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A Master's Project/Report Submitted to the Faculty of the
COLLEGE OF NURSING
In Partial Fulfillment of the Requirements
For the Degree of
Masters of Science
In the Graduate College
THE UNIVERSITY OF ARIZONA
2 0 1 0
2
STATEMENT BY AUTHOR
This master's project/report has been submitted in partial fulfillment of requirements for an advanced degree at The University of Arizona and is deposited in the University Library to be made available to borrowers under rules of the Library.
Brief quotations from this master's project/project are allowable without special permission, provided that accurate acknowledgment of source is made. Requests for permission for extended quotation from or reproduction of this manuscript in whole or in part may be granted by the copyright holder
SIGNED: Kari Rene’ Bennett
APPROVAL BY MASTER'S PROJECT DIRECTOR
This Master's Project has been approved on the date shown below:
Dextromethorphan is another NMDA-receptor antagonist. Abraham and associates (2002)
conducted a small, randomized controlled study describing the efficacy of oral dextramorphan in
the treatment of PLP. This medication was found to effectively reduce PLP without significant
side effects (Abraham, Marouani, Kellender, Meller, & Weinbroum, 2002).
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Wu and associates (2008) studied the use of mexiletine, an oral sodium channel blocker, and
sustained release morphine in treating PLP. Results showed that morphine treatment provided
lower pain scores compared with placebo and mexiletine. The study results indicate that
morphine, not mexiletine, resulted in a decrease intensity of post amputation RLP. The
discussion also showed a higher level of side effects with the use of morphine.
Aggressive pain control with opioids is crucial post-surgically to aid in prevention of PLP.
NMDA receptor antagonists are effective in prevention and treatment of PLP. Patients need to
be monitored closely for psychotomimetric side effects. Antidepressants and anti-convulsants
have been shown helpful for neuropathic pain and are recommended as mainstay therapy for
PLP.
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CHAPTER FOUR
NON-PHARMACOLOGICAL STRATEGIES
Ketz (2008) conducted a retrospective descriptive study to determine the prevalence and
characteristics of PLP as well as effectiveness of self- and standard medical treatment methods in
combat-related traumatic amputees. Sixty-eight percent of patients received treatment from their
health care providers and most were treated with gabapentin. However, greater pain relief was
achieved with non-pharmologic treatments. The conclusion of this study indicated the need for
more effective interventions for PLP.
Ramachandran and associates (1998) developed a mirror therapy based on the theory that
PLP was a result of a visual disconnects in brain. A mirror angled to allow the reflection of the
intact limb gives the illusion that the patient has two intact limbs. Patients with chronic phantom
limb spasms using Ramachandran’s mirror therapy found immediate relief after visualizing
movement of “both” limbs.
Darnall (2008) reported a case study regarding a veteran with a recent traumatic lower limb
amputation. Multiple pharmacological agents were prescribed, but did not improve the patient’s
PLP. The patient reported a correlation between frequency of mirror therapy and decrease in
pain intensity. Mirror therapy for 20 minutes a day for 1 month resulted in resolution of PLP.
This case presentation showed that mirror therapy can be an effective therapy which is
inexpensive and can be done by patients at home.
Cole and associates (2009) replicated the mirror therapy through the creation of a virtual
reality environment that allowed participants to move their phantom limbs by moving the
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residual limb. Participants, who reported having the ability to control of movement of the
phantom limb within the virtual environment, reported a 22-100% reduction in pain.
Other non-pharmacologic strategies include using trans-electric nerve stimulation (TENS).
Individuals with active PLP given home TENS stimulation to the contralateral limb reported
improvement in their PLP after one year of therapy (Giuffrida, Simpson, & Halligan, 2010).
Wilkes and associates (2008) reported successful treatment of chronic lower limb PLP with
pulsed radiofrequency treatment of the sciatic nerve. These researchers reported that this
technique allowed a patient who had experienced chronic, extreme PLP for 4 years post-
amputation to be weaned from all oral analgesics.
Distraction techniques like immersive virtual reality (VR) have helped patients learn to
modulate their pain (Gromala, Shaw, & Song, 2009). These immersive techniques mimic real
environments. The VR system combines meditation and biofeedback. This allows the users to
exert control and, as a result, pain is decreased.
