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Tuesday, 16 October, 2001, 23:25 GMT 00:25 UK
Sources of amputee pain revealed
Amputee
Some amputees experience phantom pain
The pain that amputees experience in their stumps comes from a different source than the pain that some experience from phantom limbs, research suggests.

Up to 80% of all amputees experience pain in their stumps or what feels like the missing limbs long after surgical wounds have healed.


Stump and phantom pain are quite possibly two very distinct things

Dr Cathy Stannard
Researchers from Johns Hopkins University in Baltimore have carried out tests that show that the two types of pain have different sources.

Their work gives doctors clues as to what type of pain relief medication is best for amputee patients.

At present, the treatment of both stump and phantom pain is poor because little is known about the underlying mechanisms.

The researchers found that the powerful pain relief drug morphine significantly relieved both stump and phantom pain.

However, the local anaesthetic lidocaine relieved only the stump pain.

Nerve injuries

Stump pain is believed to arise from nerve injuries at the site of the amputation.

These result in the formation of neuromas, non-cancerous tumours that grow out of the injured nerve fibres. These tumours may fire off pain impulses in a random fashion, or may give off pain signals when trapped by other tissue, such as muscle.

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.

The researchers studied 32 patients 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 30 minutes before the injection until 30 minutes after.

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.

Consensus

Dr Cathy Stannard, a consultant in pain medicine at the Frenchay Hospital, Bristol, told BBC News Online that the conclusions of the study were similar to the general consensus among experts.

She said: "Stump and phantom pain are quite possibly two very distinct things, but there is quite a strong relationship between the two - people who have stump pain are more likely to also experience phantom pain.

"It may be that although stump pain has a local pathology it feds into the general process that generating the phantom pain."

Dr Stannard said some patients were reluctant to admit to phantom pain, possibly because of embarrassment.

She also said that the strong emphasis on rehabilitation meant that some patients were not given sufficient information about the types of pain that they might experience.

The charity Action Research is currently funding research into whether administering the drug ketamine prior to amputation operations could be effective in preventing phantom pain.

Lead researcher Dr Alistair Nimmo, of the Royal Infirmary of Edinburgh, agreed that stump and phantom limb pain could be very different.

But he stressed that the latter is particularly difficult to treat.

He said: "There is still no effective remedy for phantom limb pain, which can bother amputees for many years after their operation.

"Treatment is difficult and standard pain killers are often ineffective. It is hoped that our Action Research funded project will lead to treatment to be directed at preventing this disabling pain from developing."

The research was presented to a meeting of the American Society of Anesthesiologists.

See also:

27 Mar 01 | Health
Limbs saved by cancer pioneers
22 Oct 00 | Health
Living with a dead man's hand
31 May 01 | Health
Training to beat 'phantom pain'
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