Managing acute phantom limb pain with transcutaneous electrical nerve stimulation: a case report.

INTRODUCTION: Phantom limb pain is characterized by painful sensations in the amputated limb. The clinical presentation of acute phantom limb pain may differ from that of patients with chronic phantom limb pain. The variation observed implies that acute phantom limb pain may be driven by peripheral mechanisms, indicating that therapies focused on the peripheral nervous system might be successful in reducing pain. CASE PRESENTATION: A 36-year-old African male with acute phantom limb pain in the left lower limb, was treated with transcutaneous electrical nerve stimulation. CONCLUSION: The assessment results of the presented case and the evidence on acute phantom limb pain mechanisms contribute to the current body of literature, indicating that acute phantom limb pain presents differently to chronic phantom limb pain. These findings emphasize the importance of testing treatments that target the peripheral mechanisms responsible for phantom limb pain in relevant individuals with acquired amputations.

Comportamiento del dolor fantasma en pacientes amputados en Cárdenas. Periodo 2015-2019 / Phantom pain behavior in amputated patients in Cardenas. Period 2015-2019

RESUMEN Introducción: la amputación es un procedimiento quirúrgico y la incapacidad como consecuencia se puede considerar una entidad clínica. Toda respuesta a la amputación es altamente individual. Entre el 40 y 80 % de los amputados manifiestan dolor de la zona amputada o dolor de miembro fantasma. Entre todos los problemas que se pueden presentar tras la cirugía este es uno de los más graves. Objetivo: determinar el comportamiento del dolor fantasma en la población amputada en Cárdenas y la mejoría clínica de los síntomas con los diferentes tratamientos. Periodo comprendido entre 1-1-2015 al 31-12-2019. Materiales y métodos: se realizó un estudio descriptivo de corte transversal en el Hospital General "Julio Miguel Aristegui Villamil" de Cárdenas, en el período comprendido del 1-1-2015 al 31-12-2019. Con el fin de evaluar las variables clínicas y demográficas de pacientes con antecedentes de amputación unilateral de miembro y que acudieron al cuerpo de guardia y/o consultas externas de Ortopedia y Traumatología, de Angiológica y Cirugía Vascular por presentar dolor fantasma. Resultados: con respecto a la mejoría de los síntomas y del propio dolor fantasma, según la escala de evaluación del dolor (EVA), se demostró que hubo alivio muy discreto y en un 96 % de los pacientes se presentó persistencia de los mismos. Conclusiones: los resultados fueron insatisfactorios, a pesar de los tratamientos utilizados en el estudio (AU).

ABSTRACT Introduction: amputation is a surgical procedure and disability as its consequence can be considered a clinical entity. Any response to amputation is highly individual. Between 40 and 80% of amputees refer pain in the amputated area or phantom limb pain, and among all the problems that can occur after surgery, this is one of the most serious. Objective: to determine the behavior of phantom pain in the amputated population in Cárdenas from January 1st 2015 to December 31st 2019 and the clinical improvement of symptoms with the different treatments applied. Materials and methods: a descriptive cross-sectional study was conducted in the General Hospital Julio Miguel Aristegui Villamil of Cárdenas in the period from January 1st 2015 to December 31st 2019, with the aim of evaluating the clinical and demographic variables of patients with antecedents of unilateral limb amputation who attended the emergency department or outpatient Orthopedics and Traumatology, and Angiology and Vascular Surgery consultations for presenting phantom pain. Results: regarding the improvement of the symptoms and the phantom pain itself, according to the pain evaluation scale (VAS), it was shown that there was very discreet relief and its persistence in 96% of the patients. Conclusions: unsatisfactory results are observed instead of the treatments used in the study (AU).

An observational descriptive study of the epidemiology and treatment of neuropathic pain in a UK general population.

