amputation & phantom pain thom bloomquist msn, crna, ch, faapm advanced anesthesia & pain...

Amputation & Phantom PainAmputation & Phantom Pain

Thom BloomquistThom BloomquistMSN, CRNA, CH, FAAPMMSN, CRNA, CH, FAAPM

Advanced Anesthesia Advanced Anesthesia

& Pain Management& Pain Management

Bow, NHBow, NH

Mass. knows about amputeesMass. knows about amputees

Learning ObjectivesLearning Objectives To explore and discuss; To explore and discuss;

the incidence and causes the incidence and causes

the pathophysiology the pathophysiology

neuroplasticity in phantom pain and other acute-to-chronic neuroplasticity in phantom pain and other acute-to-chronic

pain statespain states

strategies for management with a multimodal and strategies for management with a multimodal and

multidisciplinary approachmultidisciplinary approach

the possibility of phantom pain preventionthe possibility of phantom pain prevention

AmputationAmputation

New amputee each year – New amputee each year – 185,000185,000

Estimated total US Estimated total US amputees (limb) – amputees (limb) –

2, 000,0002, 000,000..

Lower extremity Lower extremity amputation,amputation,

(diabetes) - 55% will (diabetes) - 55% will

require amputation of require amputation of

other leg within 2‐3 years other leg within 2‐3 years

Amputation health care

costs per year $8.3 billion

(U.S. only)

Incidence of Phantom PainIncidence of Phantom Pain 70% - burning, cramping 70% - burning, cramping other qualities of other qualities of phantom pain phantom pain

first few weeks post-op first few weeks post-op

50% suffer50% suffer 7yrs after7yrs after some life-long continuous some life-long continuous or intermittent or intermittent

BurningBurning

StabbingStabbing

CrushingCrushing

TwistingTwisting

Lightning-likeLightning-like

Mal-positioned partMal-positioned part

Phantom painPhantom pain

Also reported after Also reported after amputation of amputation of intestines, breasts, intestines, breasts, teeth and genitals. teeth and genitals.

What is special about What is special about cuts nerves and cuts nerves and amputation?amputation?

NOTHING!NOTHING!

Wow! I didn’t know that!

CausesCauses

Vascular disease (54%) including diabetes Vascular disease (54%) including diabetes and peripheral arterial disease, and peripheral arterial disease, amputations caused by diabetes amputations caused by diabetes

increased 24% from 1988 to 2009.increased 24% from 1988 to 2009. Trauma (45%),Trauma (45%), Cancer (less than 2%)Cancer (less than 2%) Congenital malformation (small %)Congenital malformation (small %)

Under-treated Amputation PainUnder-treated Amputation Pain

Can lead to chronic painCan lead to chronic pain

Also common after thoracotomy +Also common after thoracotomy + mastectomy, herniorrhaphy….mastectomy, herniorrhaphy….

~20-40% of ALL surgeries~20-40% of ALL surgeries

Elements of Chronic Elements of Chronic Phantom PainPhantom Pain

Somatic painSomatic pain

Psychogenic aspectsPsychogenic aspects

Myofacial PainMyofacial Pain

Neuropathic painNeuropathic pain Sympathetically MaintainedSympathetically Maintained Pain (SMP)Pain (SMP)

Psychogenic FactorsPsychogenic Factors

Of course! But not Of course! But not psychosomatic - there psychosomatic - there is true anatomic basis is true anatomic basis for this pain for this pain

The illogic of pain in a The illogic of pain in a part that is no longer part that is no longer there - “Am I nuts?”there - “Am I nuts?”

Life long phantom Life long phantom limb pain?limb pain?

Somatic PainSomatic Pain

Remaining primary pathology (vascular Remaining primary pathology (vascular disease, tissue damage from trauma)disease, tissue damage from trauma)

Additional stress on affected Additional stress on affected && non- non-affected joints/tissues due to altered affected joints/tissues due to altered biomechanics. biomechanics.

Overuse syndrome of remaining structures Overuse syndrome of remaining structures and tissuesand tissues

Neuropathic painNeuropathic pain Post amputation neuroma - can take Post amputation neuroma - can take

weeks to form but spontaneous ectopic weeks to form but spontaneous ectopic discharge begins at moment of nerve discharge begins at moment of nerve division and in some nerves never fades. division and in some nerves never fades.

