Prosthetic and Amputee Pain

8/6/2019 Prosthetic and Amputee Pain

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BC Werner, MDPhysical Medicine & Rehabilitation

UCSF Department of Orthopaedic Surgery

Orthopaedic Trauma Institute

San Francisco General Hospital

Amputee Pain



Outline

Amputee Pain Historical Perspective

Current State of Amputee Pain Amputee Pain

– Residual Limb Pain

– Phantom Limb Pain Treatment

Future Considerations



Mount Rushmore



Ambroise Paré

(1510-1590) French surgeon to Kings

Innovator in battlefield medicine

Designed elaborate armor prosthetic limbs

Complete Analysis of Post-Amputation Syndrome Differentiated phantom-limb sensation “pain-free exteroceptive

sensations” from phantom-limb pain “la douleur ès partiesamputées”

Made a clear distinction between phantom (faux sentiments) andresidual limb pain – Proposed neurological models to explain the etiology of phantom-limb pain

1. peripheral changes in stump nerves2. involved memory, suggesting a cerebral origin of pain

"the patients who have, many months after cutting away of the leg,grievously complained that they still felt great pain of the leg so cut off. . . the patients imagine they have their members yet entire"

http://www.oldbookillustrations.com/gallery/monuments/halle-university.jpg



René Descartes

(1596 –1650) Philosopher and Mathematician Formulated the modern version of the mind –body paradigm Incongruencies in Objective Experience

– Pain-sensations warn us of bodily damage

– Pleasure leads us to approach things that (usually) are good for us. “God or nature” set up these relations for our benefit Our sensations are good guides for most circumstances In certain situations there can be errors in how we sense the

world

“Nerves which reliably tell us when we have hurt our foot,convey the false information to the amputee that he has pain ina foot which is not there.”

Our senses are not perfect, but within the finite mechanisms of the human mind and body, they are the best we can have



Aaron Lemos

(1774-??) Medical Student at Universitie de Halle 1798 dissertation “The Continuing Pain of an Amputated Limb” “. . . remarks of patients under my care directed my attention to a matter

which, in itself, is scarcely new, and yet, it seems to me, still unsatisfactorily explained.”

Unique theoretical description of processes underlying phantom pain Sensation was carried by the nerves and effected in the brain After an amputation - the power of the nerves to act on the brain is

diminished but remains “Only his eye and the useless attempts at using the now removed limb

convince the patient of his fallacy.” The mind faced with this disconnect relies on memory and long-

standing associations to reconstruct the lost function “Therefore the mind, repeatedly persuaded by sight, will get used to the

loss of the limb with the passage of time and will establish a new association series.”





(1829-1914) Physician and Writer

Credited with earliest modern medicaldescription of phantom limb pain Ran Philadelphia’s Turner’s Lane “Stump”

Hospital “The Case of George Dedlow”

– fictional account of quadruple amputee

Introduced to general public

Silas Weir Mitchell



Herman Melville

Phantom limb pain immortalized in Americanliterature, with graphic descriptions of Captain

Ahab’s phantom limb in Moby-Dick.

"A dismasted man never entirely loses thefeeling of his old spar. . . And I still feel thesmart of my crushed leg, though it be now so

long dissolved"



Medical Community

Phantom limb pain was not “recognized” inMedicine until 1941

Following a study of 50 patients at the Mayo Clinicpublished by Bailey and Moersch Index Medicus recognized this term in 1954 As of January 2008, over 259 citations in MEDLINE

have “phantom limb pain” as a title word and 893have this term in any field

Besides the limbs, painful phantoms have beendescribed for eyes, nose, teeth, tongue, breast,bladder, and genital organs



Statistics

Over 200,000 Surgical Amputationsperformed per year in the U.S.

