri: MOspace Evidence Based Answers CLINICAL INQUIRIES from the Family Physicians Inquiries Network Lance M. Black, MD What is the best way to Robert K. Persons, DO Eglin Air Force Base manage phantom limb pain? Family Medicine Residency, Eglin AFB, Fla Barbara Jamieson, MLS Medical Librarian, Medical Evidence-based answer College of Wisconsin Libraries, No single best therapy for phantom limb [RCTs]), and biofeedback (SOR: B, Milwaukee pain (PLP) exists. Treatment requires a numerous case studies) can reduce PLP. coordinated application of conservative, Pharmacotherapy, including opioids, pharmacologic, and adjuvant therapies. anticonvulsants (gabapentin), and Evaluative management (including nonsteroidal anti-inflammatory drugs prosthesis adjustment, treatment of (NSAIDs), can also relieve pain (SOR: B, referred pain, and residual limb care) initial rcTs and inconsistent findings). should be tried initially (strength of Adjuvant therapies (mirror box recommendation [SOR]: C, expert therapy, acupuncture, calcitonin, and opinion). other first-line treatments N-methyl d-aspartate receptor antagonists) such as transcutaneous electrical nerve haven’t been rigorously investigated for stimulation (TENS) (SOR: A, multiple alleviating PLP, but can be considered for high-quality randomized, control trials patients who have failed other treatments. FAST TRACK Treatment of z Evidence summary ting prosthesis or providing the patient An estimated 1.7 million people in the with NSAIDs when there is evidence of phantom limb United States are living with limb loss. stump inflammation may adequately pain requires The number is expected to increase be- control pain.2,3 Anatomically distant a coordinated cause of ongoing military conflicts.1 The pain syndromes, such as hip or lower application of incidence of PLP is 60% to 80% among back pain, can also aggravate PLP and amputees.1 should be managed to provide optimal conservative, pain relief.2 pharmacologic, A multidisciplinary approach Desensitization, using TENS, has re- and adjuvant A lack of comparative clinical trials of duced PLP in multiple placebo-controlled therapies for PLP has led health-care trials and epidemiologic surveys.2-5 TENS therapies. providers to adopt a multidisciplinary is an easy-to-use, low-cost, noninvasive, approach that combines evaluative man- first-line therapy.5 Its long-term effective- agement, desensitization, psychotherapy, ness in alleviating PLP remains unknown.2 and pharmacotherapy (FIGURE). Some experts suggest that pain reductions Evaluative management, based after 1 year of treatment are comparable largely on expert opinion, includes as- to placebo.2 Other forms of desensitiza- sessing the fit of the prosthesis, treating tion (percussion and massage) are sup- referred pain, and assessing aggravating ported only by anecdotal reports. factors. Because residual limb pain can Psychotherapy, including biofeed- exacerbate PLP, adjusting a poorly fit- back, has been found in several case www.jfponline.com VOL 58, NO 3 / MARCH 2009 155 ES I R I FIGURE INQU Management of phantom limb pain1-10 AL C Evaluative management If neuroma or HO is present CLINI • Prosthesis adjustment (if ill-fitting)* • Referred pain management (eg, lower back, bladder)* Consider referral for: • Specific irritant management • Socket adjustment (eg, temperature, diet)* • Residual limb injection • Residual limb care (eg, neuroma, ho, verrucous hyperplasia, folliculitis)* • Surgical removal If no pain relief Pharmacotherapy Conservative management (Attempt sequentially or in combination) • Desensitization techniques (TENS,‡ percussion,* • nsaIDs,† acetaminophen massage*) • Weak opioids,‡ strong opioids‡ • Referral to PT, oT, prothetist for dynamic • anticonvulsant (gabapentin, pregabalin)‡ evaluation and other pain management methods • Antidepressants* (TCAs) if concomitant (eg, heat, ultrasound)† depression or other psychological disorders • Biofeedback and underlying mechanism therapy† Consider If no pain relief alternatives Adjuvant therapy Refer to specialist • acupuncture† • Physical medicine and rehabilitation • Mirror box therapy† • Pain management • virtual reality • orthopedics • calcitonin† • n-methyl-d-aspartate receptor antagonists HO, heterotopic ossification; nsaIDs, nonsteroidal anti-inflammatory drugs; oT, occupational therapy; PT, physical therapy; TCAs, tricyclic antidepressants; TENS, transcutaneous electrical nerve stimulation. *Expert opinion. †Case studies. ‡Randomized controlled trials or cohort studies. studies to effectively treat chronic (number needed to treat [NNT]=2.5; PLP.2,5 Psychotherapy can reportedly 95% confidence interval [CI], 1.9-3.4) reveal the underlying mechanisms and other opioids, including tramadol (muscle