BACKGROUND: This study updated our knowledge of UK primary care neuropathic pain incidence rates and prescribing practices. METHODS: Patients with a first diagnosis of post-herpetic neuralgia (PHN), painful diabetic neuropathy (PDN) or phantom limb pain (PLP) were identified from the General Practice Research Database (2006 - 2010) and incidence rates were calculated. Prescription records were searched for pain treatments from diagnosis of these conditions and the duration and daily dose estimated for first-line and subsequent treatment regimens. Recording of neuropathic back and post-operative pain was investigated. RESULTS: The study included 5,920 patients with PHN, 5,340 with PDN, and 185 with PLP. The incidence per 10,000 person-years was 3.4 (95% CI 3.4, 3.5) for PHN; and 0.11 (95% CI 0.09, 0.12) for PLP. Validation of the PDN case definition suggested that was not sensitive. Incident PHN increased over the study period. The most common first-line treatments were amitriptyline or gabapentin in the PDN and PLP cohorts, and amitriptyline or co-codamol (codeine-paracetamol) in PHN. Paracetamol, co-dydramol (paracetamol-dihydrocodeine) and capsaicin were also often prescribed in one or more condition. Most first-line treatments comprised only one therapeutic class. Use of antiepileptics licensed for neuropathic pain treatment had increased since 2002-2005. Amitriptyline was the only antidepressant prescribed commonly as a first-line treatment. CONCLUSION: The UK incidence of diagnosed PHN has increased with the incidence of back-pain and post-operative pain unclear. While use of licensed antiepileptics increased, prescribing of therapy with little evidence of efficacy in neuropathic pain is still common and consequently treatment was often not in-line with current guidance.

Role of myofascial trigger points in post-amputation pain: causation and management.

BACKGROUND: Post-amputation pain is a multifactorial issue and thus necessitates multiple treatment strategies. Myofascial trigger points-related pain remains under diagnosed and hence not addressed. This study investigates causation and management. OBJECTIVES: To identify the presence and role of myofascial trigger points in post amputation pain. STUDY DESIGN: Post-amputation pain clinic review and recruitment. METHODS: Twenty one identified patients in the post-amputation pain clinic with myofascial trigger points were recruited, of which 13 were transtibial and eight transfemoral and all had phantom limb pain and stump pain. The trigger points were identified and injected with long-acting local anaesthetic on a weekly basis and patients were followed up on an ongoing basis. RESULTS: There was significant resolution of pain on the Visual Analogue Scale in the majority of these patients within five weeks, though some of the transtibial cohort needed further eight injections on a weekly basis for resolution of the pain. CONCLUSION: Identification of myofascial trigger points in amputation stumps and their role in post-amputation pain, followed by appropriate intervention is an important facet of management of this complex chronic pain. Clinical relevance Myofascial trigger points in amputation stumps can lead to ongoing chronic post-amputation pain and our results indicate that identification and intervention of these trigger points does lead to notable resolution of this pain.

Phantom limb pain and bodily awareness: current concepts and future directions.

PURPOSE OF REVIEW: Phantom pain is a frequent consequence of amputation or deafferentation. There are many possible contributing mechanisms, including stump-related pathology, spinal and cortical changes. Phantom limb pain is notoriously difficult to treat. Continued consideration of the factors associated with phantom pain and its treatment is of utmost importance, not only to advance the scientific knowledge about the experience of the body and neuropathic pain, but also fundamentally to promote efficacious pain management. RECENT FINDINGS: This review first discusses the mechanisms associated with phantom pain and summarizes the current treatments. The mechanisms underlying phantom pain primarily relate to peripheral/spinal dysfunction, and supraspinal and central plasticity in sensorimotor body representations. The most promising methods for managing phantom pain address the maladaptive changes at multiple levels of the neuraxis, for example, complementing pharmacological administration with physical, psychological or behavioural intervention. These supplementary techniques are even efficacious in isolation, perhaps by replacing the absent afferent signals from the amputated limb, thereby restoring disrupted bodily representations. SUMMARY: Ultimately, for optimal patient outcomes, treatments should be both symptom and mechanism targeted.

[Phantom limb pain: from physiopathology to prevention]. / Douleur du membre fantôme : de la physiopathologie à la prévention.

First described in 1545, phantom limb pain is a frequent complication after limb amputation, described by 60 to 85% of amputees. Stump pain, phantom limb sensation and phantom limb pain are often combined. Physiopathology is complex and peripheral, medullar and cortical mechanisms are combined. Pharmacological preventive treatments as well as regional anaesthesia techniques have equivalent results. Such treatments must be investigated more precisely as postoperative rehabilitation of amputees mostly depends on pain relief.

