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The treatment of established phantom limb pain: a survey of uk practice.

Dr M Human. Dr P DCollins. The Pain Clinic Department, Taunton and Somerset Hospital, Taunton, Somerset, TA1 5DA, UK.

Aim of investigation: On the 24th of March 2000 "The First International Consensus Meeting" for the management of established phantom limb pain was conducted. This survey was intended to highlight individual differences in current management and the need for internationally agreed guidelines.

Methods: Questionnaires were sent to members of the Pain Society who could be identified as UK anaesthetists (600). Practitioners were asked how often they managed established phantom limb pain and how frequently they used the medical, surgical or complementary treatments listed (24 in total). Responses were rated as "never", "rarely", "often", "mostly" or "always" and results expressed as the percentage of the total possible response.

Results: 161 replies were received. Of these 88 were treating more than 5 cases per year and only 7 more than 20. The most commonly used treatments were Tricyclic antidepressants (69%), Gabapentin (51%), TENS (54%) and Simple analgesics (49%). There was considerable variation in the treatments. "Always" used (Tricyclics the highest at 22%) whilst a few respondents "Never" used Simple analgesics (14%), Gabapentin (10%) or TENS (4%). Significant outliers were also identified.

Conclusion. Despite a few treatments being used commonly none were used "Always" by more than 22% or respondents. In addition, several of the recognised treatments were not used at all by others. This implies a need for a logical treatment strategy, especially as so few clinicians appear to be seeing this condition.

Phantom limb pain: do we use pre-emptive analgesia? A survey of anaesthetic practice in the southwest of england.

Rob Aldwinckle, Alf Collins. Dept of Anaesthesia, Musgrove Park Hospital, Taunton, TA1 5DA

Aim of investigation: To assess whether anaesthetists within the South-West region usually provide pre-emptive analgesia for patients undergoing amputation surgery.
Methods: A simple tick box questionnaire was sent to all Consultant anaesthetists within the region. The questionnaire looked at whether the anaesthetists regularly anaesthetised patients for limb amputation, and whether they usually provided pre-emptive analgesia.
Results: 90 of 196 questionnaires were returned (response rate 46%). Of these 18 anaesthetised more than 10 patients pre year for amputation. 6 of these usually provided pre-emptive analgesia. 3 provided this less than 24 hours prior to amputation surgery. 1 (+ 1 sometimes), provided this more than 24 hours pre-operatively, and 2 cases were unspecified. The pre-operative analgesic methods used were intravenous opiates (n=l) and epidural catheter placement (5 with opiates and local anaesthetic, 2 local anaesthetic only).
Conclusions: Of those anaesthetists regularly anaesthetising patients for limb amputation, a small number (n=6, 33%) usually provided pre-emptive analgesia. The method of choice for this procedure was invariably the placement of an epidural catheter. This is despite a relative lack of evidence for the efficacy of pre-emptive analgesia. The results highlight the need for an evidence based consensus opinion.

Comparison between physical fitness, perceived exertion, pain and cognitivo-emotional factors in low back pain and fibromyalgia women.

L. Barras. E. Masquelier and E. Ophoven, Pain Clinic, Clinique St-Pierre, 1340 Ottignies, Belgium.

Aim of investigation : To correlate the relationschip between physical fitness, perceived exertion, pain and cognitivo-emotional factors in a fybromyalgia syndrome (FS) and a low back pain (LBP) women population.
Methods : Nonrandomized french speaking females patients with FS (n=24, mean age=42.7 yrs) according to the ACR-criteria and LBP in subacute stage (n=23, mean age=36.6 yrs) are include in this study. A submaximal exercice test is carried out on a cycle ergometer MONARK 818 E with an initial workload of 25 Watts followed by stepwise increments of 25 Watts every 2 minutes until exhaustion. During the test, the degree of perceived exertion is recorded to a 0-10 Modified Borg Scale. Heart rate is monitored with a Polar Sport Tester and the pain is scored on a Visual Analogue Scale (VAS). The fitness index for each patient is assessed using the Work Capacity Index (W65%/kg). Beck Depression Inventory, Spielberger, Survey Of Pain Attitude (SOPA) and Kinesiophobia questionnaires are carried out.
Results : The Work Capacity Index is better for FS than for LBP patients. But perceived exertion, pain, anxiety, depression, control, disability, solicitude and medical cure factors are significantly different for FS than for LBP patients. There is no correlation between Work Capacity Index and other factors.
Conclusion : Physical fitness in FS seems to be good like healthy women. But perceived exertion, pain and cognitivo-emotional factors are worse for FS that another painful population as LBP. In FS women, the cognitivo-emotional factors and pain are very important to assess to establish rehabilitation program.

