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2. Kooijman CM, Dijkstra PU, Geertzen JHB, et al. Phantom pain and phantom sensations in upper limb amputees: an epidemiological study. Pain 2000; 87: 33-41.

3. Nikolajsen L, Ilkjœr S, Jensen TS. Relationship between mechanical sensitivity and postamputation pain: a prospective study. Eur J Pain 2000; 4: 327-334.

4. Flor H, Denke C, Schaefer M, et al. Effect of sensory discrimination training on cortical reorganization and phantom limb pain. Lancet 2001; 357: 1763-1764.

5. Aydin MD, Cesur M, Aydin N, Alici HA. Disappearance of phantom limb pain during cauda euina compression by spinal meningioma and gradual reactivation after decompression. Anesth Analg 2005; 101: 1123-1126.

6. Tessler MJ, Kleiman SJ. Spinal anaesthesia for patients with previous lower limb amputations. Anaesthesia 1994; 49: 439-441.

7. Nikolajsen L, Hansen CL, Nielsen J, et al. The effect of ketamine on phantom pain: a central neuropathic disorder maintained by peripheral input. Pain 1996; 67: 69-77.

8. Florence SL, Kaas JH. Large-scale reorganization at multiple levels of the somatosensory pathway follows therapeutic amputation of the hand in monkeys. J Neurosci 1995; 15: 8083-8095.

9. Pons TP, Garraghty PE, Ommaya AK, et al. Massive cortical reorganization after sensory deafferentation in adult macaques. Science 1991; 252: 1857-1860.

10. Flor H, Elbert T, Knecht S. Phantom limb pain as a perceptual correlate of cortical reorganization following arm amputation. Nature 1995; 375: 482-484.

11. Flor H, Elbert T, Muhlnickel W. Cortical reorganization and phantom phenomena in congenital and traumatic upper-extremity amputees. Exper Brain Res 1998; 119: 205-212.

12. Birbaumer N, Lutzenberger W, Montoya P, et al. Effects of regional anesthesia on phantom limb are mirrored in changes in cortical reorganization in upper limb amputees. J Neurosci 1997; 17: 5503-5508.

13. Huse E, Larbig W, Flor H, et al. The effect of opioids on phantom limb pain and cortical reorganization. Pain 2001; 90: 47-55.

14. Davis KD, Kiss ZH, Luo L. Phantom sensations generated by thalamic microstimulation. Nature 1998; 391: 385-387.

15. Draganski B, Moser T, Lummel N, et al. Decrease of tha-lamic gray matter following limb amputation. NeuroImage 2006; 31: 951-957.

16. Nikolajsen L, Ilkjœr S, Kroner K, et al. The influence of preamputation pain on postamputation stump and phantom pain. Pain 1997; 72: 393-405.

17. Richardson C, Glenn S, Nurmikko T, Horgan M. Incidence of phantom phenomena including phantom limb pain 6 months after major lower limb amputation in patients with peripheral vascular disease. Clin J Pain 2006; 22: 353-358.

Box 19.1 Interventions for the management of phantom limb pain

Supported by evidence (ranked according to evidence level)


Tricyclic antidepressants Opioids (morphine, tramadol) Ketamine (IV)

Calcitonin (IV) (acute phase only)

Use of a Farabloc (a metal threaded sock)

Sensory discrimination training

Refuted by evidence

Memantine (20-30 mg/day)

Epidural treatment (started 18 h before amputation)

Perineural blocks (started postoperatively)

Commonly used interventions currently unproven


Various anticonvulsants (except gabapentin)

Antidepressants (except tricyclic antidepressants)

Opioids (methadone, oxycodone)

Physical therapy



Mirror treatment

Spinal cord stimulation

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22. Hunter JP, Katz J, Davis KD. Dissociation of phantom limb phenomena from stump tactile spatial acuity and sensory thresholds. Brain 2005; 128: 308-320.

23. Carlen PL, Wall PD, Nadvorna H, et al. Phantom limbs and related phenomena in recent traumatic amputations. Neurology 1978; 28: 211-217.

24. Sherman R, Sherman C. Prevalence and characteristics of chronic phantom limb pain among American veterans: results of a trial survey. Am J Phys Med 1983; 62: 227-238.

25. Houghton AD, Nicholls G, Houghton AL, et al. Phantom pain: natural history and association with rehabilitation. Ann Roy Coll Surg Engl 1994; 76: 22-25.

26. Hill A, Niven CA, Knussen C. Pain memories in phantom limbs: a case story. Pain 1996; 66: 381-384.

27. Katz J, Melzack R. Pain 'memories' in phantom limbs: review and clinical observations. Pain 1990; 43: 319-336.

28. Desmond DM, Maclachlan M. Affective distress and amputation-related pain among older men with long-term, traumatic limb amputations. J Pain Symptom Manage 2006; 31: 362-368.

