Know Pain Know Gain: proposing a treatment approach for phantom limb pain Peter Le Feuvre, 1 D Aldington 2 1 Centre for Complex Trauma, DMRC Headley Court, Epsom, Surrey, UK 2 DMRC Headley Court, Epsom, Surrey, UK Correspondence to Major Peter Le Feuvre, Centre for Complex Trauma, DMRC Headley Court, Epsom, Surrey KT18 6JW, UK; 723lefeu@armymail.mod.uk Received 5 July 2013 Accepted 8 July 2013 Published Online First 31 July 2013 To cite: Le Feuvre P, Aldington D. J R Army Med Corps 2014;160:16–21. ABSTRACT Phantom limb pain affects between 50 and 80% of amputees. With an increasing number of battle casual- ties having had an amputation after combat trauma, it is inevitable that both primary and secondary care clinicians will come into contact with a patient with phantom limb pain (PLP). It is widely acknowledged that its complex aetiology means that this condition is often poorly understood and difficult to manage. A growing patho- physiological understanding is shedding new light on the mechanisms which underlie PLP. Knowledge of these mechanisms will inform treatment and enable clinicians to plan and implement solutions which make a differ- ence to those individuals with this condition. This paper seeks to outline current research into this condition and proposes an approach to treatment. This approach has been formulated from an amalgamation of clinical experience working with battle casualties at the Defence Medical Rehabilitation Centre, Headley Court. INTRODUCTION The poly-trauma injury pattern resulting from blast is well documented. 1 Wounding to vulnerable extremities is common and if limb salvage is unattainable, amputation will result. After amputa- tion, phantom limb pain (PLP) affects between 50 and 80% of patients and its incidence is not related to the cause of the amputation. 2 The aetiology of PLP is complex and it is often mistaken as residual limb pain (RLP) or phantom sensation. This, together with a lack of a definitive treatment, results in under-reporting of pain by patients and a lack of attention to the problem by clinicians. 3 The potential for this condition to become chronic is well documented and it can have catastrophic effects upon an individual. It is essen- tial that both primary and secondary care clinicians understand and attend to it appropriately. A growing pathophysiological understanding of PLP is shedding new light on the mechanisms involved. The purpose of this paper is to explore the interplay of factors involved in PLP and propose a multidisciplinary approach to treatment for first-line management within primary and sec- ondary care. The treatment approach has been for- mulated from the clinical experience of working with battle casualties at the Defence Medical Rehabilitation Centre (DMRC), Headley Court and the concurrent review of literature which has informed practice. Thus, this work is applicable to those who have had a traumatic amputation rather than an amputation resulting from a chronic health condition. Treatment options are also proposed to furnish the reader with ideas which they can inves- tigate further. CHARACTERISTICS OF PHANTOM LIMB PAIN PLP is often confused with pain or sensation in the areas adjacent to the amputated body part. This is known as residual limb (RLP) or stump pain and its intensity is often positively correlated with PLP. 4 Post-amputation pain at the wound site should also be distinguished from pain in the residual limb and the phantom limb. After amputation, all three may occur together. 4 PLP is classified as neuropathic pain, whereas RLP and post-amputation pain are classified as nociceptive pain. PLP is often more intense in the distal portion of the phantom limb and can be exa- cerbated or elicited by physical factors (pressure on the residual limb, time of day, weather) and psycho- logical factors, such as emotional stress. 5 Commonly used descriptors include sharp, cramp- ing, burning, electric, jumping, crushing and cramping. 3 Often the pain is associated with par- ticular movements or positions of the phantom limb. It differs from phantom limb sensation, which is a normal phenomenon for almost all amputees, but unlike PLP, is not distressing. 6 Phantom sensation has been described as itchiness, tingling or pins and needles, squeezing and toe crossing. 3 Some patients with PLP experience ‘telescoping’, which is simply the retraction or disappearance of the phantom limb into the residual limb. 4 Traditionally, this has been seen as a positive feature. However, some evidence suggests that tele- scoping is a feature of central adaptations which contributesto, rather than lessens, PLP. 7 Editor’s choice Scan to access more free content Key messages ▸ Changes within the central nervous system contribute to the experience of phantom limb pain (PLP). Peripheral and psychological influences also act to mediate symptoms. ▸ The assessment should seek to highlight whether central, peripheral or psychological factors are the predominant driver in this condition. ▸ The treatment plan should be individualised and driven by a multidisciplinary treatment approach. ▸ Continuance of PLP is associated with changes in the somatosensory cortex. Stimulation of the amputation zone within the cortex appears to reverse these changes. ▸ Reversal of cortical changes is a key consideration within the treatment plan. 16 Le Feuvre P, et al. J R Army Med Corps 2014;160:16–21. doi:10.1136/jramc-2013-000141 Review copyright. on November 28, 2021 by guest. Protected by http://militaryhealth.bmj.com/ J R Army Med Corps: first published as 10.1136/jramc-2013-000141 on 31 July 2013. Downloaded from