A multidisciplinary approach to post-operative management of amputation is necessary in
preventing and treating PLP. Pharmacological strategies in the management of PLP include
medications for acute post-operative pain and neurolopathic pain. Liberal use of opioids and
NMDA receptor antagonists should be initiated early for adequate PLP and RLP control.
Careful post-operative management of the RLP is beneficial in preventing PLP. Non-
pharmacologic strategies may be more helpful for some patients, so patients should be offered
these treatment modalities. Support groups and teaching effective coping skills have been shown
to decrease incidence and severity of PLP. (Figure 1)
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Figure 1. PLP Strategies
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CHAPTER 5
CONCLUSION
PLP is complex, yet common after amputation. It is a phenomenon experienced by most
amputees. Patients need to know PLP and PLS are “normal” and should be treated as an
expected outcome of surgery. It is important for providers to have clear, open discussions with
the patient about PLP. No single treatment has been shown to be effective in eliminating PLP,
however, effective treatment strategies should involve multiple modalities. Effective pain
management should be initiated before, during and after amputation surgery can decrease
incidence of pain memories and prevent PLP. Evaluation of coping skills before amputation
surgery is essential. Nurses can aid patients in developing active coping strategies. Many
pharmacological treatments are available, but non-pharmacological treatments may be more
effective. Further research is needed to study the causes, prevention and effective treatment
modalities for PLP.
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REFERENCES
Abraham, R. B., Marouani, N., Kellender, Y., Meller, I., & Weinbroum, A. A. (2002). Dextromethorphan for phantom pain attenuation in cancer amputees: a double-blind crossover trial involving three patients. The Clinical Journal of Pain, 18, 282-285.
Arena, J. G., Sherman, R. A., Bruno, G. M., & Smith, J. D. (1990). The relationship between
situation stress and phantom limb pain: cross-lagged correlational data from six month pain logs. Journal of Psychosomatic Research, 34(1), 71-77.
Bennett, G. J. (2000). Update on the neurophysiology of pain transmission and modulation:
focus on the NMDA-receptor. Journal of Pain Symptom Management, 19(1 Suppl), S2-6. Bloomquist, T. (2001). Amputation and phantom limb pain: a pain prevention model. AANA
Journal, 69(3), 211-217. Borghi, B., Bugamelli, S., Stagni, G., Genco, R., & Colizza, M. T. (2009). Perineural infusion of
0.5% ropivacaine for successful treatment of phantom limb syndrome: a case report. Minerva Anestesiologica, 75(11), 661-664.
Casale, R., Alaa, L., Mallick, M., & Ring, H. (2009). Phantom limb related phenomena and their
rehabilitation after lower limb amputation. European Journal of Physical Rehabilitation Medicine, 2009(45), 559-66.
Cole, J., Crowle, S., Austwick, G., & Slater, D. H. (2009). Exploratory findings with virtual
reality for phantom limb pain; from stump motion to agency and analgesia. Disability and Rehabilitation, 31(10), 846-854.
Darnall, B. D. (2008). Self-delivered home-based mirror therapy for lower limb phantom pain.
American Journal of Physical Medicine & Rehabilitation, 88(1), 78-81. Darnall, B. D. (2009). Self-delivered home-based mirror therapy for lower limb phantom pain.
American Journal of Physical Medicine & Rehabilitation, 88, 78-81. Darnall, B. D., Wegener, E. P., Dillingham, T., Pezzin, L., Rossbach, P., & Mackenzie, E. J.
(2005). Depressive symptoms and mental health service utilization among persons with limb loss: results of a national survey. Archives of Physical Medicine & Rehabilitation, 86(4), 650-658.
Department Of Veteran Affairs, Department Of Defense. (2007). Retrieved April 20, 2010, from
National Guideline Clearinghouse Web Site: http://guideline.gov/summary/summary.aspx?doc_id=11758&nbr=006060&string=phantom+AND+limb+AND+pain
27
Dijkstra, P. U., Geertzen, J. H., Stewart, R., & Van Der Schans, C. P. (2002). Phantom pain and risk factors: a multivariate analysis. Journal of Pain and Symptom Management, 24(6), 578-585.