1.7 million people living with limb loss(Ziegler-Graham 2008)

It is estimated that one out of every 200

people in the U.S. has had an amputation.(Adams) Pain is the most common complaint after

Amputation

http://en.wikipedia.org/wiki/File:Johannes_Mueller.jpg



Johannes Müller

(1801 –1856)

“The belief that these sensations are losta short time after amputation is an error of medical men, who generally do notwatch the patients longer than a fewhours”

http://en.wikipedia.org/wiki/File:Johannes_Mueller.jpg



Prevalence of Pain Symptoms

Phantom Pain Phantom Sensation Residual Limb Pain Back Pain Contralateral Pain

Kooijman 124 UE 51% 76% 49% NR NR

Schley 96 UE 44.60% 53.80% 61.50% NR NR

Ephraim 914 79.90% NR 67.70% 62.30% NR

Ebde 255 LE 72% 79% 74% 52% NRKern 537 74.50% 73.40% 45.20% NR NR

Ebrahimzadeh 31 TF 45.10% 87% 64.50% 61.20% 54.80%

Ebrahimzadeh 200 TT 17% 54% 42% 44% 38%

Hanley 104 UE 79% NR 71% 52% 33%

2000 – 20092261PLP 58% (45-79)RLP 59% (42-71)

BP 55% (44-62)



Severity

48% experienced pain few times per day or more(Kooijman)

64% experienced moderate to very much suffering fromthe phantom pain (Kooijman)

Nearly all (95%) experienced 1 or more types of amputation-related pain in the previous 4 weeks(Ephraim)

Across all pain types, a quarter of those with painreported their pain to be “extremely bothersome”(Ephraim)

Or to spin it - For most, the pain is episodic and notparticularly disabling (Ebde)



Evaluation

Several origins of Amputee Pain Approach from a broad perspective Considers all potential causes Understand pain impact on function Adequate history Thorough physical examination Appropriate Tests Amputation is not a static condition

– progressive deteriorating condition – affecting the health of the amputee over time

Resist the initial tendency to consider all painas being phantom pain



Time Frame

Early complications – Dehiscence (9.4%) – Superficial infection (14.6%) – Deep infection (26%)

Infection can also present or be detected late . . . Retrospective review 7 TF and 3 TT amputees Residual limb pain and delayed healing prompted

radiological, hematological and microbiological investigations Residual Limb Osteomyelitis diagnosed with . . . Average time between amputation and diagnosis of187 days RLO should be considered in any case of delayed wound

healing or residual limb pain in amputees(Smith)



Amputee Pain & Depression

Sampled 914 with limb loss Prevalence for significant depressive symptoms was 28.7% Risk factors:

– being divorced or separated – living at the near-poverty level

– having comorbid conditions – Presence of bothersome back pain – Presence of bothersome phantom limb pain – Presence of residual limb pain

(Darnall)

Lower levels of phantom limb pain and stump pain associatedwith positive adjustment to limb loss

(Horgan)





Etiology of Pain

Residual Limb Pain – Neuroma – Prosthetic Fit Issues – Scarring and Healing Issues

– Orthopaedic Problems• Bony Overgrowth

• Ostemoyelitis

• Stress Fracture

• Arthritis

– Trophic Skin Changes• Cellulitis

• Folliculitis

– Tumor Recurrence



Neuromas

Develop in all residual limbs after amputation Post-traumatic changes to nerve ends – Na

Channels Hypersensitive and prone to afferentactivity

Problematic when entrapped in scar tissue or inposition where they are exposed to externalmechanical loading

Neuropathic Lancinating Pain

– Tinel’s sign – Manual palpation – Socket pressure – Traction of adherent scar tissue



Neuromas

Socket modification Gel socks, liners, redistribute loads

reduce shear pressures Local anesthetic / steroid injection

– therapeutic and diagnostic

Resection of Neuroma – neuroma moved to a deeper site or byplacing the nerve end in bone

– Can reform and become symptomatic



Bone Issues

Arthritis Joints proximal to the site of amputation

– hips, knees, shoulder

Use of a prosthesis can place more strain onthe proximal joints contributing to arthritis pain Treatment algorithms for non-amputees should

be used to maintain function in a prosthesisuser (hip replacement)

Knee osteoarthritis may be partially relieved bythe addition of knee joints and a thigh corset toallow shared weight bearing between theresidual limb and the thigh



Bone Issues

Terminal Overgrowth – Problematic Issue in Skeletally Immature

• Metaphyseal Level > Diaphyseal

• Humerus, Fibula, Tibia, and Femur

• Case Reports of bone overgrowth in Adults (Dudek) Diagnosis

– Distal Residual Limb Pain – Tissue compression – Localized Pain and Tenderness

– Bursa formation – Skin ulceration Obtain Radiographs Treatment

– Socket modification

– Surgical resection of bone



Bone Issues

Heterotopic Ossification – More common in traumatic/combat – Blast Injuries – Amputations performed in zone of

