THE RICHEIMER PAIN UPDATE
from The Richeimer Pain Institute
July 2000

PHANTOM LIMB PAIN

Almost every month I have a patient who comes to me in such severe pain that they ask, "Doctor, can't you just cut the nerve?" Sometimes their distress is so great that they will suggest that I amputate the painful limb. This seems to be the logical, if horrific, end to all their pain. However, phantom limb pain is our proof that such drastic measures are likely to fail. We can suffer with severe pain, even when the painful part is no longer part of the body.

There are hundreds of thousands of patients in the United States that have undergone amputations and who suffer with persistent phantom limb pain. This pain can affect mastectomy patients as well as patients with simple tooth extractions. Phantom sensations of some kind are almost universal in patients that have undergone limb amputations. Significant pain occurs in as much as 80% of these patients, but seems to improve over time in at least half of these patients.

The cause of phantom pain is not fully understood. It is important to emphasize that the pain is not imagined, and is not the result of a psychological or emotional disturbance. We have learned that the central nervous system (the brain and the spinal cord) is capable of creating "memories" of pain that can cause the pain to persist. Furthermore, normal sensation plays an important role in inhibiting pain. (Notice our tendency to rub an area that has been injured.) The loss of a limb means that pain sensations can persist without the brakes of the normal sensations of touch and movement.

Treatment:
Before initiating treatment, it is important that the clinician carefully distinguish phantom pain from stump pain. The latter can be caused by neuromas (nerve sprouts from the ends of damaged or cut nerves), by excessive compression, by infection, or by a recurrence of the underlying disease.

There are many treatments that can help with phantom pain, but no single approach is universally successful. In fact the best approach may be to mix multiple treatments. Phantom pain is the prime example of neuropathic pain; i.e., pain that is caused by a damaged or malfunctioning nervous system. Therefore, all the medications that are used for neuropathic pain can be useful for phantom pain. This includes anti-convulsant and antidepressant medications. Transcutaneous electrical nerve stimulation (TENS) of the stump can occasionally provide relief. Interestingly, stimulation of the intact, opposite limb is often more effective. In some patients, rehabilitation with active exercise and use of the stump and a prosthesis can be the most beneficial treatment. Placement of spinal electrical stimulators has had mixed results, but if the pain has been refractory to all prior treatments then this should be considered.

Prevention:
Perhaps even more important than treatment is prevention. There is some evidence that the chance of developing phantom pain can be reduced by the use of regional anesthesia to provide thorough pain relief prior to surgery and for the first few postoperative days.

We clearly have much to learn about phantom pain, and there is much exciting research in this area. Meanwhile, although cure is not always possible, careful assessment and treatment can often bring about significant improvement.

Until next time…Steven Richeimer, M.D.

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Steven Richeimer, MD
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