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Amputee Stump Pain Quite Different From Phantom Pain

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  • Amputee Stump Pain Quite Different From Phantom Pain

    Amputee Stump Pain Quite Different From Phantom Pain

    Fifty to 80 percent of all amputees experience pain in their stumps or what feels like the missing limbs long after surgical wounds have healed.
    Now new research from Johns Hopkins suggests the two pains have different sources, bringing us a step closer to understanding what types of drugs might help.

    In a study examining stump pain vs. "phantom pain," researchers observed that the powerful pain reliever morphine significantly relieved both stump and phantom pain, while the local anesthetic lidocaine relieved only the stump pain.

    "Our results suggest that different therapeutic sensitivities of stump and phantom pain to these drugs exist, and that the mechanisms of these two types of pain may differ," says Srinivasa N. Raja, M.D., lead author of the study and professor of anesthesiology and critical care medicine at Hopkins. The report was presented Tuesday (Oct. 16) in New Orleans at the annual meeting of the American Society of Anesthesiologists.

    "Overall, the treatment of phantom and stump pain has been disappointing, in part due to the uncertain nature of the mechanisms behind the pain and the lack of well-controlled clinical studies," Raja said.

    Stump pain is believed to arise from nerve injuries at the site of the amputation and the resulting formation of neuromas, noncancerous tumors that grow out of the injured nerve fibers.

    Phantom pain is thought to reside in the brain. When the part of the brain that controlled the limb before it was amputated no longer has a function, other areas of the brain fill in. The Hopkins data supports that theory, in that lidocaine, a drug that predominantly works on the peripheral nervous system, did not relieve phantom pain. Morphine acts on the peripheral and central nervous systems.

    For the study, Raja and his colleagues studied 32 patients with an average age of 54 who had amputated limbs. Twelve patients had pain in the region of the stump, while nine had pain in the missing part of the limb. Eleven patients experienced both types of pain.

    On three consecutive days, each patient was given an intravenous injection of either morphine, lidocaine or placebo. Pain measures and patient satisfaction scores were recorded every five minutes from a half-hour before the injection until a half-hour after. The study was double-blind, meaning neither the patients nor the researchers knew which injection was being given.

    Patient satisfaction scores were similar and significantly higher for both lidocaine and morphine compared to placebo, which did not significantly reduce either type of pain.

    Other study authors were Christopher L. Wu, M.D.; Peter S. Staats, M.D.; Prabhav K. Tella, M.B.B.S., M.P.H.; and Rachel Vaslav.

    The study was funded by the National Institutes of Health.

    (Reference: Abstract #A-955 "Analgesic Effects of Intravenous Lidocaine and Morphine on Post-Amputation Pain: A Randomized Double-Blind, Active-Placebo-Controlled, Crossover Trial")

    Related websites:

    Johns Hopkins' Department of Anesthesiology and Critical Care Medicine

    American Society of Anesthesiologists

  • #2
    I find this interesting because morphine is traditionally considered to be less effective for neuropathic pain.

    wise.

    Comment


    • #3
      Need More Info on Results

      I went to the Johns Hopkins website but couldn't find more info. on this study. I can't tell from this article if lidocaine gave the same relief to people with just phantom limb pain or with a combo of stump pain/phantom limb pain, or if lidocaine is as efficacious as morphine for a stump pain/phantom pain combo. I have central pain syndrome, so I'm not sure how these results would translate into possible treatments for CPS.

      I also may be having a dense attack. Could you elucidate?

      Originally posted by Wise Young:

      I find this interesting because morphine is traditionally considered to be less effective for neuropathic pain.

      wise.

      Comment


      • #4
        Results Questions re: Johns Hopkins study on stump/phantom limb pain

        I see I should have paid more attention to para. no. 2 of this article. I would like to see more info. on the findings should you know where to find it.

        Thanks!

        Originally posted by Wise Young:

        I find this interesting because morphine is traditionally considered to be less effective for neuropathic pain.

        wise.

        Comment


        • #5
          central pain

          Calico,

          Where is your pain? Has it gotten worse since it first developed? Mine started a month after my accident (that first month, I felt absolutely nothing below the level of injury), and has intensified since. Central pain is a real bummer.
          Alan

          Proofread carefully to see if you any words out.

          Comment


          • #6
            Pain History

            In December 1996, I felt fine. In January 1997, I started having some wrist pain and the pain progressed in my arms and hands to include the typical CPS burning/aching pain. It took until July 1997 to get an MRI showing severe spinal stenosis and degenerated disks at c5-6/c6-7. Surgical fusion in August 1997 did nothing to improve the pain, although the pain hasn't gotten worse.

            It appears there is a great debate in the medical community about the efficacy of morphine and opiods in the treatment of neuropathic pain. The study posted here would indicate that morphine helps with phantom limb/stump pain. Perhaps that means it would help with CPS as well, at least for some people and perhaps administered in certain ways. My guess is method of administration may be almost as important as drug selection itself.

            None of my treating physicians wants to try me on opiods. My neurologist would like me to try a spinal cord stimulator.

            Calico

            [QUOTE]Originally posted by alan:

            Calico,

            Where is your pain? Has it gotten worse since it first developed? Mine started a month after my accident (that first month, I felt absolutely nothing below the level of injury), and has intensified since. Central pain is a real bummer.[/QUOTE

            Comment


            • #7
              SCS

              I had a spinal cord stimulator installed back in the mid-80s. In a year, it's position was revised three times. No position or setting provided any relief at all. Your mileage may vary, of course.

