[Therapeutic concept for preventing chronic phantom pain after traumatic brachial plexus lesion]

Phantom limb pain in daily practice--still a lot of work to do!

OBJECTIVES

Effective treatment of phantom limb pain (PLP, pain felt in the part of the body of an amputated limb) is still difficult to achieve, and improved treatment is needed. It is therefore of paramount interest to understand the current practice of PLP therapy outside pain centers.

DESIGN

As a part of a nationwide survey, 537 amputees were asked 11 questions related to their treatment experiences and the pain relief. Furthermore, the patients' opinion about the quality of medical care was also asked.

RESULTS

Five hundred thirty-seven out of 1088 amputees returned the questionnaire (49.4%). Four hundred (74.5%) suffered from PLP. The patients rated their caregivers' knowledge about PLP lower than their own. Many (41.6%) of PLP patients had never been informed about the possibility of occurrence and mechanisms of PLP. The vast majority of the PLP patients did not try any treatment. Among those treated, more than 30% consulted more than three physicians for beneficial treatment. A >50% pain reduction was achieved in only 12.7% of PLP patients. The most successful treatments were opioids (67.4%) and anticonvulsants (51.7%). Surgery was performed in 46.4% of all PLP patients and in 29.7% due to a clinically suspected neuroma. After surgery, pain was worse or unchanged in 50% and improved in 41.6%, and 7.4% were pain-free.

CONCLUSIONS

Our results suggest that there are primary needs for better information about PLP pathophysiology and treatment not only for patients but also for caregivers. Limited therapeutic success reveals a further need for increased research in PLP management.

Management of phantom pain with a textile, electromagnetically-acting stump liner: a randomized, double-blind, crossover study

The treatment of phantom pain is frequently dissatisfying. We wanted to find out whether an electromagnetically shielding stump stocking interwoven with metal (medipro(R)Liner RELAX [medi Bayreuth, Bayreuth, Germany]) could have a positive effect on phantom pain. A double-blind, randomized, crossover trial in a total of 30 leg amputees compared the experimental (=verum) silicon liner (VL) fitted to the amputation stump with a dummy (=placebo) liner (PL). Each liner was worn for two weeks after a two-week baseline period. Daily documentation focused on phantom pain, quality of sleep and improvement of well-being. Twenty-seven of 30 patients completed the 6-week study, and 22 documentations proved valid. On a 0-10 numeric rating scale (NRS), the median pain intensity before treatment was 4, and the median of maximum pain was 6. VL versus PL reduced pain significantly more often (P=0.008), the odds ratio being 5.95. The degree of pain reduction was likewise highly significant (<0.001). Wilcoxon's matched-pairs signed-rank test for the medians of daily maximum pain showed a significant reduction for both PL (P < 0.001) and VL (P <0.001) as compared to baseline, with VL being highly superior again (P < 0.001) versus PL. The experimental device also led to significant amelioration of general well-being (P = 0.037) with an odds ratio of 3.85, and an improvement in the quality of sleep, which was not significantly different than PL (P = 0.223). In this study, the influence of a silicon liner with electromagnetically protecting properties on phantom pain was highly significant. The mechanisms underlying this effect are unclear. Possibilities include reduction of ectopic neuroma activity, shielding from possible electromagnetic weather impulses (sferics), or analgesic effects of changes in the electromagnetic field. PET or fMRI examination with or without a shielding silicon liner might help to elucidate this observation further.

[Long-term treatment of phantom- and stump pain with Botulinum toxin type A over 12 months. A first clinical observation]

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.