Phantom pain: are professionals providing patients with adequate information?

C Mortimer. W M Steedman, I R McMillan The Scottish Network for Chronic Pain Research and The Department of Occupational Therapy Queen Margaret University College, Edinburgh.

Aim of Investigation: The literature has emphasised the importance of patient education as a crucial step in the management of phantom pain. The aim of this study was to explore current practice in patient education in Central Scotland from both patient and professional perspectives.
Methods: Focus group studies were conducted with amputation patients and professionals. Questions examined the level of information provided and potential ways of improving practice.
Results: Areas identified by patients:
- Professionals were not consistently the main source of information.
- Responses indicated that the information provided by professionals about the nature, duration and cause of phantom pain was inconsistent and often insufficient.
- The information given was frequently leaving patients confused and concerned about the phantom experience.
- There was a unanimous feeling that clear information that took into account the variability of the experience should be provided before or soon after amputation.
Areas identified by professionals:
- Responses indicated that efforts were made to discuss phantom phenomena with patients.
- There was, however, no evidence of a standardised approach to the content of or professional responsibility for education.
- Comments relating to what people should be told revealed uncertainties and some misconceptions regarding the nature and causes of phantom pain.
Conclusions: Currently there are inconsistencies in the information that patients are given about phantom pain. Patients both desire and require well-researched information to assist in the development of effective pain management. Efforts should be devoted to developing standardised education and co-ordinating practice.

Correlation between epilepsy-related risk factors, personality traits, aura-like phenomena and phantom limb pain in human amputees

Inna Belfer1. Edith Gershon1, Mods Azaria;, Tian Xia Wu Yoram Shir4, Jean-Jacques Vatine4, Rail Zeltser4, Mitchell Max1, Scott R. Diehl1 and Ze'ev Seltzer1-; 'Faculty of Dental Medicine, Hebrew University, Jerusalem, Israel (HUJI); :Sheba Medical Center, Ramat Can, Israel; 'NIDCR, NIH, Bethesda MD, USA; "Hadassah University Hospital, Jerusalem, Israel; 'Faculty of Medicine, HUJI, 91120 Jerusalem, Israel

Aim of investigation: Neuropathic pain and epilepsy in humans and animals share certain clinical features, mechanisms and treatment. Recently we found that a genetic locus on chromosome 6p21 may be associated with phantom limb pain (PLP) in human amputees. The same chromosomal region is also associated with juvenile myoclonic epilepsy. This raised the possibility that the same genetic locus may play a role in PLP and epilepsy. In this study we examined whether epilepsy-related risk factors, personality traits and aura-like phenomena are associated with PLP in human amputees.
Methods: Israeli male veterans (N=92) were recruited to the study 23.5±0.8(avg±sem) years after loosing one leg in combat. Using a questionnaire they estimated the intensity, frequency and duration of a typical PLP episode, presence of fits, risk factors for epilepsy, aura-like events preceding PLP episodes and epilepsy-related personality traits. Intensity, duration and frequency of PLP were combined into a single individual numerical index, clustering as two groups: 'low' (n=41) and 'high' (n=51) PLP.
Results: We found that "aura-like" emotional, cognitive and somatosensory events occasionally preceded PLP episodes in 43% of amputees, in 22% occurring very frequently. Some amputees experienced more than one aura-like type. Some risk factors known to be associated with epilepsy (advanced mother's age, abnormal early cognitive and motor development, and endurance of physical hardships) were also correlated to PLP. No epileptoid personality traits were significantly correlated to PLP.
Conclusion: The present results are compatible with the hypothesis that epilepsy and PLP share similar risk factors, pathophysiological mechanisms and presumably some genes.

Correlation between phantom limb pain and other phantom sensory phenomena in human amputees

Edith Gershon'. Jean-Jacques Vatine;, Yoram Shir, Tian Xia Wu\ Moris Azaria4, Rafi Zeltser, Inna Belfer1, Mitchell Max', Scott R. Diehl' and Ze'ev Seltzer15; 'Faculty of Dental Medicine, Hebrew University, Jerusalem, Israel (HUJI); :Hadassah University Hospital, Jerusalem, Israel; 'NIDCR, NIH, Bethesda MD, USA; 4Sheba Medical Center, Ramat Gan, Israel; 'Faculty of Medicine, HUJI, 91120 Jerusalem, Israel

