Significant pain may be experienced in the preoperative period due to gangrene, vascular disease, a tumor, infection or trauma, and may continue right up to the moment of surgery.
This pain and anxiety relief may require narcotic and non-narcotic pain medications, anti-anxiety medications, and other techniques that should be familiar to the physician, surgeon, and anesthesiologist providing care. This is not a time to suffer in silence. This is a time to ask for, and, if necessary, demand adequate relief of pain and anxiety. When a person experiences pain, the chemicals produced by the brain to deal with pain and stress are used at a rapid rate. Once depleted, they are not available in the postoperative period to assist with recovery. Going to the operating room for an amputation in a calm, relatively pain-free state is much more conducive to an easy recovery than doing so after days or weeks of severe, unrelieved pain and anxiety. In addition, medical literature increasingly suggests that excellent pain relief (analgesia) in the preoperative period may result in a decrease of ongoing postoperative pain.
Amputation is, unfortunately, a painful surgical procedure. Every type of tissue in the limb is severed during the amputation, including skin, muscle, bone, tendon, nerve, and blood vessels. Every one of these tissues has abundant nerve endings and all can hurt during and after amputation.
When available, anesthesia has been used for amputations since it was invented over 100 years ago. Usually, a type of general anesthetic that puts patients to sleep is used, rendering the patient unaware of the amputation and its painful nature. Recently, several studies have revealed that interrupting the painful nerve impulses before they reach the brain may actually decrease the probability of long-term post-amputation pain.
For many years, medical science has known that injecting Novocaine, cocaine, procaine, marcaine, or lidocaine in or around the nerves can prevent pain impulses from reaching the brain. The anesthesia can be injected into either the nerve or nerve sheath itself, the spinal cord (spinal analgesia), the area just outside the spinal cord (epidural analgesia) or a combination of these places. There is often confusion about the difference between spinal and epidural anesthesia. A spinal involves injection of the medication in the space right next to the spinal cord (between the spinal cord and the dura – the cord’s covering). It is usually a one-time shot, and a catheter is rarely left in for repeat injections. An epidural involves injection of the medication in the epidural space (outside of the dura). With this technique, a catheter is usually left in place for repeat injections over longer periods. Occasionally, the epidural catheter is left in place for several days to give postoperative pain relief.
The anesthesiologist often employs a combination of techniques. The patient about to undergo an amputation should always discuss in detail with the anesthesiologist and surgeon the techniques and anesthetics they plan to use during surgery. This discussion should focus on issues of safety, risks, and pain relief during and after the surgery. There may be excellent reasons that one anesthetic technique is recommended over another. This is the time when an informed consumer is his or her own best advocate.
Immediate postoperative pain
During the first 72 hours following an amputation, swelling occurs, tissues are stretched, severed nerves are not sending normal impulses to the spinal cord, and many other new realities are being experienced. Tension, fear, anger and denial may be producing a strong emotional "stew" for the new amputee. Physically, this is the time that patients will experience the most severe pain. There is clear evidence that adequate relief of pain and anxiety during this chaotic period is extremely important in preventing long-term postoperative pain.
It is important to consider various types of pain relief in the postoperative period, including narcotic and non-narcotic analgesic medications, anti-anxiety medications, and anti-depressants. Narcotic pain medications like morphine, Demerol and Fentanyl have been used for years to relieve severe pain. The use of these strong pain medications has been the cornerstone of relieving pain after amputation.
Patient controlled analgesia
One administration technique is Patient Controlled Analgesia. This means that the patient actually controls the timing of the doses of pain medication. To do this, a small electric pump containing a syringe of pain medication is attached to a switch. When the patient pushes a button, the pump gives a premeasured dose of the pain medicine. The doctor determines how much medicine is safe and how often it can be given. The analgesia is then given through an intravenous tube so that it enters the blood stream immediately. A small amount can be given as often as every six to 10 minutes. This has several benefits compared to the traditional injection in the muscle. It takes effect much more quickly, and there is less risk of over-sedating the patient. This method also gives the patient more control of his or her medication and the quick onset helps to relieve the anxiety of waiting for medication delivered in other ways.
In addition to narcotic pain medications, less potent non-narcotic analgesics include aspirin, acetaminophen, ibuprofen, and other nonsteroidal anti-inflammatory drugs. All are useful when properly administered and should be used with guidance from a surgeon and anesthesiologist. Other medications that can be helpful include tranquilizers such as Vistaril, anti-depressants such as Elavil, and anti-seizure medications such as Neurontin.