“…“…self sustaining neuronal activity at the self sustaining neuronal activity at the spinal cord level….if exceeds a critical spinal cord level….if exceeds a critical level pain may occur in the phantom limb” level pain may occur in the phantom limb” (Raj)(Raj)

Sympathetically Maintained Sympathetically Maintained Pain (SMP)Pain (SMP)

Neuroma firing is increased by Neuroma firing is increased by sympathetic activity (Nor-Epi) sympathetic activity (Nor-Epi)

Example: urination, defecation and Example: urination, defecation and ejaculation can activate sympathetic ejaculation can activate sympathetic efferents and trigger episodes of phantom efferents and trigger episodes of phantom arm pain. arm pain.

““Wind-Up” Wind-Up”

Once the noiceptive system is stimulated, Once the noiceptive system is stimulated, suppression of pain signaling becomes suppression of pain signaling becomes more difficult and leads to … more difficult and leads to … Hyperalgesia (severe pain from mildly noxious Hyperalgesia (severe pain from mildly noxious

stimuli)stimuli)

Allodynia (pain produced by innocuous Allodynia (pain produced by innocuous stimuli)stimuli)

Sherman, R.A. , Phantom Pain, 1997, New York: Plenum Publishing.

Transmission in Spinal CordTransmission in Spinal Cord

Neuroplasticity of Entire Neuroplasticity of Entire Nocoiceptive System? Nocoiceptive System?

Peripheral,.e.g., neuromaPeripheral,.e.g., neuroma

Spinal cord level Spinal cord level (sensitization and perhaps (sensitization and perhaps hardwired WDRs) hardwired WDRs)

Cortical-reorganization Cortical-reorganization alteration of neuromatrix alteration of neuromatrix

NeuroplasticityNeuroplasticity

Critical adaptability us evolve when Critical adaptability us evolve when dinosaurs died out (a trait we may need in dinosaurs died out (a trait we may need in the future?) can work against us in this the future?) can work against us in this situation. situation.

However, that very stimulus-response However, that very stimulus-response relationship gives us a clue. relationship gives us a clue. Cause Cause Effect Effect

Cause of Phantom Limb PainCause of Phantom Limb Pain Not clearly established Not clearly established Combination of peripheral, central and Combination of peripheral, central and

sympathetic factorssympathetic factors Positive correlation between painful limb Positive correlation between painful limb

pre-op and developing phantom limb pain pre-op and developing phantom limb pain Recruitment of normally silent high-Recruitment of normally silent high-

threshold nociceptorsthreshold nociceptors Genetics Genetics Chemically induced?Chemically induced?

How to Treat Changed Anatomy?How to Treat Changed Anatomy?

Best Rx may be prevention!Best Rx may be prevention!

Nociception drives the changes. Nociception drives the changes. Effective pain management may Effective pain management may decouple the stimulus-response decouple the stimulus-response relationship.relationship.

Diminish stimulus – prevent the Diminish stimulus – prevent the response! response!

Evidence? Yes!Evidence? Yes!

““Pre-op epidural……. (Bach).Pre-op epidural……. (Bach).

““Perioperative epidural with diamorphine, Perioperative epidural with diamorphine, clonidine and bupivacaine….. (Jahangiri).clonidine and bupivacaine….. (Jahangiri).

““Pre-, intra- and postoperative epidural…Pre-, intra- and postoperative epidural…(Gehling)(Gehling)

In other words …In other words …

Preliminary evidence - effective Preliminary evidence - effective

pre-operative analgesia pre-operative analgesia

IN COMBINATION WITH IN COMBINATION WITH

effective sustained post-operative pain effective sustained post-operative pain management management

…………can lower the incidence +/or severity of can lower the incidence +/or severity of phantom limb pain. phantom limb pain.

How?How?

““Because of the Because of the low success rate of low success rate of treatment in treatment in chronic phantom chronic phantom limb pain, … limb pain, … prevention cannot prevention cannot be be overemphasized” overemphasized” (Raj).(Raj).

Multi-Modal and Multidisciplinary Multi-Modal and Multidisciplinary Pain Management Pain Management

• Pharmacological• Non pharmacological• Psychchological / social

Primum non nocere!Primum non nocere!

