Factors associated with phantom limb pain: a 3½-year prospective study

Abstract

Objective: To analyse the prevalence of phantom (limb) pain over time and to analyse factors associated with phantom (limb) pain in a prospective cohort of amputees.

Design: A multicentre longitudinal study.

Patients: One hundred and thirty-four patients scheduled for amputation were included.

Methods: Patients filled in questionnaires before amputation, and postal questionnaires six months, 1½ years and 2½ years to a maximum of 3½ years after amputation. Preoperative assessment included patients’ characteristics, date, side and level of, and reason for amputation. The follow-up questionnaires assessed the frequencies of the experienced phantom pain, prosthetic use and walking distance. The occurrence of phantom pain was defined as phantom pain a few times a day or more frequently.

Results: Pre- and postoperative questionnaires were available filled in by 85 amputees (33 females and 52 males). The percentage of lower limb amputees with phantom pain was the highest at six months after amputation, and of upper limb amputees at 1½ years. In general, more women than men experienced phantom pain. One and a half years and 2½ years after amputation the highest percentages of the lower limb amputees used their prosthesis more than 4 hours a day (66%), after that time this percentage decreased to 60%. The results of the two-level logistic regression analysis to predict phantom pain show that phantom pain was less frequently present in men (odds ratio (OR) = 0.12), in lower limb amputees (OR = 0.14) and that it decreased in due course (OR = 0.53 for 1 year).

Conclusion: Protective factors for phantom pain are: being male, having a lower limb amputation and the time elapsed since amputation.

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References

Sherman RA , Sherman CJ , Parker L. Chronic phantom and stump pain among American veterans: results of a survey . Pain 1984; 18: 83-95.

Kalauokalani DAK , Loeser JD Phantom limb pain. In Crombie IK. ed. Epidemiology of pain, Seattle, IASP Press, 1999, 143-53.

Kooijman CM , Dijkstra PU , Geertzen JHB , Elzinga A. , Schans van der CP Phantom pain and phantom sensations in upper limb amputees. An epidemiological study. Pain 2000; 87: 33-41.

Dijkstra PU , Geertzen JHB , Stewart R. , Schans van der CP Phantom pain and risk factors: a multivariate analysis. J Pain Symptom Manage 2002; 24: 578-85.

Nikolajsen L. , Jensen TS Phantom limb. In McMahon SB , Koltzenburg M. eds. Wall and Melzack’s textbook of pain, fifth edition. Edinburgh, Elsevier Churchill Livingstone, 2006, 961-71.

Pohjolainen T. A clinical evaluation of stumps in lower limb amputees. Prosthet Orthot Int 1991; 15: 178-84.

Houghton AD , Nicholls G. , Houghton AL , Saadah E. , McColl L. Phantom pain: natural history and association with rehabilitation . Ann R Coll Surg Engl 1994; 76: 22-25.

Wartan SW , Hamann W. , Wedley JR , McColl I. Phantom pain and sensation among British veteran amputees. Br J Anaesth 1997; 78: 652-59.

Borsje S. , Bosmans JC , Schans van der CP , Geertzen JHB , Dijkstra PU Phantom pain: a sensitivity analysis. Disabil Rehabil 2004; 26: 905-10.

10.

Jensen TS , Krebs B. , Nielsen J. , Rasmussen P. Immediate and long-term phantom limb pain in amputees: incidence, clinical characteristics and relationship to pre-amputation limb pain. Pain 1985; 21: 267-78.

11.

Melzack R. Phantom limbs. Sci Am 1992; 266: 120-26.

12.

Nikolajsen L. , Ilkjær S. , Krøner K. , Christensen JH , Jensen TS The influence of pre-amputation pain on postamputation stump and phantom pain. Pain 1997; 72: 393-405.

13.

Raichle KA , Hanley MA , Molton I. et al. Prosthesis use in persons with lower- and upper-limb amputation . J Rehabil Res Dev 2008; 45: 961-72.

14.