(2008). Chronic phantom limb pain: the effects of calcitonin, ketamine, and their combination on pain and sensory thresholds. Anesthesia & Analgesia, 106(4), 1265-1273.
Ephraim, P. L., Wegener, S. T., Mackenzie, E. J., Dillingham, T. R., & Pezzin, L. E. (2005).
Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. Archives of Physical Medicine and Rehabilitation, 86(10), 1910-1919.
Flor, H. (2002). Phantom limb pain: characteristics, causes and treatment. Lancet Neurology, 1,
182-189. Flor, H. (2008). Maladaptive plasticity, memory for pain and phantom limb pain: review and
suggestions for new therapies. Expert Review Neurotherapeutics, 8(5), 809-818. Flor, H., Nikolajsen, L., & Troels, S. J. (2006). Phantom limb pain: a case for maladaptive CNS
plasticity. Nature Reviews Neuroscience, 7, 875-861. Giuffrida, O., Simpson, L. D., & Halligan, P. (2010). Contralateral stimulation, using TENS, of
phantom limb pain: two confirmatory cases. Pain Medicine, 11(1), 133-141. Gromala, D., Shaw, C., & Song, M. (2009). Chronic pain and the modulation of self in
immersive virtual reality. Papers from the AAAI Fall Symposium, FS-09-01, . Hackworth, R. J., Takarz, K. A., Fowler, I. M., Wallace, S. C., & Stedje-Larsen, E. T. (2008).
Profound pain reduction after induction of memantine treatment in two patients with severe phantom limb pain. Anesthesia & Analgesia, 107(4), 1377-1379.
Halbert, J., Crotty, M., & Cameron, I. D. (2005). Evidence for the optimal management of acute
and chronic phantom pain: a systematic review. Clinical Journal of Pain, 18, 84-92. Hanley, M. A., Ehde, D. M., Jensen, M., Czerniecki, J., Smith, D. G., & Robinson, L. R. (2009).
Chronic pain associated with upper limb loss. American Journal of Physical Medicine & Rehabilitation, 88(9), 742-51.
Hanley, M. A., Jensen, M. P., Smith, D. G., Edwards, W. T., & Robinson, L. R. (2007).
Preamputation pain and acute pain predict chronic pain after lower extremity amputation. The Journal of Pain, 8(2), 102-109.
28
Hanling, S. R., Wallace, S. C., Hollenbeck, K. J., Belnap, B. D., & Tulis, M. R. (2010). Preamputation mirror therapy may prevent development of phantom limb pain: a case series. Anesthesia & Analgesia, 110(2), 611-614.
Herman, J. (1998). Phantom limb: from medical knowledge to folk wisdom and back. Annals of
Internal Medicine, 128, 76-78. Hill, A. (1993). The use of pain coping strategies by patients with phantom limb pain. Pain, 55,
347-353. Hocking, G., & Cousins, M. J. (2003). Ketamine in chronic pain management: an evidence-based
review. Anesthesia & Analgesia, 97, 1730-1739. Horgan, O., & Maclachlan, M. (2004). Psychosocial adjustment to lower-limb amputation: a
review. Disability & Rehabilitation, 26(14-15), 837-50. Jaeger, H., & Maier, C. (1992). Calcitonin in phantom limb pain: a double-blind study. Pain,
48(1), 21-7. Katz, J., & Melzack, R. (1990). Pain 'memories' in phantom limb: review and clinical
observations. Pain, 43, 319-336. Kern, U., Busch, V., Rockland, M., Kohl, M., & Birklein, F. (2009). Prevalence and risk factors
of phantom limb pain and phantom limb sensations in Germany. A nationwide field survey. Schmerz, 23(5), 479-88.
Lambert, A. W., Dashfield, A. K., Cosgrove, C., Wilkins, D. C., Walker, A. J., & Ashley, S.
(2001). Randomized prospective study comparing preoperative epidural and intraoperative perineural analgesia for the prevention of postoperative stump and phantom limb pain following major amputation. Regional Anesthesia and Pain Medicine, 26(4), 316-321.
Melzack, R. (2006). Phantom limbs. Scientific American Special Ediction, 16(3), 52. Mishra, S., Bhatnagar, S., Gupta, D., & Diwedi, A. (2008). Incidence and management of
phantom limb pain according to world health organization analgesic ladder in amputees of malignant origin. American Journal of Hospice & Palliative Medicine, 24(6), 455-462.