Acute pain strategies can be Acute pain strategies can be counterproductive in chronic paincounterproductive in chronic pain

Higher amputation attempted – Higher amputation attempted –

------ ------ restarted same process!restarted same process!

Neuropathic Pain - RxNeuropathic Pain - Rx

NSAIDs are ineffective and opiates are not NSAIDs are ineffective and opiates are not first line for neuropathic painfirst line for neuropathic pain

Local anesthetics (Na+ Channel blockers) Local anesthetics (Na+ Channel blockers) can provide pain relief in doses that will can provide pain relief in doses that will not cause sensory or motor blocknot cause sensory or motor block

MMPM - Medications for MMPM - Medications for Chronic PainChronic Pain

Antidepressants (Tricyclics, SNERIs, Antidepressants (Tricyclics, SNERIs, SSRIs, Dopamenerics)SSRIs, Dopamenerics)

Alpha 2 agonists (clondine)Alpha 2 agonists (clondine)

Antiarrhythmics (mexiletine, lido)Antiarrhythmics (mexiletine, lido)

NSAIDs (Cox 1 or Cox 2)NSAIDs (Cox 1 or Cox 2)

Opiates - when appropriate Opiates - when appropriate

Anticonvulsants Anticonvulsants Carbamazepine Gabapentin Lamotrigine

Pregabalin P.O. Pre-op -D.O.S..

Topiramate Topiramate Valproic Acid and Valproic Acid and

Derivatives Derivatives ******

Narcotics for Chronic PainNarcotics for Chronic Pain(selected cases)(selected cases)

Oxycontin and MSContin - work well Oxycontin and MSContin - work well (expensive) (expensive)

Methadone (just as effective and less Methadone (just as effective and less expensive)expensive)

Provide immediate release preparation for Provide immediate release preparation for breakthrough painbreakthrough pain

Use MMPM to lower narcotic requirement Use MMPM to lower narcotic requirement and increase effectivenessand increase effectiveness

EUPHORIA

METHADONEMETHADONEOXYCONTINOXYCONTINMS CONTINMS CONTIN

PERCOCETPERCOCETVICONDINVICONDIN

PAINLEVEL

WITHDRAWAL

Topical - PharmacolgicTopical - Pharmacolgic(peripheral factors)(peripheral factors)

Mutli-cmpd topical preparationsMutli-cmpd topical preparations E.g. gabapentin, NSAID, local anesthetic E.g. gabapentin, NSAID, local anesthetic

combination from compounding pharmacist. combination from compounding pharmacist.

5% lidocaine patches (Lidoderm)5% lidocaine patches (Lidoderm)

OTCs (capsaicin, ASA) OTCs (capsaicin, ASA)

NMDA Blockers NMDA Blockers

Receptor site modulates nociceptive Receptor site modulates nociceptive afferent signals. afferent signals. resting state, blocked by Mg+. resting state, blocked by Mg+.

KetamineKetamine

AlsoAlso amantadine (antiviral), amantadine (antiviral), dextromethorphan (cough medicine).dextromethorphan (cough medicine).

Perioperative Epidurals Perioperative Epidurals

Effective but may not feasible in your Effective but may not feasible in your setting setting

Expensive Expensive

InvasiveInvasive

Complication rateComplication rate

Option? – O. P. MMPM Option? – O. P. MMPM

Consider mutli-modal program including:Consider mutli-modal program including: NSAID (Cox1 or Cox2)NSAID (Cox1 or Cox2) Opiates (SR & IR)Opiates (SR & IR) Antidepressants (multi-pathway)Antidepressants (multi-pathway) AnticonvulsantAnticonvulsant NMDA blocker (dextromethorphan)NMDA blocker (dextromethorphan) Clonidine ?Clonidine ?

Outpatient Program - cont’dOutpatient Program - cont’d

Important - include counseling with Important - include counseling with prepared amputee & psych.prepared amputee & psych.

Meet with ProsthetistMeet with Prosthetist Include family/spouseInclude family/spouse Amputee support groupAmputee support group

(no “Whine fests)(no “Whine fests) ACA Peer VisitorACA Peer Visitor

Non-Pharmacologic Modalities Non-Pharmacologic Modalities HeatHeat

MassageMassage

MeditationMeditation

PsychotherapyPsychotherapy

Shrinker SocksShrinker Socks

Wearing Your Artificial Wearing Your Artificial Limb Limb

AcupunctureAcupuncture

BiofeedbackBiofeedback

ChiropracticChiropractic

ColdCold

Electrical StimulationElectrical Stimulation

ExerciseExercise

Hypnosis (huge!)Hypnosis (huge!)

