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Lance M. Black, MD What is the best way to Robert K. Persons, DO Eglin Air Force Base manage ? 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 (SOR: B, Milwaukee pain (PLP) exists. Treatment requires a numerous case studies) can reduce PLP. coordinated application of conservative, Pharmacotherapy, including , pharmacologic, and adjuvant therapies. anticonvulsants (), and Evaluative management (including nonsteroidal anti-inflammatory drugs adjustment, treatment of (NSAIDs), can also relieve pain (SOR: B, , and residual limb care) initial RCTs and inconsistent findings). should be tried initially (strength of Adjuvant therapies (mirror box recommendation [SOR]: C, expert therapy, , , and opinion). Other first-line treatments N-methyl d-aspartate receptor antagonists) such as transcutaneous electrical 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 , 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 -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 Clinical Inquiries 156 *Expert opinion. ; TENS,transcutaneous electricalnervestimulation. ‡ † HO, heterotopic ossification; NSAIDs,nonsteroidal anti-inflammatorydrugs;OT, occupationaltherapy;PT, physicaltherapy;TCAs,tricyclic Randomized controlled trialsorcohortstudies. Case studies. figu • Antidepressants* (TCAs)ifconcomitant • Anticonvulsant(gabapentin,pregabalin) • NSAIDs, (Attempt sequentiallyorincombination) Pharmacotherapy • Weak opioids, receptor antagonists • N-methyl-d-aspartate • Calcitonin • Virtualreality • Mirror boxtherapy • Acupuncture Adjuvant therapy

depression orotherpsychological disorders r e † acetaminophen † alternatives Consider † ‡ strong opioids † callyevaluated for treating it. criti been have few a only , as typically treated is juncttoother treatments. techniques. focus other or biofeedback by ventions inter therapeutic direct therefore mechanisms and insufficiency) vascular underlying spasm, (muscle the chronic reveal treat effectively PLP. to studies vol

58, Pharmacotherapy 2,5 N Psychotherapy can reportedly reportedly can Psychotherapy o

3 ‡

/ Management of phantom limb pain

March • Residual limbcare (eg,neuroma, HO, • Specific irritantmanagement • Referred painmanagement • Prosthesis adjustment(ifill-fitting)* Evaluative management • Orthopedics • Painmanagement • Physicalmedicineandrehabilitation Refer tospecialist 2

verrucous hyperplasia,folliculitis)* (eg, temperature, diet)* (eg, lowerback,bladder)*

2009 ‡

is best used as an ad Th e If nopainrelief Journ 2 AlthoughPLP 6 a • Referral toPT, OT, prothetist fordynamic •  Conservative management •  l of of l If nopainrelief (eg, heat,ultrasound) evaluation andotherpainmanagementmethods massage*) Desensitization techniques(TENS, Biofeedback andunderlyingmechanismtherapy Fa mily Pr mily

- - - act an oaiis n ae fe ue for used often are and modalities pain documentedhave neuropathicbenefit in gabapentin, includingAnticonvulsants, nobenefit of TCAs over placebo in PLP. demonstrated RCT recent conditions, a neuropathic pain other in (TCAs) sants theproven benefit of tricyclic antidepres pathic pain) help some neuropatients. in 2.7-6.7 CI, 95%(NNT=3.9; tramadol including opioids, other and 1.9-3.4) [CI], interval confidence [NNT]=2.5;95% treat to needed (number i ce

1-10 is present If neuroma orHO † • • • Consider referral for: Surgical removal Residual limbinjection Socket adjustment ‡ percussion,*

6,7 Despite †

- - 8

Phantom limb

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 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 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 Clinical Inquiries Read about about Read