spasm, vascular insufficiency) (NNT=3.9; 95% CI, 2.7-6.7 in neuro- and therefore direct therapeutic inter- pathic pain) help some patients.6,7 Despite ventions by biofeedback or other focus the proven benefit of tricyclic antidepres- techniques.2 sants (TCAs) in other neuropathic pain Pharmacotherapy is best used as an ad- conditions, a recent RCT demonstrated junct to other treatments.2 Although PLP no benefit of TCAs over placebo in PLP.8 is typically treated as neuropathic pain, Anticonvulsants, including gabapentin, only a few medications have been criti- have documented benefit in neuropathic cally evaluated for treating it.6 Morphine pain modalities and are often used for 156 VOL 58, NO 3 / MARCH 2009 THE JOURNAL OF FaMILY PRactIce Phantom limb pain management PLP.6 However, their value in reducing are promising and have prompted fur- PLP is still under investigation.6 One ther research.11 2002 RCT showed benefit regarding an improvement of the visual analog scale Recommendations by an average of 3 points (on a 10-point The US Department of Veterans Affairs scale) after 6 weeks of gabapentin ther- and Department of Defense recently issued apy.9 A similarly designed 2006 RCT of clinical guidelines for rehabilitating lower- gabapentin, however did not identify sig- limb amputees that include a segment on nificant pain reductions.10 pain management.12 The guidelines stress the importance of an interdisciplinary Promising adjuvant therapies team approach that addresses each pa- use mirroring techniques thology plaguing the amputee. Of the adjuvant treatments mentioned They recommend narcotics during previously, only mirror box therapy has the immediate postoperative period, fol- shown promise. This technique allows the lowed by transition to a non-narcotic amputee to perceive the missing limb by medical regimen during the rehabilitation focusing on the reflection of the remain- process. The guidelines don’t support a ing limb during specific movements and single, specific pain control method over activities. Theoretically, this perception others; they recommend the following allows reconfiguration of the amputee’s approaches to PLP: sensory cortex. • pharmacologic treatment, which Virtual reality therapy employs simi- may include antiseizure medications, tri- lar techniques based on the idea that the cyclic antidepressants, selective serotonin brain can be deceived. Initial case studies reuptake inhibitors, NSAIDs, dextro- FAST TRACK Of the available adjuvant treatments for managing phantom limb pain, only mirror CLINICAL INQUIRIES box therapy online this month at www.jfponline.com has shown promise. • Does routine amniotomy have a role in normal labor? • Does reducing smoking in the home protect children from the effects of second-hand smoke? Get the answers to these Clinical Inquiries by going to www.jfponline.com and clicking on “Online Exclusives” in the left-hand navigation bar. www.jfponline.com VOL 58, NO 3 / MARCH 2009 157 ES I R I INQU methorathane, or long-acting narcotics 5. Baron R, Wasner G, Lindner V. Optimal treatment of phantom limb pain in the elderly. Drugs Aging. • epidural analgesia, patient- 1998;12:361-376. AL C controlled analgesia, or regional analgesia 6. Finnerup NB, Otto M, McQuay HJ, et al. Algorithm • nonpharmacologic therapies, in- for neuropathic pain treatment: an evidence-based cluding TENS, desensitization, scar mo- proposal. Pain. 2005;118:289-305. CLINI 7. Huse E, Larbig W, Flor H, et al. The effect of opioids n bilization, relaxation, and biofeedback. on phantom limb pain and cortical reorganization. Pain. 2001;90:47-55. Acknowledgments 8. Robinson LR, Czerniecki JM, Ehde DM, et al. Trial of amitriptyline for relief of pain in amputees: re- The opinions and assertions contained herein are the sults of a randomized controlled study. Arch Phys private views of the authors and not to be construed Med Rehabil. 2004;85:1-6. as official, or as reflecting the views of the US Air Force Medical service or the us air Force at large. 9. Bone M, Critchley P, Buggy DJ. Gabapentin in postamputation phantom limb pain: a random- ized, double-blind, placebo-controlled, cross-over References study. Reg Anesth Pain Med. 2002;27:481-486. 1. Ziegler-Graham K, MacKenzie EI, Ephraim PL, et 10. Nikolajsen L, Finnerup NB, Kramp S, et al. A ran- al. Estimating the prevalence of limb loss in the domized study of the effects of gabapentin on post- United States: 2005 to 2050. Arch Phys Med Re- amputation pain. Anesthesiology. 2006;105:1008- habil. 2008;89:422-429. 1015. 2. Sherman RA. Postamputation pain. In: Jensen TS, 11. Chan BL, Witt R, Charrow AP, et al. Mirror therapy for Wilson PR, Rice AS, eds. Clinical Pain
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