29. Schoppen T, Boonstra A, Groothoff JW, et al. Employment status, job characteristics, and work-related health experience of people with a lower limb amputation in The Netherlands. Arch Phys Med Rehabil 2002; 82: 239-245.

30. Schott G D. Pain and its absence in an unfortunate family of amputees. Pain 1986; 25: 229-231.

31. Halbert J, Crotty M, Cameron ID. Evidence for the optimal management of acute and chronic phantom pain: a systematic review. Clin J Pain 2002; 18: 84-92.

32. Robinson LR, Czerniecki JM, Ehde DM, et al. Trial of amitriptyline for relief of pain in amputees: results of a randomized controlled study. Arch Phys Med Rehabil 2004; 85: 1-6.

33. Wilder-Smith CH, Hill LT, Laurent S. Postamputation pain and sensory changes in treatment-naive patients: characteristics and responses to treatment with trama-dol, amitriptyline, and placebo. Anesthesiology 2005; 103: 619-628.

34. Bone M, Critchley P, Buggy DJ. Gabapentin in postamputation phantom limb pain: a randomized, double-blind, placebo-controlled, cross-over study. Region Anesth Pain Med 2002; 27: 481-486.

35. Smith DG, Ehde DM, Hanley MA, et al. Efficacy of gabapentin in treating chronic phantom limb and residual limb pain. J Rehabil Res Dev 2005; 42: 645-654.

36. Nikolajsen L, Finnerup NB, Kramp S, et al. A randomized study of the effects of gabapentin on postamputation pain. Anesthesiology 2006; 105: 1008-1015.

37. Wu CL, Tella P, Staats PS, et al. Analgesic effects of intravenous lidocaine and morphine on postamputation pain. Anesthesiology 2002; 96: 841-848.

38. Nikolajsen L, Gottrup H, Kristensen AGD, et al. Memantine (a N-methyl D-aspartate receptor antagonist) in the treatment of neuropathic pain following amputation or surgery: a randomized, double-blind, cross-over study. Anesth Analg 2000; 91: 960-966.

39. Maier C, Dertwinkel R, Mansourian N, et al. Efficacy of the NMDA-receptor antagonist memantine in patients with chronic phantom limb pain - results of a randomized double-blinded, placebo-controlled trial. Pain 2003; 103: 277-283.

40. Wiech K, Kiefer RT, Töpfner S, et al. A placebo-controlled randomized crossover trial of the N-methyl-d-aspar-tic acid receptor antagonist, memantine, in patients with chronic phantom limb pain. Anesth Analg 2004; 98: 408-413.

41. Schley M, Topfner S, Wiech K, et al. Continuous brachial plexus blockade in combination with the NMDA receptor antagonist memantine prevents phantom pain in acute traumatic upper limb amputees. Eur J Pain 2007; 11(3): 299-308

42. Jaeger H, Maier C. Calcitonin in phantom limb pain: a double-blind study. Pain 1992; 48: 21-27.

43. Conine TA, Herschler C, Alexander ST, et al. The efficacy of Farabloc in the treatment of phantom limb pain. Can J Rehabil 1993; 6: 155-161.

44. Brodie EE, Whyte A, Niven CA. Analgesia through the looking-glass? A randomized controlled trial investigating the effect of viewing a 'virtual' limb upon phantom limb pain, sensation and movement. Eur J Pain 2007; 11(4): 428-436.

45. Bach S, Noreng MF, Tjéllden NU. Phantom limb pain in amputees during the first 12 months following limb amputation after preoperative lumbar epidural blockade. Pain 1988; 33(3): 297-301.

46. Jahangiri M, Jayatunga AP, Bradley JWP, et al. Prevention of phantom pain after major lower limb amputation by epi-dural infusion of diamorphine, clonidine and bupivacaine. Ann Roy Coll Surg Engl 1994; 76: 324-326.

47. Nikolajsen L, Ilkjœr S, Kroner K, et al. Randomized trial of epidural bupivacaine and morphine in prevention of stump and phantom pain in lower-limb amputation. Lancet 1997; 350: 1353-1357.

48. Pinzur MS, Garla PGN, Pluth T, et al. Continuous postoperative infusion of a regional anaesthetic after an amputation of the lower extremity. J Bone Joint Surg 1996; 78: 1501-1505.

49. Lambert AW, Dashfield AK, Cosgrove C, et al. Randomized prospective study comparing preoperative epidural and intraoperative perineural analgesia for the prevention of postoperative stump and phantom limb pain following major amputation. Region Anesth Pain Med 2001; 26: 316-321.

50. Dertwinkel R, Heinrichs C, Senne I, et al. Prevention of severe phantom limb pain by perioperative administration of ketamine - an observational study. Acute Pain 2002; 4: 9-13.

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