Ból kończyny resztkowej – Patofizjologia i mechanizm

Ból kończyny resztkowej
Patofizjologia i mechanizm

Ból kończyny resztkowej (RLP) to dolegliwość występująca u około 60% pacjentów po amputacji, charakteryzująca się bólem zlokalizowanym w zachowanej części kikuta, najczęściej w pobliżu miejsca amputacji. RLP różni się od bólu fantomowego (PLP), który jest odczuwany w nieistniejącej części kończyny, choć oba zespoły bólowe często współistnieją. Patomechanizm RLP opiera się głównie na procesach obwodowych, takich jak tworzenie neurom – zdezorganizowanych skupisk zakończeń nerwowych o zwiększonej aktywności ektopowej, nasilającej się pod wpływem bodźców mechanicznych i chemicznych. Neuromy wykazują nadekspresję kanałów sodowych, co prowadzi do nadpobudliwości i spontanicznych wyładowań, a także zjawiska „sprouting” i aktywności w zwoju korzenia grzbietowego (DRG). Centralne mechanizmy obejmują uwrażliwienie neuronów tylnego rogu rdzenia kręgowego, sensytyzację centralną oraz reorganizację korową w obszarach somatosensorycznych i ruchowych, co może wpływać na intensywność i charakter bólu. Czynniki ryzyka RLP to m.in. poziom amputacji, intensywność bólu przed amputacją, wiek pacjenta oraz stres emocjonalny, który może nasilać dolegliwości i wpływać na przebieg choroby.

Wprowadzenie do bólu kończyny resztkowej

Ból kończyny resztkowej (ang. residual limb pain, RLP) to rodzaj bólu odczuwany w zachowanej części kończyny po amputacji. Występuje u ponad połowy osób, które przeszły zabieg amputacji, dotykając około 60% pacjentów¹². Jest to dolegliwość bólowa zlokalizowana w zachowanej części amputowanej kończyny (kikucie), najczęściej w pobliżu miejsca amputacji³. Trzeba podkreślić, że ból kończyny resztkowej różni się od bólu fantomowego (phantom limb pain, PLP), który jest odczuwany w nieistniejącej już części kończyny⁴. Choć są to dwa odrębne zespoły bólowe, często współistnieją ze sobą u tego samego pacjenta – badania wskazują, że ponad połowa osób z bólem fantomowym doświadcza również bólu kończyny resztkowej⁵⁶.

Ból kończyny resztkowej może pojawić się wkrótce po zabiegu amputacji, często w pierwszym tygodniu po operacji, jednak w przeciwieństwie do typowego bólu pooperacyjnego, może utrzymywać się długo po okresie gojenia⁷. Jest on zwykle opisywany jako ostry, pulsujący, piekący lub przeszywający⁸. Ta przewlekła dolegliwość może znacząco ograniczać funkcjonowanie pacjenta, pogarszać jakość życia i utrudniać rehabilitację⁹.

Patomechanizmy bólu kończyny resztkowej

W przeciwieństwie do bólu fantomowego, ból kończyny resztkowej często ma identyfikowalne przyczyny fizyczne. Rozumienie patomechanizmów RLP wymaga uwzględnienia zarówno czynników obwodowych, jak i ośrodkowych, choć uważa się, że komponenta obwodowa odgrywa tu kluczową rolę¹⁰.

Mechanizmy obwodowe

Podczas amputacji dochodzi do przecięcia nerwów obwodowych, co prowadzi do masywnego uszkodzenia tkanek i neuronów, powodując zaburzenie normalnego wzorca aferentnych impulsów nerwowych do rdzenia kręgowego¹¹. W procesie gojenia na proksymalnych końcach przeciętych nerwów tworzą się neuromy – skupiska zdezorganizowanych zakończeń włókien A i C o zwiększonej aktywności ektopowej, nasilającej się podczas bodźców mechanicznych i chemicznych¹²¹³. W neuromach dochodzi do zwiększonej ekspresji kanałów sodowych, co prowadzi do nadpobudliwości i spontanicznych wyładowań¹⁴.

