Epidemiology

Phantom limb pain

The reported prevalence of phantom pain varies much in the literature. Very early studies claimed that the prevalence was 2-4%, but today most studies agree that 60-80% of all amputees experience phantom pain following amputation. The prevalence of phantom pain seems to be independent of age in adults, gender, side or level of amputation and cause (nontraumatic versus traumatic) of the amputation. Interestingly, phantom limb pain is more frequent when the amputation occurs in adulthood, less frequent in child amputees and virtually nonexistent in congenital amputees.

Prospective studies in patients amputated mainly because of peripheral vascular disease have shown that the onset of phantom pain is usually within the first week after amputation [16, 17]. Amputees who do not experience phantom pain in the first days or weeks after amputation are less likely to develop phantom pain later in the course. Richardson et al. [17] prospectively examined the incidence of phantom pain in 52 amputees. Phantom pain was reported by 92.3% in the first week after amputation and by 78.8% after 6 months. The onset of phantom pain, however, can be delayed for months or even years. In some cases a trauma to the stump can elicit phantom pain in a previously pain-free individual. The exact long-term course of phantom limb pain is unclear because no prospective studies with long-term (many years) follow-up exist. Some prospective studies with a maximum follow-up period of 2 years have reported a slight decline in the proportion of patients affected over time.

Phantom limb pain is episodic in nature, and only few amputees are in constant pain. Diary studies have shown that most amputees report pain attacks to occur daily or at daily or weekly intervals.

The reported intensity of phantom pain varies between studies. In a recent study of 57 amputees, the average phantom pain intensity was 2.05 on a numeric rating scale (0-10) 24 months after the amputation [18]. In another recent study of 914 amputees, pain was classified into three categories: 38.9% experienced severe pain intensity (rating 7-10), 26.4% experienced moderate pain intensity (rating 5-6) and 34.7% experienced mild pain intensity (rating 1-4) [19].

Phantom limb pain can have several different qualities and is often described as shooting, pricking, stabbing, throbbing, burning, pin and needles, tingling, crushing or cramping. The pain seems to be more intense in the distal portions of the missing limb: fingers and palm in upper limb amputees, toes, foot and ankle in lower limb amputees. In a prospective study of 52 amputees, the position of phantom pain within the phantom limb was in the toes or the foot in 66.7% of cases [20]. These distal parts of the limbs are represented by a larger area in the sensory cortex compared to more proximal parts, and this may play a role in the more frequent phantom experience of hands and feet.

Phantom limb sensations

Phantom sensation is experienced by almost everyone who undergoes limb amputation, but it rarely represents a clinical problem. Immediately after the amputation, the phantom limb often resembles the preamputation limb in shape, size and volume. The sensation can be very vivid and often includes feelings of posture and movement. The phantom sensation may fade over time. One hundred and twenty-four upper limb amputees were asked about the frequency of phantom sensations a median time of 19 years after amputation. Forty percent experienced phantom sensations always, another 20% had phantom sensations daily, and the rest had sensations at intervals of weeks, months or even years [2].

In some patients, a phenomenon called telescoping occurs when the distal parts of the phantom are gradually felt to approach the residual limb, and eventually they may even be experienced within the stump. It has been suggested that phantom pain prevents telescoping, but Montoya et al. [20] failed to find such a relation: 12/16 patients with phantom pain and 5/10 patients without pain reported telescoping.

Stump pain

Not surprisingly, stump pain is common in the early postoperative period, but in most patients it subsides with healing. In some patients, however, stump pain persists beyond the stage of surgical healing. The prevalence of chronic stump pain is reported to vary between 5% and 100%. In a survey of 78 traumatic amputees, 14.1% suffered from severe and constant pain in the stump [21]. Similar results have been found by others in patients who have undergone amputation for different reasons, including medical.

Stump pain may be described as pressing, throbbing, burning, squeezing or stabbing. Some patients have spontaneous movements of the stump, ranging from slight, hardly visible jerks to severe contractions.

Careful sensory examination of amputation stumps may reveal areas with sensory abnormalities such as hypoesthesia, hyperalgesia or allodynia. However, it is not clear whether there is any correlation between phantom pain and the extent and degree of sensory abnormalities in the stump. Hunter et al. [22] carefully examined the stump in 12 traumatic upper limb amputees but failed to find any simple relation between psychophysical thresholds and phantom phenomena.

Stump pain and phantom pain are strongly correlated. Carlen et al. [23] noted that phantom pain was decreased by the resolution of stump-end pathology. In a survey of 648 amputees, stump pain was present in 61% of amputees with phantom pain, but in only 39% of those without phantom pain [24]. Similar results have been found in other studies.

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