Managing Pain

Residual Limb Wound Pain

This type of pain is associated with the injury itself and its treatment, such as postoperative pain. It commonly comes from the bones and surrounding soft tissues and is described by patients in many ways, such as achy, gnawing or deep.

Phantom Limb Sensation and Pain

This type of pain is associated with the limb that has been amputated. The feeling is commonly described as a squeezing, burning or irritating pain that seems to come from some part of the amputated or phantom limb. There is no doubt that phantom pain is real pain.

To effectively manage pain, it is helpful to distinguish these two types of pain from phantom sensation, which refers to the feeling that the amputated limb is still present. The patient may also have an itch at their phantom limb that is relieved by scratching their soundside limb. Phantom sensation is normal in the postoperative period, and almost all amputees experience it.

Other Sources of Pain

Pain after amputation may also come from other sources. The residual limb may be a source of pain due to infection, blood collection (hematoma), swelling of soft tissues (edema), bone spurs, abnormal bone growth, the healing end of a nerve that was cut during surgery (a neuroma), or to the mechanical effects of wearing a compression device to decrease edema. Postoperative compression devices include casts, elastic bandages, stockinettes and shrinker socks.

Pain may also occur during the prosthetic fitting process, and adjustments may have to be made to the fit of a socket over a residual limb that is still healing, shaping and shrinking. During physical therapy, occupational therapy, and new activities, patients may have discomfort as they continue to build their tolerance to pain.

The loss of a limb further affects normal body mechanics, such as the way a person lies, sits or moves, and pain may occur in the back, the neck, and the remaining limbs. Sometimes after an amputation, pain in parts of the body that were once only mildly painful may become worse due to the overuse and increased wear and tear on those areas of the body.

Neuromas

Traumatic stump neuroma is a disorganized proliferation of nerve fascicles occurring after limb amputation. In other words, the nerve that would normally connect to the missing limb has been severed and is now trying to find its missing limb and grows into a bundle. Preferably, the bundle is buried in deep tissue, but may still cause pain. Alternatives for pain include injections of the neuroma or a surgery that will move it higher in the residual limb.

Describing the Pain

To better manage pain associated with amputation, the type of pain experienced should be clearly described in the patient’s own words. Commonly, members of the amputee care team will want to distinguish between wound pain and phantom limb pain. Other aspects of the pain that should be described include its intensity, duration and quality. Most members of the amputee care team will use a 0–10 painintensity scale with 0 meaning no pain and 10 meaning the worst pain imaginable. Often, getting the pain intensity to a level of four or less provides adequate pain management so that patients can sleep and participate fully in their rehabilitation process during the day. It can also be helpful to describe what makes the pain worse or better, such as moving into certain positions or making specific movements. This information is helpful as the patient and the amputee care team put together an individualized plan to adequately manage the various types of pain that may occur after amputation.

Interventions for Pain

Several interventions are available to manage pain associated with an initial injury and around the time of amputation surgery. Commonly, analgesic (pain-killing) medicines are given intravenously (through an IV) and are used for several days to manage pain. Medicines that may be used with an IV include opioid analgesics and nerve-blocking agents. A patientcontrolled analgesia (PCA) pump attached to an IV also helps to provide good pain management as it allows the patient to push a button to release a measured amount of analgesic medicine in a given period of time. These pain control methods are also useful when a patient is going to the operating room for multiple washouts and debridements of a dirty wound or when wound-dressing changes are expected to be particularly painful. As patients recover and become more mobile, IV medicines are switched over to oral analgesic medicines to reduce the risk of infection and to promote comfort and freedom of movement. Gradually, opioid analgesic medicines (both oral and those applied as patches to the skin) are tapered downward and then discontinued.

Treating Phantom Pain

Pain management for phantom limb pain may last weeks, months or sometimes years and includes several approaches. Opioid analgesics are used primarily around the period of initial trauma and amputation surgery. Prolonged use of these medicines, however, is associated with tolerance, which means that over time, the patient will begin to need a larger dose of the medicine for the same effect. Opioid analgesics can also cause side-effects, such as drowsiness, clouded judgment, constipation and breathing difficulties.

Antidepressant, antiseizure and antiinflammatory medications may be used in certain situations. Antidepressant medications are sometimes highly effective in the treatment of phantom limb pain for some individuals. In addition, these medications are useful for treating clinical depression, which can worsen the symptoms of phantom limb pain or increase the frequency of its occurrence.

Antiseizure medication, such as Neurontin (gabapentin), is now one of the most commonly used medications to treat phantom limb pain. Neurontin seems to decrease the intensity of pain and the number of pain episodes with fewer side-effects than other antiseizure medications.

Anti-inflammatory medications, such as aspirin and other over-thecounter medications, do not directly control phantom limb pain itself, but can help by decreasing the local tissue inflammation that sometimes leads to phantom pain flare-ups.

It is important that patients review with their physicians the potential side- effects of all medications (including vitamin, mineral, food and herbal supplements) that might be used alone or in combination to treat their pain.

Other Possible Treatments

Though often lacking in scientific evidence, many physical treatments have also been reported to be effective in treating amputation-related pain. These treatments include physical therapy, acupuncture, massage and tapping near the incision line, transcutaneous or percutaneous electrical nerve stimulation, the use of compression devices, mirror imaging, therapeutic touch, magnet therapy, and the use of special liners and topical agents. Clinical experience has shown that, at a minimum, effective phantom limb pain management usually includes shrinking and shaping the residual limb for full weight-bearing, maintaining mobility, sleeping adequately, gently massaging the soft tissues around the residual limb, and reducing stress. Services, such as counseling (individual, family, group and vocational), self-hypnosis and biofeedback training, are also available to help patients reduce stress and thereby improve their overall pain management.

Working Together for Success

It is not uncommon for pain associated with an amputation to seem worse at night when the activity of the day subsides and the person may feel alone. No one should despair, however. Good communication between the patient and the amputee multidisciplinary care team can help them design and implement a dynamic and individualized pain-management plan that can provide sufficient comfort over the entire day while enabling the patient to participate fully in his or her recovery and rehabilitation process.