Istotnym mechanizmem jest także zjawisko „sprouting” (kiełkowania), w którym proksymalne części przeciętych nerwów obwodowych wytwarzają wypustki, tworząc neuromy¹⁵. Proces ten jest wynikiem retrogradalnej degeneracji i skrócenia neuronów aferentnych w następstwie urazu, obrzęku i regeneracji aksonów¹⁶.

Ważnym miejscem ektopowych wyładowań jest również zwój korzenia grzbietowego (DRG), który łączy aktywność ektopową pochodzącą z neurom kikuta i wzmacnia ją lub wywołuje pobudzenie krzyżowe, prowadząc do depolaryzacji sąsiednich neuronów¹⁷¹⁸.

Wpływ uszkodzenia nerwów obwodowych

Neuromy mogą nie tylko wywoływać ból kończyny resztkowej, ale również powodować zlokalizowaną allodynię, hiperalgezję i ból utrudniający korzystanie z protezy¹⁹. Badania wykazały, że blokowanie kanałów potasowych indukuje spontaniczną aktywność we włóknach nerwowych, co sugeruje, że kanałopatia potasowa może przyczyniać się do zespołów bólowych²⁰.

Ponadto, podczas amputacji dochodzi do znacznego urazu nerwów i otaczających tkanek, co zakłóca normalne sygnały aferentne i eferentne związane z brakującą kończyną²¹. Procesy regeneracyjne rozpoczynające się na obwodzie, takie jak kiełkowanie uszkodzonych neuronów i rozwój neurom, generują nieprawidłowe impulsy aferentne²².

Mechanizmy ośrodkowe i rdzeniowe

Choć mechanizmy obwodowe są kluczowe dla RLP, nie można pomijać roli układu ośrodkowego. Po uszkodzeniu nerwu obwodowego występują dowody na centralne uwrażliwienie neuronów tylnego rogu rdzenia kręgowego²³. Ten proces charakteryzuje się długotrwałą potencjalizacją, w której krótkotrwałe bodźce nocyceptywne generują zwiększone potencjały postsynaptyczne przez długi okres²⁴.

W rdzeniu kręgowym dochodzi do procesu zwanego sensytyzacją centralną, podczas którego aktywność neuronalna wzrasta, pole receptorowe neuronów rozszerza się, a nerwy stają się nadwrażliwe²⁵. Uszkodzenie nerwu prowadzi również do funkcjonalnego połączenia wejść o niskim progu z wstępującymi neuronami projekcyjnymi rdzenia, które przekazują informacje nocyceptywne do ośrodków nadrdzeniowych²⁶.

Na poziomie rdzenia kręgowego opisano uwrażliwienie, przy jednoczesnym zmniejszeniu aktywności interneuronów hamujących²⁷. Obserwuje się również zwiększoną aktywność rdzeniowych pronociceptywnych systemów pobudzających, ze zwiększoną aktywnością glutaminianu i receptorów NMDA²⁸.

Reorganizacja korowa i jej związek z bólem

Reorganizacja korowa, będąca często wymienianym czynnikiem w patogenezie bólu fantomowego, może również wpływać na ból kończyny resztkowej. Po amputacji obszary korowe reprezentujące amputowaną kończynę są zajmowane przez sąsiednie strefy reprezentacyjne zarówno w korze somatosensorycznej, jak i ruchowej²⁹.

Stopień reorganizacji korowej okazał się być bezpośrednio związany ze stopniem bólu i wielkością odafferentowanego obszaru³⁰. Reorganizacja korowa częściowo wyjaśnia, dlaczego nocyceptywna stymulacja nerwów w kikucie i otaczającym obszarze może powodować ból i uczucia w brakującej kończynie³¹.

Eksperymenty wykazały, że po amputacji palca u dorosłej małpy następuje inwazja obszarów neuronalnych sąsiadujących z obszarem korowym, gdzie reprezentowany był amputowany palec, co jest zgodne ze zmianami neuroplastyczności w pierwotnej korze ruchowej (M1) i pierwotnej korze somatosensorycznej (S1)³²³³.