When desired, the When desired, the mind can literally mind can literally affect what the body affect what the body does/perceives. does/perceives.

Proof?Proof? Visualize a lemonVisualize a lemon Smell the lemon – cut Smell the lemon – cut

the lemon- feel the the lemon- feel the juice – bite the lemon juice – bite the lemon – taste the lemon – taste the lemon

Did you salivate?Did you salivate?(I did)(I did)

It’s that simple It’s that simple and this was and this was the merest the merest exampleexample

Mirror TherapyMirror TherapyThe subconscious mind can The subconscious mind can

re-map perception re-map perception

Multi-disciplinary PM TeamMulti-disciplinary PM Team

Anesthesia/Pain Mgt. Anesthesia/Pain Mgt. PrimaryPrimary PT/OT/MassagePT/OT/Massage ProsthetistProsthetist Psych (ARNP, PhD, MD/DO)Psych (ARNP, PhD, MD/DO) Support group Support group

Survivors or “whine festival”Survivors or “whine festival”

Progress - but more to doProgress - but more to do

What’s in he pipeline?What’s in he pipeline?

Neuroplasticity as a Neuroplasticity as a treatment?treatment?

Osseointegrated pinsOsseointegrated pins

You can play an important role in You can play an important role in preventing unwanted neuroplastic preventing unwanted neuroplastic changes! changes!

You can be somebody’s hero!You can be somebody’s hero!

Thank You!Thank You!My family sleeps well & safe – because of themMy family sleeps well & safe – because of them

HistoryHistory

The Rig-Veda, an ancient sacred poem of The Rig-Veda, an ancient sacred poem of India, is said to be the first written record India, is said to be the first written record of a prosthesis. of a prosthesis.

Written in Sanskrit between 3500 and Written in Sanskrit between 3500 and 1800 B.C., it recounts the story of a 1800 B.C., it recounts the story of a warrior Queen Vishpla, who lost her leg in warrior Queen Vishpla, who lost her leg in battle, was fitted with an iron prosthesis, battle, was fitted with an iron prosthesis, and returned to battle.and returned to battle.

HistoryHistory

Herodotus wrote of a prisoner who Herodotus wrote of a prisoner who escapes his chains by cutting off his own escapes his chains by cutting off his own foot. He later fashioned a substitute from foot. He later fashioned a substitute from wood. wood.

The oldest known artificial limb, dating The oldest known artificial limb, dating from 300 BC was made from copper and from 300 BC was made from copper and wood - unearthed near Capri, Italy. wood - unearthed near Capri, Italy.

In FranceIn France

Parre, a French surgeon describes Parre, a French surgeon describes Phantom limb pain in 1551.Phantom limb pain in 1551.

Larry, Napoleon's surgeon, recorded in his Larry, Napoleon's surgeon, recorded in his memoirs that extremely cold weather memoirs that extremely cold weather (-19 (-19 ooF) allowed him to perform painless F) allowed him to perform painless amputations.amputations.

Revolutionary WarRevolutionary War ““If amputation was chosen, the patient was If amputation was chosen, the patient was laid out at table height, covered with double laid out at table height, covered with double blankets, and given pillows for his head. blankets, and given pillows for his head. Alcohol, if available, was used to help sedate Alcohol, if available, was used to help sedate the patient. The following procedure was then the patient. The following procedure was then performed by a surgeon.performed by a surgeon.A good surgeon cut fast, performing the A good surgeon cut fast, performing the procedure in about a minute. If the patient was procedure in about a minute. If the patient was lucky, he'd pass out before feeling the searing lucky, he'd pass out before feeling the searing pain.” pain.”

Civil WarCivil War

Chloroform came into use for anesthesia, Chloroform came into use for anesthesia, for PM. Opium and derivatives were widely for PM. Opium and derivatives were widely used. used.

Civil War veterans Civil War veterans commonly suffered commonly suffered in agony from war in agony from war wounds for the rest wounds for the rest of their livesof their lives