Aim of investigation: Limb amputation causes phantom limb pain (PLP) in about 80% of amputees. Recent reports suggested that PLP is correlated to plasticity of cortical somatotopic maps representing the missing limb. All amputees experience non-painful sensations in the missing limb. Some amputees report of bizarre sensations suggesting neural plasticity, like: gradual phantom limb shortening ('telescoping'), its unnatural position (UP), 'mirror image' pain contralaterally (MIP) and movements of the phantom limb. Here we examined whether these bizarre phenomena are correlated to levels of PLP and stump pain.
Methods: Israeli male veterans (N=92), were recruited to the study 23.50.8(avgsem) years after loosing one leg in combat. Using VAS and category scales they estimated the typical intensity, frequency and duration of PLP and stump pain episodes. These parameters were combined into a single individual phantom pain index (PPI) and stump pain index (SPI). Subjects also reported of the incidence of these bizarre sensations in the missing limb and contralaterally.
Results: Most amputees (80%) frequently experienced at least one such non-painful sensory-motor phenomenon. Levels of PPI and SPI were higher in amputees experiencing telescoping (18% of amputees), MIP (11%), UP (18%) and volitional (65%) or non-volitional (17%) movements of the phantom limb, compared to amputees who did not experience these phenomena. Pre-amputation pain preceded PLP in <10% of amputees.
Conclusion: PLP is frequently accompanied by other bizarre sensory phenomena ipsi- and contralaterally. Like PLP, our results are compatible with the hypothesis that these phenomena may result from neural plasticity.

Employment, pain and rehabilitation in an amputee population

Whyte, A. S. & Carroll. L.J Scottish Network for Chronic-Pain Research, University of Stirling, Stirling FK9 4LA, UK Telephone: (44) 1786 466343 I Fax: (44) 1786 466344 I Email: a.s.whyte@stir.ac.uk

Introduction: Long-term amputees frequently have problems which curtail their activities and impoverish their lives. These difficulties are seldom brought to the attention of those involved in the rehabilitation process. Problems include phantom pain, psychological distress, and disability. This study examines the impact of these factors on employment
Materials and Method= The study sample was drawn from patient records held at three artificial limb and appliance centres (ALAC's) in Central Scotland. In all, 315 of those contacted agreed to take part in the study. After excluding those who were deceased, or no longer lived at the contact address and those who did not meet the study criteria (did not experience phantom limb pain). This figure represents a 62% response rate.
Results: Amputation, in this group had severe consequences in terms of employment status. A large proportion of the sample (75%) was in employment prior to their amputation, however, since their amputation, only 43.5% remained in employment. Ten percent of the sample had retired early on health grounds. In general, those who changed occupation moved from manual to non-manual types of employment. Those in manual occupations were more likely to become unemployed following amputation. These findings suggest that employment prospects are not good following amputation. Current employment status was related to the intensity of phantom limb pain in this group with those who were unemployed reporting higher levels of pain (F1.53, p<0.01).
Conclusions: Further research is required to determine whether these figures result from amputee's disabilities, their attitudes towards themselves in relation to work, or to employers' attitudes about the capabilities of an individual following amputation.

Use of health and social services in an amputee population

Whyte. A. S. Scottish Network for Chronic Pain Research, University of Stirling, Stirling FK9 4LA, UK Telephone: (44) 1786 466343 I Fax: (44) 1786 466344 I Email: a.s.whyte@stir.ac.uk

Introduction: Following amputation, individuals are likely to experience a number of difficulties can be addressed by health, social and voluntary service. The primary complaint in this population is pain, both phantom limb pain and pain related to the amputation. This study sought to examine amputees' use of such services and the perceived benefit obtained from them.
Materials and Method: The sample consisted of 315 amputees aged between 20 and 60yrs attending prosthetic services in the central belt of Scotland. A postal questionnaire was used to determine use and perceived benefits of 20 services available to this population.
Results: These data suggest that few amputees make use of available services for general pain problems (mean number of services used 4.28 range 0-12) and even fewer services are used for phantom limb pain (mean 1.55 range 0 - 9). Of those who do use services only 2.57 (range 0-8) were reported as being useful for pain. The main services used by this population were General Practitioners and Prosthetists. Few amputees used complementary therapies such as hypnotherapy, aromatherapy etc.
Discussion: Given the number services available that may potentially ameliorate pain problems, further research is required to determine why few amputees make use of them. One possible explanation is lack of information on what services are available. Other factors might include cost, accessibility difficulties or poor understanding of what these services provide.

Pain in Europe III. EFIC 2000, Nice, France, September 26-29, 2000. Abstracts book, p. 249, 250, 256, 262, 265, 267.

   

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