Morey, T. E., Giannoni, J., Duncan, E., Scarborough, M. T., & Enneking, F. K. (2002). Nerve
sheath catheter analgesia after amputation. Clinical Orthopaedics and Related Research, 397, 281-289.
29
Nikolajsen, L., Hansen, C. L., Neilsen, J., Keller, J., Arendt-Neilsen, L., & Jensen, T. S. (1995). The effect of ketamine on phantom pain: a central neurpoathic disorder maintained by peripheral input. Pain, 67, 69-77.
Nikolajsen, L., & Jensen, T. S. (2001). Phantom Limb Pain. British Journal of Anaesthesia,
87(1), 107-116. Petrenko, A. B., Yamakura, T., Baba, H., & Shimoji, K. (2003). Anesthesia & Analgesia. The
role of n-methyl-d-aspartate (NMDA) receptors in pain: a review, 97, 1108-1116. Prantl, L., Schreml, S., Heine, N., Eisenmann-Klein, M., & Angele, P. (2005). Surgical treatment
of chronic phantom sensation and limb pain after lower limb amputation. Plastic and Reconstructive Surgery, 118(7), 2005.
Ramachandran, V. S., & Hirstein, W. (1998). The perception of phantom limbs-The D.O. Hebb
lecture. Brain, 121, 1603-1630. Ramachandran, V. S., Rogers-Ramachandran, D., & Cobb, S. (1995). Touching the phantom
limb. Nature, 377(6549), 489-490. Ramachandran, V. S., Stewart, M., & Rogers-Ramachandran, D. C. (1992). Perceptual correlates
of massive cortical reorganization. NeuroReport, 3, 583-586. Richardson, C., Glenn, S., Horgan, M., & Nurmikko, T. (2007). A prospective study of factors
associated with the presence of phantom limb pain six months after major limb amputation in patients with peripheral vascular disease. Journal of Pain, 8(12), 998.
Robbins, C. B., Vreeman, D. J., Sothmann, M. S., Wilson, S. L., & Oldridge, N. B. (2006). A
review of the long-term health outcomes associated with war-related amputation. Military Medicine, 174(6), 588-592.
Roullet, S., Nouette-Gaulain, K., Brochet, B., & Sztark, F. (2009). Phantom limb pain: from
pysiopathology to prevention. Annals of French Anesthesia Reanim, 28(5), 460-72. Schley, M. T., Wilms, P., Toepfner, S., Schaller, H. P., Schmelz, M., Konrad, C. J., et al. (2008).
Painful and nonpainful phantom and stump sensations in acute traumatic amputees. The Journal of Trauma Injury, Infection and Critical Care, 65(4), 858-864.
Sherman, R. A., & Sherman, C. J. (1980). A survey of current phantom limb treatment in the
United States. Pain, 8, 85-99. Sherman, R. A., & Sherman, C. J. (1983). Prevalence and characteristics of chronic phantom
limb pain among american veterans. American Journal of Physical Medicine, 62(5), 227-238.
30
Sugarbaker, P. H., Weiss, C. M., Davidson, D. D., & Roth, Y. F. (1984). Increasing phantom limb pain as a symptom of cancer recurrence. Cancer, 54, 373-375.
Wilder-Smith, C. H., Hill, L. T., & Laurent, S. (2006). Postamputation pain and sensory changes
in treatment-naive patients: characteristics and responses to treatment with tramadol, amitriptyline and placebo. Survey of anesthesiology, 50(3), 157-158.
Wilkes, D., Ganceres, N., Solanki, D., & Hayes, M. (2008). Pulsed radiofrequency treatment of
lower extremity phantom limb pain. Clinical Journal of Pain, 24(8), 736-739. Woodhouse, A. (2005). Phantom limb sensation. Clinical and Experimental Pharmacology and
Physiology, 32, 132-134. Wu, C. L., Agarwal, S., Tella, P. K., Klick, B., Clark , M. R., Haythornthwaite, J. A., et al.
(2008). Morphine versus mexiletine for treatment of postamputation pain. Anesthesiology, 2008(109), 289-296.