[Long-term treatment of phantom- and stump pain with Botulinum toxin type A over 12 months. A first clinical observation]. / Langszeitbehandlung von Phantom- und Stumpfschmerzen mit Botulinumtoxin Typ A über 12 Monate. Eine erste klinische Beobachtung.

Recently we were able to describe the successful treatment of phantom pain and stump pain with botulinum toxin A in a first pilot study. This case report over a 1-year period now demonstrates that long-term treatment for this indication is possible. We injected 4 x 25 IU of botulinum toxin A (Botox) into trigger points of the stump muscles of a lower limb amputee who suffered from severe phantom and stump pain. With four injections performed every 3 months, the patient became almost completely pain-free, and his intrathecal morphine therapy could be reduced to 40% of the initial dose. Intrathecal clonidine was eliminated completely, as were the oral analgesics. A surgical treatment suggested for the stump pain was no longer necessary, and we suppose that botulinum toxin can also improve the tolerance of artificial limbs in cases of stump pain.

Immediate and long-term plasticity in human somatosensory thalamus and its involvement in phantom limbs.

This paper describes studies on plasticity that the author undertook with Patrick Wall in the mid '70s, and then reviews recent related studies in humans carried out in the author's laboratory. The human studies have shown that thalamic neurons frequently have subliminal receptive fields (RFs) and immediately following a reversible block of afferent activity from the RF some neurons develop increased sensitivity to tactile stimulation at sites outside their normal RF. Also described and discussed are novel findings in patients that had a limb amputated. The results suggested an expansion of the representation of the proximal limb into the thalamic region that used to represent the amputated part. Furthermore, in those patients that had a phantom limb, microstimulation in this region induced sensations perceived as originating on the phantom.

Topical capsaicin as an adjuvant analgesic for the treatment of traumatic amputee neurogenic residual limb pain.

The treatment of amputee residual limb pain can at times be a challenge for the physician. Occasionally, traditional analgesic medication regimens cannot be used or are ineffective in relieving the pain. Topical capsaicin cream has been a beneficial adjuvant medication in the treatment of some painful conditions. The authors present three patients with traumatic upper limb amputations where topical capsaicin cream was of benefit in the treatment of neurogenic residual limb pain. The hope is that these cases will increase awareness of the potential use of capsaicin cream as an adjuvant analgesic in patients with residual limb pain. Common causes of residual limb pain and the pharmacology of capsaicin cream are discussed.

Psychosomatic treatment of phantom limb pain with post-traumatic stress disorder: a case report.

The successful treatment of severe left lower limb phantom pain is reported. Hypnosis and antidepressant drugs were the basis for the treatment which controlled the phantom limb pain and an associated post-traumatic stress disorder.

[The action of sodium valproate in central pain syndromes]. / Deistvie val'proata natriia pri tsentral'nykh bolevykh sindromakh.

A model of acute spinal and phantom pain syndromes caused by the formation of an abnormally increased excitation generator (AIEG) in the system of dorsal horns of the spine was used to study the effects of sodium valproate when used chronically in the phantom pain syndrome, when given in a single dose in the acute pain syndrome and when applied to the spine with disinhibitors inducing the pain syndrome. It was shown that during chronic administration sodium valproate produced a stress-preventive action, but failed to affect pain sensation and to prevent the development of the pain syndrome. When used in the acute pain syndrome, sodium valproate had a marked analgesic effect, and when applied to the spine it substantially reduced the manifestations of the pain syndrome. The action of sodium valproate on the AIEG can be accounted for by the higher GABA level that results in the hyperpolarization of neurons which are a part of AIEG. When the latter is formed and operates in acute and chronic pain syndromes there are differences in the functional activity of the neurochemical structures responsible for the realization of pain reaction components. This is suggested by varying effects of sodium valproate on pain sensation during acute and chronic experiments.

[The effect of fenazepam and sidnocarb in the phantom pain syndrome]. / Effekty fenazepama i sidnokarba pri fantomno-bolevom sindrome.