– Asymptomatic – Painful and Refractory - surgical excision(Potter)

Fractures – Decreased bone density in Residual Limb – Hip and Distal Portion (Sherk) – TF osteoporosis and fragility fractures in the hip

(Gonzalez) – Fall while wearing the prosthesis as the most common

cause of injury



Tumor Recurrence

Tumor Recurrence

Late pain occurs in a limbamputated because of tumor

Local recurrence is a

possibility



Dermatologic Disorders

Prevalence 30-50% Hyperhidrosis

– More prevalent since advent of silicone liners• Contact Dermatits

• Infection

• Cellulitis and Folliculitis

Keratin plugging of sebaceous glands with follicular hyperkeratosis

– Epidermoid Cysts – Dermal Granulomas

Round or oval swellings deep within the skin Sensitive to touch or pressure The skin may break down and erode or ulcerate



Phantom Sensation

Awareness of non-painful sensation in amputated part of alimb

Resembles the somatosensory experience of the physicallimb before amputation – warmth, itching, sense of position, and mild squeezing

Phantom limb sensations 90-98% in immediate post-opperiod

Typically is more intense in the early stages after amputation and can gradually fade with time – The more distal segments (toes etc.) tend to present the most

vivid sensations – In some cases the symptoms persist – treatment is not typically required (nonpainful)

71% (54-87%)



Phantom Pain



Phantom Pain

Pain perceived in the amputated portionof the extremity

Described as burning sensation, cramp,stabbing, squeezing, prickling, shooting

Phantom Posture – Painful contortions of the limb

– Clenched fist – Spasm – Fingernails digging into palm



Prevention

Correlation of phantom limb pain with pre-amputationpain

Aggressive attempts to control peri-amputation limb

pain – Epidural

– Peripheral nerve anaesthesia



Phantom Pain

Pathophysiology

Not completely understood

Has this changed in 500 years

Several Proposed Theories

– Peripheral and Spinal Sensitization

– Somatosensory Cortical Rearrangements

– Neuromatrix Theory



Phantom Pain

The treatment of phantom pain is difficult

No one treatment has shown to be

effective in a majority of sufferers. – Can often require many therapeutic

modalities



Phantom Pain

“Most bothersome to Mitchell was the fact thatthere was still not an effective way to treat thispainful disorder. Additional amputations, nerve

resection, cauterization, acupuncture, opiates,morphine, atropine, and other drugs had beentried, but even when changes for the better were observed, they rarely lasted.” (Finger)





Gabapentin

Double Crossover Study 24 patients with RLP or PLP 5-week washout interval Titrated 300 mg - 3,600 mg Measures of pain intensity, pain interference, depression, life

satisfaction, and functioning were collected throughout the

study. Analyses revealed no significant group differences in pre- toposttreatment change scores on any of the outcome measures.

(Smith)

Double Crossover Study 19 patients 6 weeks UE/LE PLP 1 week washout Gabapentin and placebo both reduced pain vs. baseline but

after 6wks, gabapentin was better There was no difference in mood, sleep interference or function

with respect to ADL’s (Bone)



Tricyclics

Double Blind Controlled Study 39 patients with at least 6 mos PLP 6 wks of amitriptyline (titrated up to 125

mg/d) vs. placebo No difference between drug and placebo Not effective in the treatment of phantom

limb pain at the dose used(Robinson)



Botulinum Toxin

Report of 3 phantom and stump pain patients, refractive toprevious treatments

All three patients evaluated the clinical global improvementwith 3 (marked improvement)

The pain intensity and pain medication was reduced

significantly in all three cases The duration of response lasted up to 11 weeks(Lin)

Case series 4 patients with chronic PLP > 3yrs Injection into 4 areas with 100 IU BTX-A Follow-up 1, 2, 5 wks All reported pain decrease by 60-80% Frequency of pain in 3 down by 90%

(Kern)



Opioids

Study of 42 cancer patients with limb amputation Effectiveness of WHO 3-step analgesic ladder in

treating residual limb & phantom limb pain Monitored monthly first 2 months postoperatively and

Q2 months for 2 years. Month 1 versus 2 years after addition of opioid - %

with phantom pain decreased from 60% to 32% % of patients with stump pain decreased from 31% to

