Phantom Limb Pain Treatment

By:R A Candra Putra (5718035)

Auntouch T (5718036)Harashdeep Grover (5718037)Rina F Rahmawati (5718038)

Contents

• Introduction• Causes• Treatment

– Pharmacological Treatment– Nonpharmacological Treatment– Surgical Treatment

• Conclusion

The concept of Phantom Limb Pain as being in pain that feels like it's coming from a body part that's no longer there.

Doctors once believed this post-amputation phenomenon was a psychological problem, but experts now recognize that these real sensations originate in the spinal cord and brain.

Introduction

•The exact cause of phantom pain is unclear, but it appears to originate in the spinal cord and brain.

•During imaging scans — such as magnetic resonance imaging (MRI) or positron emission tomography (PET) — portions of the brain that had been neurologically connected to the nerves of the amputated limb show activity when the person feels phantom pain.

•A number of other factors are believed to contribute to phantom pain, including damaged nerve endings, scar tissue at the site of the amputation and the physical memory of pre-amputation pain in the affected area.

Causes

PHARMACOLOGICAL TREATMENT

PreEmptive Analgesia and Anesthesia

absence of sensibility to pain, particularly the relief of pain without loss

 of consciousness;  or noxious stimulation.

Lack of feeling or sensation

Advantages

•Stable intraoperative conditions (e.g. Cardiovascular)•Effective•Reduced nausea and vomiting•No effect on urinary function.•Improved early mobilization of major joints.

•Time consuming –takes around 15-30 minutes to be effective•Failure rate about 5% even in the best hands.•Inadequate training of consultants and trainees.

Disadvantages

Acetaminophen and Nonsteroidal Anti-Inflammatory Drugs

( NSAIDs )

  A cross sectional study found that acetaminophen and NSAIDs were the

most common medications used in the treatment of PLP .

The analgesic mechanism of acetaminophen is not clear but serotonergic and multiple other central nervous system pathways are likely to be involved.

NSAIDs inhibit the enzymes needed for the synthesis of prostaglandin and decrease the nociception peripherally and centrally.

One of the major side effects is that they decrease the effect of the normal blood clotting factors in blood.

Opioids (Morphine)

• Bind to CNS and PNS• Provide analgesia

without loss of touch, proprioception, or conciousness

• Effective for treatment neuropathic pain including PLP, Diminish cortical reorganization (Huse E 2001)

• Controversial and their use is limited due to the side effects and potential for abuse

Tricyclic Antidepressant (TCAs)• Commonly used for

neuropathic pain• Analgesic – inhibition of

serotonin-norephineprine uptake blockade

• Average dose of 55mg of amitriptyline is effective to control PLP

• Nortryptyline and desipramine equally effective with less side effects

• Side effects - cardiotoxicity, orthostasis, tachycardia, arrhythmias, insomnia, dizziness, weight gain, and anticholinergic effects

Anticonvulsants

• Anticonvulsants - prevent or reduce the severity and frequency of seizures in various types of epilepsy but which are also effective for pain. They work in a number of different ways, all of which have relevance to their effect on pain.

• Gabapentin – show positive result in controlling PLP by inhibitory action at voltage-gated calcium channels The most common side effects were dizziness and somnolence, but weight gain, nausea, abdominal pain, asthenia,

• Carbamazepine has been reported to reduce pain associated with PLP

• Oxcarbazepine and pregabalin – need further studies

NMDA receptors play a role in sensitization at the spinal cord level

memantine produce an analgesic effect that may be beneficial in the treatment of PLP

it may be successful in treating PLP if initiated in early post-amputation period(Hackworth, et al 2008)

CalcitoninNMDA receptor

antagonists Calcitonin is a peptide with high a molecular weight.

The exact mechanism of action is still unclear (Eichenberger, et al 2008)

But it leads to decreased formation of local cytokines and prostaglandin

It may reduce the intensity and frequency of pain; however, a more recent randomized, controlled trial showed that calcitonin alone was ineffective against PLP

Other medications

• The beta blocker propanolol and the Ca channel blocker nifedipine - used for treatment PLP. However their effectiveness is still unclear

NONPHARMALOGICAL TREATMENT

Treatment of Phantom pain (PLP)

• Nonpharmacological treatment• Transcutaneous

Electrical Never Stimulation (TENS)- Standard device ,

inexpensive - Safe and easy to

use - Using battery to

control - Generates to the

skin to activate the effected nerves.

Mirror Therapy• was first introduced by

Ramachandran in 1996

• persons with amputated limb use either a mirror or mirror box to reflect an image of the intact limb. It is hypothesized that this works by preventing cortical restructuring

• patients with PLP showed a decrease in pain at the 6-month follow-up (Diers, 2010)

• mechanisms underlying the effects of mirror training or motor imagery, are still unclear

Biofeedback – It can help to reduce

muscle tension and increase blood flow.

– by using visual or other sensory stimuli to retrain the brain to stop sending pain signals

Prosthesis- Help to regain the feeling

of loosing limb- An electrical prosthetic

limb moved by signals.

SURGICAL INTERVENTION

• Should be avoided

• Stump Revision – Patients with continued

phantom limb pain – Stump with vascular

insufficiency– Infection– Neuromas may undergo

stump revision

Surgical Remove the nerve sending the pain

signals• Neurectomy : Nerve

removal • Rhizotomy : sever nerve

roots in the spinal cord• Cordotomy : sever nerve

cord in the spinal cord• Lobectomy• Patient experience

numbness, tingling or impairment of the surrounding nerves

• May provide short term relief but pain commonly reappears

Surgical Dorsal Root Entry Zone

• Phantom pain because of brachial plexus avulsion, sacral plexus avulsion or Spinal Cord Injury

• Dorsal root : nerve fibers send the brain messages about sensations and pain

• Destroying the area where damaged nerves join the central nervous system. This intercepts pain messages from nerves to the brain

• Most patients experience relief of pain immediately after surgery

• Sustain good pain relief over the long term

Conclusion

• Multidisciplinary approach, tailored to the individual needs of the patient, has the best chance of improving the symptoms of phantom limb pain and the functional outcome

TENSAcupunctureBio-feedback

HypnosisMassage

UltrasoundECT

Nerve blocksNeurectomy

Stump revisionRhizotomyCordotomyLobectomy

SympathectomySpinal cord stimBrain stimulation

TCAAnticonvulsants

LidocaineOpioids

NMDA antagonistsclonidine

THANK YOU FOR YOUR ATTENTION