FaCulTy Journal ofFamilyJournal Practice. The by reviewed peer and edited was It Media. Health University dowden and Cincinnati the of of sponsorship joint the through developed was activity CME This by aneducational grantSupported from AstraZeneca. no off -labeluseofdrugsordevices are discussedinthissupplement. mercial interests. haverelevant no Media disclosed fi any nancial with relationship(s) com- Health dowden for Wandersee Katherine and Williams, Charles Georgi, tol-Myers Squibb, Pfi zer,Sepracor, and Wyeth. Bristol-Myers Squibb; and is on the speakers bureau of AstraZeneca, Bris- speakers bureau for AstraZeneca, GlaxoSmithKline, andPfi zer. Glaxo and Co, & lilly Eli AstraZeneca, SmithKline. for consultant a as serves and Pharmaceuticals andreceives grant(s) from Forest laboratories. the speakersbureau ofAstraZeneca, Janssen,andPfi zer. PfiInc., Pharmaceutical America sanofi zer, and Roche, on is and -aventis; Otsuka Janssen, laboratories, Forest AstraZeneca, from grants receives PfiJanssen, AstraZeneca, for consultant zer,Pharmaceuticals; and vanda isa Pharmaceuticals; Pfi vanda and Janssen, zer, Cephalon, traZeneca, levels ofevidence. and reported, studies scientifi of balance, objectivity fair c for reviewed are materials educational All presentation. the of value the decreasing tence of these interests or relationships is not viewed as implying bias or conflthe resolve to mechanism exis- a The ict(s). initiate to Cincinnati of confla identifi is interest University of the of ict responsibility the is it ed, areidentifithat ships are ed reviewed potential for confl interest. If of icts relation- relevant All activity. this to related companies commercial the contentare required anytodisclose relevant fi nancial with relationships editors,toareposition controlwho managers,a individuals in other and According to the disclosure of policy the University of Cincinnati, faculty, ing medicaleducation for physicians. accreditedis nati College Medicine of byACCME the to provide continu- the University of Cincinnati College of Medicine. The University of Cincin- of sponsorship the through (ACCME) Education Medical Continuing for CouncilAccreditation the of Policies and Areas Essential the with dance accor- in implemented and planned been has activity CME activity. This the in participation their of extent the with commensurate credit claim a 2.5 for of activity maximum educational this designates Cincinnati of University The als whotreat patients withpsychotic andmooddisorders profession- care health other and physicians, care primary Psychiatrists, treat- long-term and short- for agent(s) appropriate most the Select • or monotherapy includes that plan eff treatment an ective develop • other and eff ects, hepatic action, of mechanisms the Understand • Utilize available screening tools eff ectively • Achieve andaccurate early diagnosis ofpatients withmooddisorders • After reviewing thismaterial, cliniciansshouldbebetter ableto: PlannInG CoMMITTee: PlannInG MuzIna DR PaRIseR DR GolDBeRG DR BlaCk DR nasRallaH DR aCknoWleDGeMenT suPPoRT FolloWInG: THe RePoRTeD Has FaCulTy THe InTeResT oF ConFlICTs anD DIsClosuRes FInanCIal sTaTeMenT aCCReDITaTIon CMe auDIenCe TaRGeT oBJeCTIves leaRnInG DaTe: exPIRaTIon DaTe: Release Columbus, Ohio Ohio State University College of Medicine director,Medical neuropsychiatry director,Medical Psychiatry Clinics Professor ofPsychiatry, Obstetrics andGynecology Cleveland, Ohio Cleveland Clinic department of Psychiatry & Psychology Associate Professor ofMedicine vice Chairfor Research &Education Silver Hospital, Hill newCanaan, Connecticut ofMedicine,Mt SinaiSchool new York, new York Associate ClinicalProfessor ofPsychiatry Iowa City, Iowa University ofIowa College Carver ofMedicine Professor ofPsychiatry Cincinnati, Ohio University ofCincinnati College ofMedicine Professor ofPsychiatry, , andneuroscience sTePHen F. PaRIseR, MD F. PaRIseR, sTePHen MD MuzIna, J. DavID MD F. GolDBeRG, JosePH MD W.BlaCk, DonalD MD, nasRallaH, a. HenRy ment to meetindividualpatient needs combination therapy on treatment impact potential and their agents available eff of metabolic ects jfponline.com jfponline.com reports that he is a consultant for Forest laboratories and Jazz Forestforand consultantlaboratories a is he that reports reports that he is on the advisory board of AstraZeneca and AstraZeneca of board advisory the on is he that reports eot ta h rcie gat fo Pizr n i onthe is Pfi and from zer grants receives he that reports © 2008 AMERICAn ACAdEMY OF ClInICAl PSYCHIATRISTS PSYCHIATRISTS ClInICAl OF ACAdEMY AMERICAn © 2008 reports that he is on the advisory board, speakers bureau, speakers board, advisory the on is he that reports reports that he is on the advisory board of Abbott, As- Abbott, of board advisory the on is he that reports DeCeMBeR 1, 2008 1, DeCeMBeR M PA aeoy credits 1 Category PRA AMA DeCeMBeR 1, 2009 1, DeCeMBeR Kay Kay Weigand, Kristen Cincinnati;and of University And dOWdEn HEAlTH MEdIA HEAlTH dOWdEn And and currentclinicalpractice.com PROGRAM CHAIR PROGRAM . hscas hud only should Physicians ™. will enhance and confi rm your own approach to diagnosing and treating patients treating and diagnosing to confi approach and own enhance your will rm in themanagement ofmooddisorders: truth ofasignifithe him defect. cant birth from hiding were parents his believed also He thinking. his preoccupied greatlyand him distressed which girlfriend, his break-upwith a to led had they and complaints, chief his were inside”“dead feeling and sadness persistent Profound, smallness. self-described his change to use supplement and lifting weight of gram symptomsratherbegan months14 abruptly earlier, coinciding intensean with pro- His own. his on medications venlafaxine,discontinuedboth then but and sertraline chologistfor treatmentswings, mood ,of given been had confusion.He and psy- and PCP his by evaluation psychiatric for referred was who man 20-year-old a careof mostinterest providers. to primary of issue 2008 december the to supplement a in appears discussion panel this of version larger A importance of being toalert critical clues in a patient’s history or the family’s history. the underscore cases these particular, In settings. outpatient and inpatient both in patients such of management of nuances the into insights practical further lends faculty the all of experience collective the which in discussion panel a by followed mood disorders, we invited 4 expert faculty members to present actual patient cases sion accompanied by symptoms ofmaniaorhypomania. care,mary far less information is available about patients in this setting with depres- pri- in depression of treatment and prevalence the on exist reports many Although T 1. Olfson M,Gameroffdas AK, MJ, etal.Screening care practice.for bipolardisorder JAMA. inaprimary REFERENCE with psychotic andmooddisorders. in primary care in primary psychotic disorders andmood Recognizing andmanaging 2005;293:956-963. ing process and an important clinical topic for primary care clinicians (PCPs). clinicians care primary for topic clinical important an and process ing evolv- an is disorders mood and psychotic of management and diagnosis he 2.5 CME