              I don't know if opiates would work for you, or me - I've never gotten up to high doses to find out. Also can't tell you if a pain pump would help us.
              I'm currently looking for yet another pain clinic - perhaps you should try one (or a different one, if you're using one now.) I can think of no good reason for not trying opiates on a chronic pain patient. Quality pain docs will use opiates, even at high doses, when appropriate. They are constipating, so you need to take lots of laxatives with them.
              Alan

              Proofread carefully to see if you any words out.

              Comment


              • #8
                I am a recent amputee the limb was removed August the 28th 09. I feel intense pain on a daily bases. It is mostly a tingling sensation a hundred times worse than the feeling you get when a limb falls asleep. I was wondering if there were any drugs out there that can help. I am on percocet, but frankly they cloud up my mind and make me jumpy. Any help would be appreciated.

                Comment


                • #9
                  Originally posted by Wise Young View Post
                  I find this interesting because morphine is traditionally considered to be less effective for neuropathic pain.

                  wise.
                  Morphine does work for my central pain and neuropathic pain, but my tolerance for the drug increased quickly. I used to have Dilaudid in my baclofen pump and I had to keep getting it turned up for it to be effective at all. I've since had the Dilaudid removed, which has made it much easier to control my weight, and there is really no difference in pain. I'll take a Percocet or two a day just to bring down the edge but I don't count on it to thoroughly help with the pain.
                  C-5/6, 7-9-2000
                  Scottsdale, AZ

                  Make the best out of today because yesterday is gone and tomorrow may never come. Nobody knows that better than those of us that have almost died from spinal cord injury.

                  Comment


                  • #10
                    I can't even get my Doctors to acknowledge that phantom pain exists,
                    much less find a solution for it. Maybe I should present them with this
                    article.

                    Comment


                    • #11
                      Originally posted by Buck_Nastier View Post
                      I can't even get my Doctors to acknowledge that phantom pain exists,
                      much less find a solution for it. Maybe I should present them with this
                      article.
                      Good grief. Or ask him if he's ever heard of Dr S. Weir Mitchell, the great Civil War physician who described phantom pain back in the 19th century.

                      One of his best remembered works is "The Case of George Dedlow." This story, published anonymously in the Atlantic Monthly in 1866, tells the story of a young man who, as a result of war injuries, had his arms and legs amputated, leaving just his torso. This is the first known written account of phantom limb pain, and it accurately describes the hallmark symptoms of nerve injury pain, such as dysesthetic burning.
                      http://www.painonline.org/mitchell.htm

                      Comment


                      • #12
                        Thought there was a great write up a few years back about amputee's and phantom pain relief. Something about placing a mirror next to an existing limb to give the brain the appearance it's there and diminishing or totally removing the phantom effect.
                        Rick Brauer or just call me - Mr B

                        http://www.riseadventures.org

                        Comment


                        • #13
                          Originally posted by Rbrauer View Post
                          Thought there was a great write up a few years back about amputee's and phantom pain relief. Something about placing a mirror next to an existing limb to give the brain the appearance it's there and diminishing or totally removing the phantom effect.
                          You're right. Here is a journal article:

                          http://content.nejm.org/cgi/content/full/357/21/2206

                          "Our findings showed that mirror therapy reduced phantom limb pain in patients who had undergone amputation of lower limbs. Such pain was not reduced by either covered-mirror or mental-visualization treatment. Pain relief associated with mirror therapy may be due to the activation of mirror neurons in the hemisphere of the brain that is contralateral to the amputated limb. These neurons fire when a person either performs an action or observes another person performing an action.4 Alternatively, visual input of what appears to be movement of the amputated limb might reduce the activity of systems that perceive protopathic pain.5 Although the underlying mechanism accounting for the success of this therapy remains to be elucidated, these results suggest that mirror therapy may be helpful in alleviating phantom pain in an amputated lower limb."

                          And the NIH is currently conducting a study:

                          http://clinicaltrials.gov/ct2/show/NCT00623818

                          "This study, conducted at the National Institutes of Health (NIH) and at Walter Reed Army Medical Center (WRAMC), will explore the phenomenon of phantom limb pain (a continued feeling of pain in an amputated limb) and will use functional magnetic resonance imaging (fMRI) to investigate the effect of mirror therapy on phantom limb pain."

                          Comment


                          • #14
                            I Know

                            I know what you mean my doctor refuses to see phantom pain as a real deal. I just wish these doctors would research it more. I mean I am a recent amputee I lost my leg below the knee from a motorcycle wreck in June of 08. I tried to keep the limb but it was just too painful. I don't know whats worse the pain from the limb or the phantom pain...


                            Kenny

                            Comment


                            • #15
                              Just as more evidence that phantom pain is linked to the brain, I recall a report about a surgery done by Dr Sergio Canavero several years ago where a woman wound up with phantom pain in a 3rd arm that never existed. All from "tweaking" something in her brain and apparently messing up something with the brain's "map" of the body. Canavero has done a lot of good work, but there's always risk when you're on the cutting edge.

                              Edit: Here's a reference for that report.
                              http://www.biomedexperts.com/Abstrac...in_Case_report

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