Czynniki ryzyka i korelacje kliniczne

Istnieje szereg czynników, które mogą zwiększać ryzyko rozwoju bólu kończyny resztkowej lub wpływać na jego intensywność:

Współistnienie różnych typów bólu poamputacyjnego

Najbardziej powszechnym czynnikiem pozytywnie związanym z bólem fantomowym jest właśnie ból kończyny resztkowej (zidentyfikowany w pięciu badaniach, reprezentujących łącznie 920 uczestników)³⁴. Ta bliska asocjacja między RLP a PLP prawdopodobnie wskazuje na potencjalny wkład czynników obwodowych w wystąpienie bólu fantomowego, takich jak stan pozostałych zakończeń nerwowych po podwiązaniu i przecięciu, zmiany molekularne w nerwie wywołane jego przecięciem lub ektopowe impulsy nerwowe pochodzące z neuroma lub zwoju korzenia grzbietowego³⁵.

Biorąc pod uwagę wysoką kowariację między RLP a PLP, istotne jest zrozumienie, czy te dwa zjawiska bólowe są ze sobą powiązane mechanistycznie³⁶. Ta korelacja może być kluczowa dla opracowania skutecznych strategii terapeutycznych.

Ból przed amputacją i inne czynniki

Niektóre badania wykazały, że czynniki ryzyka bólu kończyny resztkowej mogą obejmować:

Poziom amputacji (wysokość na ciele, gdzie kończyna została usunięta)³⁷
Intensywność bólu przed amputacją³⁸³⁹
Przyczynę amputacji⁴⁰
Starszy wiek w momencie amputacji⁴¹

Według metaanalizy przeprowadzonej przez Limakatso i współpracowników, ból przed amputacją był drugim najczęstszym czynnikiem pozytywnie związanym z bólem fantomowym, co może mieć również znaczenie dla RLP⁴².

Wpływ czynników psychologicznych

Stres emocjonalny, taki jak strach i brak wsparcia emocjonalnego, może nasilać ból kończyny resztkowej⁴³⁴⁴. Osoby z bólem kikuta mogą być bardziej podatne na depresję lub zaburzenia lękowe niż osoby, które nie doświadczają takiego bólu⁴⁵.

Czynniki psychologiczne, choć wydają się nie być częścią etiologii, mogą wpływać na przebieg i nasilenie bólu⁴⁶⁴⁷. Długotrwały ból może wpływać na sen, zwiększać poziom stresu oraz nasilać problemy ze zdrowiem psychicznym (np. lęk, depresję i zaburzenia związane z używaniem substancji)⁴⁸.

Ból przewlekły, jak wykazano, jest wieloczynnikowy i ma silny komponent psychologiczny. Ból kończyny resztkowej często może rozwinąć się w zespół bólu przewlekłego i aby leczenie miało większą szansę powodzenia, należy uwzględnić zachowania bólowe pacjenta i jego przetwarzanie bólu⁴⁹.

Przyczyny anatomiczne i mechaniczne

W przeciwieństwie do bólu fantomowego, ból kończyny resztkowej często jest manifestacją podstawowej przyczyny anatomicznej lub mechanicznej⁵⁰. Do najczęstszych przyczyn należą:

Neuromy i uszkodzenia nerwowe

Neuroma to zbiór lub wiązka zakończeń nerwowych, które tworzą się pod skórą kikuta⁵¹. Można je porównać do splątanych włosów – neuroma może stać się bardzo wrażliwa, szczególnie gdy splątanie uciska protezę. Ból pochodzący z neuromy może mieć charakterystyki neurogeniczne, takie jak uczucie elektryzowania, strzelania, mrowienia, ostre i kłujące lub kłujące doznania⁵².

Bolesne neuromy mogą wystąpić w każdym przeciętym nerwie (wskutek operacji lub urazu) i mogą powodować ból, który odczuwany jest jako elektryczny, strzelający, mrowienie, ostry i kłujący lub pulsujący⁵³.

Niestety, operacja usunięcia neurom zwykle nie jest skuteczna, ponieważ często po prostu tworzą się one ponownie⁵⁴.