We hope the insights you glean from this exchange of practical clinical issues clinical practical of exchange this from glean you insights the hope We • Suggestions for enablingpatient compliance withprescribed regimens effan for implications • and medications available of ec- action of Mechanisms • Pros andcons ofmonotherapy andcombination therapy • Pitfalls to avoid thediagnostic during evaluation issues severalpivotal of discussion faculty a presentationis Followingcase the concerns Md,and Muzina, david by is here presentationfor selected case The and psychotic of identifi treatment the and cation on dialogue a facilitate To CREDITS FREE tive treatment plan Supplement to The Journal ofFamily Practice Supplement toTheJournal InTRoDuCTIon InTRoDuCTIon and and C URRENT P SYCHIATRY . We’ve extracted the portion that we felt would be wouldfelt we that We’veportion the extracted › HEnRY A. nASRAllAH, Md nASRAllAH, A. HEnRY ❙ Vol 57,No12s 1 ea ❙ December2008 private 1. References The Acknowledgments bilization, relaxation, and biofeedback. cludingdesensitization,TENS, mo scar controlled analgesia, or regional analgesia methorathane, or long-acting narcotics 4. 2. 3. as Medical ServiceortheUSAirForce atlarge. B S5 official, opinions Wilson pain estimating al. Ziegler-Graham the Halbert 2002;18:84-92. Pain. Chronic ment: SRA . herman habil. Wartan SW, Hamann lishing; 2002;32:427-436. tees. States: United phantom t Th • • hr ipola r

views is is opamclgc hrpe, in patient- therapies, nonpharmacologic analgesia, epidural optimal oug and Br JAnaesth. C and mood disorders in primary care Recognizing and managing psychotic or 2008;89:422-429. and mood disorders. mood and psychotic with patients of care the manage experts how out find and care primary by psychiatry to referred case a Read n 2.5 f 2.5 n M as, rice PR, crotty J, as E h and of sensation pain: Don’t miss this 12-page C 12-page this miss Don’t

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C ph Department 2001;90:47-55. r nt nt of double-blind, a incinn r BL, d ph y A. A. y critchley M, Reg AnesthPainMed. l J. Muzin J. en F. P F. en ME a d fr study F. F. D Witt R, Charrow AP, limb Wasner a 2007:1-55. Pain. randomized edit W. Bl W. o Na G pain. limb m limb a v of supplement supplement 2004;85:1-6. NB, Finnerup ol of i pain. ti ti Ast W, of ar s 2005;118:289-305. pain for ra of V a s db phantom a the pain lower pain Flor H, Anesthesiology. V Lindner G, ise n a affairs/Department eterans ck, MD ck, M, raZ placebo-controlled, clinical relief ll N Engl J Med. J Engl N d , MD , e P, eterans Affairs, treatment: o effects Do r r HJ, McQuay ah controlled in and vailable , MD , g, MD g, Buggy enec amputation. et the of Ehde JM, wd , MD, P MD, , r s limb al. cortical practice S, Kramp of pain et 2002;27:481-486. a en He en elderly.

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