One of the most debilitating accidents someone can experience is an injury to an arm or leg that requires amputation, or an accident that causes a traumatic amputation. In addition to the initial pain of injury, some people will later experience a phenomenon called “phantom limb pain.” This type of pain is exactly as it sounds. The person no longer has the body part that they perceive as painful. It is as if there is a ghostly body part that is still sending signals to the brain; for example, right foot pain when the person has had a below the knee amputation of the right lower leg. This type of pain is not fully understood, but it is very prevalent in people who have suffered an amputation.
There are around 2 million people in the United States living with amputations. Trauma is the 2ndleading cause of amputation. An amputation of a leg, arm, finger, or toe can by caused by many mechanisms. Below is a non-exhaustive list of causes for these injuries.
- Motor vehicle collision
- Machinery accident: manufacturing involving paper, wood, logging, carpentry; food processing
- Gun violence
- Exposure to an explosive device: military combat; terrorist attacks
- Fingers caught between doors
- Lawn mowers
Phantom limb pain may be described by the injured person as burning, aching, dull, squeezing, cramping, or electric-type (i.e. shooting) pain. In a study where 124 upper limb amputees were questioned, 76% reported phantom sensations (i.e. tingling), and 51% reported phantom pain. 48% of the subjects experiencing phantom pain had episodes a few times per day or more. 64% of the same group of subjects experienced moderate to high level suffering from the phantom pain (Kooijman, 2000).
There is no standard treatment for this phenomenon as pain is subjective and may be psychological in this case. When a person has a painful area of the body that can be identified, such as a laceration, broken bone, heart attack, or infection, then the pain can have a tailored treatment that helps to heal the problem. A healthcare provider must treat pain as measured by the person experiencing the pain. It is difficult to pinpoint a way to treat a painful limb that no longer exists.
In a study from 2007, the drug memantine was tested and showed positive results for reducing and decreasing the occurrence of phantom limb pain. The long-term effect of the drug was not established in this study. Memantine is in a drug class called “NMDA receptor antagonists” that decreases abnormal activity in the brain. Another drug in this class that has been shown to improve phantom limb pain is ketamine. The problem with ketamine is that it is a drug also used for anesthesia, so it has respiratory depression side effects that must be closely monitored by a healthcare professional. Other drugs that have been used in attempt to resolve this abnormal nerve pain are gabapentin, amitriptyline, mexiletine, and lidocaine. Some other non-pharmacologic options for treatment are as follows:
- Using a mirror to psychologically help the brain connect psychologically to the new body
- Virtual reality
- Target muscle reinnervation (nerve transfer procedure)
- Peripheral nerve stimulation- surgically implanted electrical device
Another treatment option is mental imagery. This therapy includes multiple weeks where a therapist helps the injured person to relax and intentionally imagine movements and sensations of the phantom limb. By using fMRI (functional magnetic resonance imaging), scientists are able to see what areas of the brain are being used for different functions in the body. When someone has an amputation, the normal nerve pathways are disrupted and reorganized. In one study, it was noted that the area of the brain that was active during lip movement and imagined limb movement was the same area in normal humans. When someone has an amputation, there was an additional area of the brain that was being used during normal hand and phantom hand movements. After 6 weeks of therapy, the neuron signals from the fMRI were significantly decreased in the “reorganized” area. With the change in fMRI results, 9 of the 13 participants had greater than 50% phantom pain relief (MacIver, 2008).
A wellness center in Tennessee, Revitalist, says that fewer than 10% of people with phantom limb pain have lasting relief. Residual pain from the absent limb has been associated with PTSD and depression. It is important for those affected by a traumatic amputation injury be treated by a multidisciplinary team approach to healing, including the psychological care for loss of limb and the potential for phantom limb pain to cause further psychological frustration in a changing lifestyle.
One study discovered the total lifetime cost for treatment for an amputation was $509,275. This dollar amount did not take into account prosthetics and years the person would most likely live. As this is a disabling injury it could be very difficult or impossible, for the injured person to make money or hold a job with benefits, to support this follow-up medical care. In addition to financial burden, the person’s activities of daily living are significantly altered, and they will need to learn how to transport themselves, cook, get a shower, and cope with the loss of function. If you, or someone you love, have experienced a traumatic limb amputation and are suffering from phantom limb pain, you may be entitled to compensation. We, at Premier Law Group, would love to help you navigate this difficult circumstance.