5% Analgesic ladder / use of opioids may help inmanagement of phantom limb pain

(Mishra)



Opioids and Mexiletine

60 patients with 6+ months of PLP 3 treatment arms

– morphine, mexiletine, placebo 4 wk titration, 2 wk maint, 2 wk taper, 1 wk washout

period between treatment arms 35 pts completed all 3 arms; mean dose morphine

112mg/day, mexiletine 933 mg/day Pain Decrease: morphine 53%, mexiletine 30%,

placebo 19% Morphine associated with high incidence side effectsand did not improve overall functional activity and

pain-related daily activit(Wu)



Ketamine / Memantine: NMDA Antagonist

Ketamine or placebo randomized to receive at anesthesia inductionand for 72hrs post-op

45 Patients AKA + BKA pts F/u at 6 months to eval for incidence of PLP Incidence of PLP was 71% in control group, 47% in ketamine group

- not statistically significance (p=0.28)(Hayes)

Memantine vs. placebo over 4 wk period 36; Post-traumatic amputees, 56% UE, 44% LE with > 12 months PLP 2 wks, then tapered off for 1 wk Pain relief in memantine avg 47%, placebo group 40% Ten pts in the memantine group (56%) and 6 in the placebo group

(33%) had pain relief greater than 50%(Maier)



Memantine

2 Case reports

27yo M bilat TF on methadone 10mg TID, gabapentin 1200mgTID, amitriptyline 75mg qHS, celecoxib 200mg BID, dilaudidPCA at 100mg/day

Rec’d memantine 10mg BID x 6 mo. Off opioids on day 1,maintained PLP free on celecoxib only at 8 mo.

21yo M R TT on methadone 5mg TID, dilaudid PCA at80mg/day, iv fentanyl, nortriptyline 100mg qHS, gabapentin900mg TID.

Rec’d memantine 10-15mg BID x 4 mo. PLP free and off allmeds at 4 mo

(Hackworth)



Central Stimulation

3 patients Deep Brain Stimulation of periventricular grey matter and

somatosensory thalamus for the relief of chronic neuropathicpain associated with phantom limb in three patients

Assessed preoperatively and at 3 month intervals

postoperatively up to 13 months Periventricular gray stimulation alone was optimal in two

patients, combination of periventricular gray and thalamicstimulation produced the greatest degree for third patient

Intensity of pain was reduced by 62% (range 55-70%) In all three patients, the burning component of the pain was

completely alleviated. morphine sulphate intake was reduced in the two patients

Quality of life measures indicated a statistically significantimprovement

(Bittar)









Virtual Reality Therapy

8 Male participants with phantom limb pain(PLP)

Several times per week times per week for 8followed movements of virtual image of amissing limb

Patients reported an average 38% decrease inbackground pain on a visual analog scale(VAS), with 5 patients out of 8 reporting a

reduction greater than 30% This decrease in pain was maintained at 4weeks postintervention in 4 of the 5participants

(Mercier)



Cortical Re-Organization

“Aware of the lack of a once associated organ,the mind tried to supply its functions. But sincethe mind had become accustomed toassociation, it strove immediately to restore

the original association . . . And therefore themind, repeatedly persuaded by sight, will get used to the loss of the limb with the passageof time and will establish a new association

series. It is only after a long time that thisfallacious sensation is utterly extinguished,because the mind cannot immediately remove

previously acquired associations and needstime to get used to these new

representations.” – Aaron Lemos 1798



Prosthesis Use

Case series 21 UE Amputee Constraint-induced movement therapy ala post-CVA

to reverses cortical-reorganization caused by disuse 9 pts used Sauerbruch prosthesis 12 pts used a cosmetic prosthesis VAS for pain intensity before and after prosthetic use. PLP pain decrease in treatment group was signif

(p<0.02) Difference between groups was signif (p<.005)

(Weiss)



Cortical Re-Organization

Captain Ahab: “Look ye, carpenter, I dare say thou callest thyself a rightgood workmanlike workman, eh? Well, then, will itspeak thoroughly well for thy work, if, when I come tomount this leg thou makest, I shall nevertheless feelanother leg in the same identical place with it; that is,carpenter, my old lost leg; the flesh and blood one, Imean. Canst thou not drive that old Adam away?”





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Prosthetic and Amputee Pain