Pain Management Methods
June 2008 Issue
A broad and creative variety of techniques, devices, and strategies for managing pain experienced by the amputee have been utilized over the years, and new ideas emerge as older methods continue to evolve. The array ranges from sympathectomy, dorsal root entry-zone lesions, cordotomy, neurostimulation, local anesthesia, methadone, hypnosis, electromyography, and biofeedback, to pharmacological interventions including anticonvulsants, barbiturates, antidepressants, neuroleptics, and muscle relaxants.
Ann Kobiela Ketz, MN, RN, AOCNS, CPT, AN, USA, finds that studies report that such treatments have been beneficial only 30 percent of the time-comparable to the placebo effect. "Investigators continue to search for ways to treat postamputation pain consistently," Ketz concludes.
"The last time I put a lecture together on pain in the amputee" recalls Clay Kelly, MD, "there were 76 different treatments that were published in the attempted treatment of phantom pain. And that tells us a very important point: nothing is working that well. The more treatments are described, the less any of them are working. If one worked perfectly, we would have just that one."
Here are a few methods that are currently being used with reported success:
A multidisciplinary team approach to treatment: Kelly encourages the surgeon, physician, prosthetist, and physical therapist to work together to address and solve issues related to fit, function, and comfort in a "one-stop shopping" approach. "As a team, we keep the patients in their program going forward, with all of us agreeing on where we're going prosthetically, functionally, and medically," he says.
Kevin Carroll, MS, CP, FAAOP, also believes "multidisciplinary" to be a key word in managing chronic pain. "Not one of us has all the answers; we have to seek the knowledge to come up with a good solution. The problem now is that everyone is so busy, we're not communicating enough. We need to pick up the phone or meet at clinic and interact with one another and try to discover the root causes of a patient's pain."
Psychological intervention: Pam Forducey, PhD, ABPP, notes that as a rehabilitation psychologist, she is most likely to be called in to troubleshoot when difficulties arise in an acute inpatient rehabilitation setting. "There may be depression, anxiety, and adjustment to perceived disability/handicap, which adversely affects their ability to cope with the pain and actively participate in the rehabilitation process. The patient's perception of that pain, their coping responses, as well as their pre-morbid personality and social support system are variables that are instrumental in how they respond to the multidisciplinary team's interventions."
Two-way communication is essential. "The patient comes in complaining and it's a matter of trying to understanding what type of pain he or she has. We have to let them describe to us what they're feeling," advises Carroll. "That helps them. Somebody is actively listening to them. It's not that I can instantly fix it for them, but they're verbalizing it-and that can help them; we're listening."
Sandy Fletchall, FAOTA, OTR/L, CHT, MPA, tries to get patients to be specific without using the word "pain." "Sometimes because of their inability to get connected with their feelings, I may have to ask, 'Is it stabbing, is it burning, is it throbbing, is it electrical-like?-giving them a variety of choices. Sometimes just verbalizing-and being listened to-is very helpful to them in coping."
Neurostimulation methods: Transcutaneous Electrical Nerve Stimulator or TENS units are regarded with mixed levels of approval and don't seem to be used as much as previously. "Some physicians recommend them, others don't," says Carroll.
Jo Baroli, PT, offers that although TENS and other forms of electrical nerve stimulation are not commonly used in her workplace for residual limb pain, they do incorporate manual stimulation to achieve the same desensitization goal. "Within the soft tissue of the residual limb, there are nerve endings throughout that are likely in a state of chaos, not quite understanding the messages they're supposed to be interpreting and sending on to the brain," Baroli says. "We attempt to desensitize those nerve endings with various materials and teach the patient to do the same-including washcloths, rubberized materials, Saran" Wrap, feathers, brushes, different stimuli to engage or activate those nerve endings."
Pharmacological interventions: "The nice thing about phantom pain is that it extincts itself in most patients," points out Kelly. "It reverse telescopes, meaning it gets closer to the end of the residual limb and tends to go away. For those patients who end up with chronic problems, however, we have been leaning more heavily on a couple of medications-namely, Lyrica® and Cymbalta®. Lyrica (pregabalin) is an anti-seizure medication, and Cymbalta (duloxetine) is actually an antidepressant, but both of them have FDA indications for diabetic nerve pain. I'm finding these medicines to be effective and am using them more and more in my practice."
"New Age" alternatives: Fletchall notes that some individuals she has interviewed believe strongly that vitamins, herbs, and homeopathic remedies are the answer to problem pain. "If they think it works for them, great! But by the time these people were able to find some degree of relief, generally it was over a year, and many times it was three years later. Since physiological changes occur as long as three years post-trauma, how much of that relief was due to the natural maturation process?"
Baroli suggests, "If you're controlling your diet and supplementing it with vitamins, minerals, herbs, etc., aren't you going to feel better overall? If you feel better overall, your stump is probably going to feel better also. That, in conjunction with the maturation of the residual limb, your gait with the appropriate prosthesis, and your rehabilitation all contribute to perceived improvement."
"People do search for alternative methodologies," agrees Forducey. "You see it a lot with cancer patients. When you're facing your own mortality, people get very creative in their attempt to integrate mind, body, and spirit. A remedy that may work for one person may not for another because humans and their reactions to disease and pain are so diverse and multi-factorial. A human is a very complex being. If it works for you and you believe in it, even if it's a placebo, where's the harm?"
Using a mirror to reinforce the impression that a person wearing a prosthesis is again a "whole" person in his or her own mind is a method that gets mixed reviews.
"Although I frequently use visual imagery, I don't like using mirrors," says Fletchall, "because that makes the person dependent on where they need to relieve that abnormal sensation-and notice that I call it abnormal sensation rather than pain."
"Wearing the prosthesis sometimes psychologically reduces the painful situation," Carroll explains, "because they look down and there's a mirror image of their leg right there. This is why we should encourage the use of cosmetic covers for patients with phantom pain. But when we start talking about getting a mirror and putting it beside their leg, the family starts looking at us funny and thinking we're crazy-yet some find that it does seem to reduce the discomfort."
Tomorrow's techniques: Ketz describes a crossover study done by two groups of amputees, first with Group A wearing the socket liner made with a metallic weave while Group B wore an identical placebo liner; then with Group B wearing the metallic weave liner while Group A wore the placebo liner.
Both groups reported less pain, slept better, and wore their prosthesis more often when they were using the metallic weave liner. The unexplained benefits of the metallic component are still being explored.
Judith Philipps Otto
Kern U, Altkemper B, Kohl M. "Management of Phantom Pain with a Textile, Electromagnetically-Acting Stump Liner: A Randomized, Double-Blind, Crossover Study." J Pain Symptom Manage . 2006;32(4):352-360.