Lotze M. , Grodd W. , Birbaumer N. , Erb M. , Huse E. , Flor H.

Does use of a myoelectric prosthesis prevent cortical reorganization and phantom limb pain?

Nature Neurosci 1999 ; 2: 501-502.

15.

Jensen TS , Krebs B. , Nielsen J. , Rasmussen P. Phantom limb, phantom pain and stump pain in amputees during the first 6 months following limb amputation. Pain 1983 ; 17: 243-56.

16.

Jahangiri M. , Jayatunga AP , Bradley JW , Dark CH Prevention of phantom pain after major lower limb amputation by epidural infusion of diamorphine, clonidine and bupivacaine . Ann R Coll Surg Engl 1994; 76: 324-26.

17.

Pinzur MS , Garla PG , Pluth T. , Vrbos L. Continuous postoperative infusion of a regional anesthetic after an amputation of the lower extremity. A randomized clinical trial. J Bone Joint Surg Am 1996; 78: 1501-505.

18.

Lambert A. , Dashfield A. , Cosgrove C. , Wilkins D. , Walker A. , Ashley S. Randomized prospective study comparing preoperative epidural and intraoperative perineural analgesia for the prevention of postoperative stump and phantom limb pain following major amputation. Reg Anesth Pain Med 2001; 26: 316-21.

19.

Geertzen JHB , Bosmans JC , Schans van der CP , Dijkstra PU Claimed walking distance of lower limb amputees. Disabil Rehabil 2005; 27: 101-104.

20.

Merskey H. , Bogduk N. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms, second edition. Seattle , IASP Press, 1994.

21.

Holdcroft A. , Berkley KJ Sex and gender differences in pain and its relief. In McMahon SB , Koltzenburg M. eds. Wall and Melzack’s textbook of pain, fifth edition. Edinburgh, Elsevier Churchill Livingstone, 2006, 1181-97.

22.

Derbyshire SWG. Gender, pain, and the brain. Pain Clin updates 2008; 16: 1-4.

23.

Keogh E. , Denford S. Sex differences in perceptions of pain coping strategy usage. Eur J Pain 2008; 13: 629-34.

24.

Hirsh AT , Dillworth TM , Ehde DM , Jensen MP Sex differences in pain and psychological functioning in persons with limb loss. J Pain 2010; 11: 79-86.

25.

Gallagher P. , Allen D. , Maclachlan M. Phantom limb pain and residual limb pain following lower limb amputation: a descriptive analysis . Disabil Rehabil 2001; 23: 522-30.

26.

Weiss SA , Lindell B. Phantom limb pain and etiology of amputation in unilateral lower extremity amputees. J Pain Symptom Manage 1996; 11: 3-17.

27.

Hunter JP , Katz J. , Davis KD Stability of phantom limb phenomena after upper limb amputation: a longitudinal study. Neuroscience 2008; 156: 939-49.

28.

Lotze M. , Flor H. , Grodd W. , Larbig W. , Birbaumer N. Phantom movements and pain. An fMRI study in upper limb amputees. Brain 2001; 124: 2268-77.

29.

Devor M. Response of nerves to injury in relation to neuropathic pain. In McMahon SB , Koltzenburg M. eds. Wall and Melzack’s textbook of pain, fifth edition. Edinburgh, Elsevier Churchill Livingstone, 2006, 905-27.

30.

Flor H. , Nikolajsen L. , Jensen TS

Phantom limb pain: a case of maladaptive CNS plasticity?

Nat Rev Neurosci 2006; 7: 873-81.

31.

Maclver K. , Lloyd DM , Kelly S. , Roberts N. , Nurmikko T. Phantom limb pain, cortical reorganization and the therapeutic effect of mental imagery. Brain 2008; 131: 2181-91.

32.

Nikolajsen L. , Ilkjær S. , Christensen JH , Krøner K. , Jensen TS Randomised trial of epidural bupivacaine and morphine in prevention of stump and phantom pain in lower-limb amputation . Lancet 1997; 350: 1353-57.