Written by: Courtney Tolin, RN, BSN, CEN
American Society of Health-System Pharmacists, Inc. (2016, April 15). Memantine. Retrieved April 23, 2020, from https://medlineplus.gov/druginfo/meds/a604006.html
Chung, K. C., Yoneda, H., & Collins, K. A. (2018, August 29). Upper extremity amputation. Retrieved April 23, 2020, from https://www.uptodate.com/contents/upper-extremity-amputation?search=phantom limb pain§ionRank=1&usage_type=default&anchor=H1158268838&source=machineLearning&selectedTitle=2~18&display_rank=2#H1158268838
Dadourian, M. (2018, March 22). Man has leg amputated, fights for his life after horrific motorbike crash in Thailand. Retrieved April 23, 2020, from https://www.foxnews.com/health/man-has-leg-amputated-fights-for-his-life-after-horrific-motorbike-crash-in-thailand
Dumanian, G. A., Potter, B. K., Mioton, L. M., Ko, J. H., Cheesborough, J. E., Souza, J. M., … Jordan, S. W. (2019). PubMed. Retrieved from https://www.uptodate.com/contents/lower-extremity-amputation?search=phantom limb pain§ionRank=1&usage_type=default&anchor=H614734724&source=machineLearning&selectedTitle=1~18&display_rank=1#H614734724
Kalapatapu, V. (2020, January 3). Lower extremity amputation. Retrieved April 23, 2020, from https://www.uptodate.com/contents/lower-extremity-amputation?search=phantom limb pain§ionRank=1&usage_type=default&anchor=H614734724&source=machineLearning&selectedTitle=1~18&display_rank=1#H614734724
Kooijman, C. M., Dijkstra, P. U., Geertzen, J. H., Elzinga, A., & van der Schans, C. P. (2000). Phantom pain and phantom sensations in upper limb amputees: an epidemiological study. PubMed.gov, 33–41. doi: 10.1016/s0304-3959(00)00264-5
Lewis, R. (2008, October 25). Marine amputee returns to combat after near death experience. Retrieved April 23, 2020, from https://www.1stmardiv.marines.mil/News/News-Article-Display/Article/541887/marine-amputee-returns-to-combat-after-near-death-experience/
Lusardi, M. M., Jorge, M., & Nielsen, C. C. (2013). Orthotics and Prosthetics in Rehabilitation (3rd ed.). Retrieved from https://books.google.com/books?id=__ILBAAAQBAJ&pg=PA467&lpg=PA467&dq=Ziegler-Graham K, MacKenzie EJ, Ephraim PL, et al. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil 2008;89:422-429.&source=bl&ots=FLzA6VcVf0&sig=ACfU3U2M-Xthm3vMk4i7Z3zRA7Psm5IBJA&hl=en&sa=X&ved=2ahUKEwjs04rnsPzoAhVL_J4KHRXVCBcQ6AEwBnoECAcQAQ#v=onepage&q=Ziegler-Graham K, MacKenzie EJ, Ephraim PL, et al. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil 2008;89:422-429.&f=false
MacIver, K., Lloyd, D. M., Kelly, S., & Nurmikko, T. (2008). Phantom limb pain, cortical reorganization and the therapeutic effect of mental imagery. PubMed Central. doi: 10.1093/brain/awn124
Nayak, R., & Banik, R. K. (2018). Current Innovations in Peripheral Nerve Stimulation. PubMed Central. doi: 10.1155/2018/9091216
Ramirez, C., & Menaker, J. (2017, May 1). Traumatic Amputations. Retrieved April 23, 2020, from https://www.reliasmedia.com/articles/140552-traumatic-amputations
Revitalist Clinic. (2020). Phantom Limb Pain. Retrieved April 23, 2020, from https://revitalistclinic.com/phantom-limb-pain-treatment/
Schley, M., Topfner, S., Wiech, K., Schaller , H. E., Conrad, C. J., Schmelz, M., & Birbaumer, N. (2012). Continuous brachial plexus blockade in combination with the NMDA receptor antagonist memantine prevents phantom pain in acute traumatic upper limb amputees. PubMed.gov, 299–308. doi: 10.1016/j.ejpain.2006.03.003
UC San Diego School of Medicine. (n.d.). What is fMRI? Retrieved April 23, 2020, from http://fmri.ucsd.edu/Research/whatisfmri.html