The phantom-pain syndrome model was used to examine the effects of phenazepam, sydnocarb and their combination in chronic oral administration. Phenazepam was shown to have no effects on the development of the phantom-pain syndrome. Sydnocarb arrested the progression of the pain syndrome, reduced its symptoms, alleviated inflammatory manifestations and extremity edema. The agent increased animals' excitability. When their combination was used, the clinical signs of the pain syndrome developed in the same way as with sydnocarb alone. At the same time phenazepam decreased the animals' aggression and excitability caused by sydnocarb. It is suggested that enhancing the efficiency of inhibitory GABAergic processes may result in lower clinical signs of the phantom-pain syndrome in case of involvement of brain catecholaminergic systems whose activation increases the inhibitory functions of its related GABA. The sympathomimetic action of sydnocarb induces an elevation of norepinephrine concentrations in the nerve endings and postsynaptic receptors, resulting in trophic improvement and restoration of tissue viability.

Transcutaneous electrical nerve stimulation after major amputation.

We studied the effect of transcutaneous electrical nerve stimulation (TENS) on stump healing and postoperative and late phantom pain after major amputations of the lower limb. A total of 51 patients were randomised to one of three postoperative treatment regimens: sham TENS and chlorpromazine medication, sham TENS only, and active low frequency TENS. There were fewer re-amputations and more rapid stump healing among below-knee amputees who had received active TENS. Sham TENS had a considerable placebo effect on pain. There were, however, no significant differences in the analgesic requirements or reported prevalence of phantom pain between the groups during the first four weeks. The prevalence of phantom pain after active TENS was significantly lower after four months but not after more than one year.

[Contralateral local anesthesia in stump, phantom and post-traumatic pain]. / Kontralaterale Lokalanaesthesie (KLA) bei Stumpf-, Phantom- und posttraumatischem Schmerz.

Contralateral local anaesthesia was employed in patients with chronic (n = 42) and acute (n = 8) pain syndromes (see Table 1). I. Phantom limb and stump pain: n = 10; II. Pain of face and ear: n = 10; III. Pain of neck and trunk: n = 14; IV. Pain of the hip joint: n = 6; V. Pain of the extremities: n = 10: Sa. = 50 patients. Among these were n acute pain syndromes: I.: n = 0; II.: n = 1; III.: n = 1; IV.: n = 1; V.: n = 5 (Sa.: n = 8). 42 patients with chronic pain syndromes were treated with contralateral local anaesthesia (CLA). In 27 patients CLA displayed a clear effect upon the chronic pain; in 8 patients pain release was more than 50%, in 15 patients pain release was less than 50%. 3 patients relapsed into their former condition of pain. CLA was without any positive influence in 12 cases. The medium frequency of treatments was between 5 and 6 in both groups. The average time of treatment amounted to 6 and 7 months respectively. In 8 patients with acute pain syndromes contralateral local anaesthesia produced the following results: 6 patients were permanently released from their pain; in 2 patients CLA remained without any success. The average frequency of treatment was 1.25; the average time of observation was 2.3 months. Hence we suggest that CLA should be employed as early as possible in acute or chronic posttraumatic or postoperative pain syndromes. The influence of contralateral pain therapy on acute and chronic pain conditions of the opposite side can be affirmed; its mechanism remains to be clarified. Obviously it is possible to exert an inhibitory influence from the contralateral side upon peripheral, spinal, reticular and thalamic regions, which can lead to the extinction of acute and chronic pain conditions on the opposite side. According to our experiences it is necessary that the cerebro-spinal nerve system - apart from the traumatic lesion - is intact and that the pain syndrome is not maintained by a psychic disturbance.

Chlorprothixene (taractan) in post-herpetic neuralgia and other severe chronic pains.

Two trials of chlorprothixene were carried out, mainly on patients with moderate to severe post-herpetic neuralgia. When the drug was given as 50 mg b.d. to outpatients, unpleasant side-effects were more important than slight effects in alleviating pain. When the drug was given as 50 mg 6 hourly to inpatients for 5 days only, there was alleviation of constant chronic pain in a third of the patients; the effect is still lasting over a period of months in a few patients. The side-effects during the course of treatment are prominent. It is concluded that the drug is worth trying in the course recommended by Farber and Burks [1] when other means of controlling postherpetic neuralgia have failed. It would be best to give the course only to inpatients.