First six weeks post-amputation
During the first six weeks after amputation, many changes are occurring rapidly. Most of them are positive changes with decrease of pain and swelling and increase of mobility and accommodation to the physical reality of amputation; however, there are many real problems during this period, physical as well as emotional.
There is typically a decreasing need for pain medication, but there may be an increased need for medicine to help with sleep or to deal with anxiety or depression. There is change in physical activity and the need to learn new methods of dealing with formerly routine tasks. Coming home from the hospital may be highly desired, but also feared. It requires increased physical efforts as well as the emotional challenge of dealing with old relationships and demands despite a new physical reality.
Fears of dependency, inadequacy, and rejection may be the most important but unspoken part of the new amputee’s thoughts. Questions about the ability to work or maintain physical independence may demand a share of the emotional resources now dedicated to learning to walk or to bathe independently. While the physical pain may decrease dramatically, the emotional turmoil may spiral uncontrollably during the six or eight weeks after an amputation. This stress may significantly affect the amputee’s ability and willing-ness to deal with the remaining physical pain. The chemicals in the brain that help alleviate pain may be expended by this time, increasing the amputee’s pain, anxiety, and stress.
Phantom pain is real; however, only a small percentage of amputees have severe problems with phantom pain. For many, the pain occurs in very short episodes, passes quickly, occurs less as time goes on, and, in general, is very manageable. Much is still unknown about phantom sensations in absent limbs and phantom pain, but medical science is learning more about its origins and treatments.
Some patients say the pain they felt in their limbs immediately before amputation persists as a kind of pain memory. For example, soldiers who had grenades explode in their hands reported that their phantom hand is in a fixed position, clenching the grenade, ready to toss it. The pain in the hand is excruciating - the same they felt the instant the grenade exploded.
A woman in England suffered severe frostbite on her thumb as a child. Gangrene developed and the thumb had to be amputated. Now, 50 years later, she reports having chilblains (a frost-like pain due to cold weather) in her thumb when the weather turns cold.
A girl born without forearms experienced phantom hands six inches below her residual arms. She reported using her phantom fingers to calculate arithmetic problems.
Today, thousands of such stories have the medical profession acknowledging that what these people feel is real - and often debilitating. Many doctors even specialize in phantom pain and sensation. Their hope is that research will help thousands of people around the world enjoy pain-free lives.
Relief for phantom pain
Despite intense research in this area, there is still much to be learned about the physiology of the nervous system and how to treat phantom pain. Therapies include medications and biofeedback, electrical nerve stimulation, massage, heat, cold, compression, acupuncture and acupressure, cranial sacral therapy, and touch treatment therapy. Just as the amount of pain people feel differs between patients, so do treatment results. What works for one person may not be effective for another.
Researchers are currently investigating the different types of pain and sensations following amputation. Studies have indicated that painless phantom limb sensations were quite common, and occurred more frequently than phantom limb pain. Residual limb pain and back pain were also common following amputation.
In one recent study, back pain was surprisingly rated as more bothersome than phantom limb pain or residual limb pain. Back pain was significantly more common in people with above-knee amputations. Research also suggests that back pain following lower-extremity amputation is likely to be overlooked but is an important pain problem, warranting additional clinical attention and study.
All of the recent studies also support the importance of looking at pain as a multidimensional rather than a one-dimensional construct. This means that the impact pain has on an individual’s life is influenced by its frequency, duration, intensity, bothersomeness, and whether it is episodic or continual. All of these different factors make pain very difficult to measure and study accurately.
Unfortunately, there are no magic treatments to fully eliminate pain; however, physicians are emphasizing prevention with symmetrical gait training, proper back care, good sitting posture, and good lifting habits.
For now, until research offers improved pain treatment, it is a matter of managing the problem rather than curing it. The important thing is to educate patients in the options available to them so that they can restore their functions and attain a better quality of life.
For more information on the various therapies to combat amputation pain, contact the Amputee Coalition office toll-free at 1-888/AMP-KNOW (267-5669).
Sources: Information compiled from inMotion magazine articles, NLLIC information specialists, and Dr. Doug Smith, Amputee Coalition medical director.
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