Problemy z tkankami miękkimi i kośćmi

Istnieje szereg problemów anatomicznych, które mogą przyczyniać się do bólu kończyny resztkowej:

Problemy w kości lub tkance miękkiej, takie jak owrzodzenia lub ostrogi kostne⁵⁵⁵⁶
Infekcje⁵⁷
Słabe ukrwienie zachowanej części kończyny⁵⁸
Guzy⁵⁹
Uszkodzenie nerwów⁶⁰

Słabe pokrycie tkanką może być spowodowane nieodpowiednim przycięciem kości na końcu kikuta podczas operacji, co może powodować ból przy noszeniu protezy⁶¹.

Problemy związane z protezą

Problemy z dopasowaniem lub używaniem protezy są częstą przyczyną bólu kończyny resztkowej⁶². Niektórzy pacjenci z tradycyjną protezą mocowaną na lej doświadczają przewlekłego, nawracającego bólu kończyny resztkowej spowodowanego przewlekłym podrażnieniem skóry z powodu pocenia się oraz owrzodzeń wywołanych ciśnieniem/tarciem⁶³⁶⁴.

Prowadzi to do mniejszej kontroli nad protezą, utraty funkcji, zmniejszonej niezależności i gorszej jakości życia⁶⁵. Dobrze dopasowana proteza może złagodzić ucisk między kikutem a protezą, co może pomóc zapobiec bólowi kończyny resztkowej⁶⁶.

Dbanie o skórę, która kontaktuje się z protezą, również może pomóc zapobiec bólowi kończyny resztkowej⁶⁷. Trwały ból jest częstszy u pacjentów z krótko zachowanymi strukturami kostnymi i/lub deformacjami tkanek miękkich kikuta⁶⁸.

Różnicowanie z bólem fantomowym

Chociaż ból kończyny resztkowej i ból fantomowy często współistnieją, są to odrębne zespoły bólowe o różnej patofizjologii i wymagają różnego podejścia terapeutycznego⁶⁹.

Kluczowe różnice

Ból kończyny resztkowej (RLP) to ból odczuwany w faktycznie istniejącej części amputowanej kończyny (kikucie), najczęściej blisko miejsca amputacji⁷⁰. Jest to ból zlokalizowany w kikucie, często związany z konkretną przyczyną fizyczną, taką jak neuroma, infekcja, problemy z dopasowaniem protezy⁷¹.

Ból fantomowy (PLP) to ból odczuwany w nieistniejącej już części kończyny po amputacji⁷². Jest to neuropatyczny ból, który wydaje się pochodzić z kończyny, która fizycznie już nie istnieje⁷³.

Współistnienie i interakcje

Wiele osób doświadcza zarówno bólu kończyny resztkowej, jak i bólu fantomowego⁷⁴⁷⁵. Ważne jest, aby znać różnicę między nimi, ponieważ przyczyny i metody leczenia każdego z nich są różne, ale także należy być świadomym, że oba te elementy mogą współistnieć jednocześnie⁷⁶.

Występuje wyraźna korelacja między bólem kikuta a bólem fantomowym⁷⁷. Utrzymujące się problemy z kikutem, takie jak blizny, neuromy (poamputacyjny rozrost zawierający tkankę układu nerwowego) lub ostrogi kostne, mogą bezpośrednio wpływać na intensywność i czas trwania bólu fantomowego⁷⁸.

Interesującym aspektem jest fakt, że problematyczne neuromy w kikucie mogą przyczyniać się do rozwoju bólu fantomowego, gdyż po leczeniu neurom ból fantomowy również ulega poprawie⁷⁹.

Bliskie powiązania etiopatogenetyczne

Chociaż ból kończyny resztkowej i ból fantomowy są odrębnymi zespołami bólowymi, istnieją między nimi bliskie powiązania etiopatogenetyczne⁸⁰. Neuromy mogą nie tylko powodować ból kończyny resztkowej, ale również mogą być źródłem nieprawidłowych impulsów do ośrodkowego układu nerwowego, gdzie takie dane wejściowe mogą przyczyniać się do reorganizacji centralnej, co z kolei może przyczyniać się do późniejszego rozwoju bólu fantomowego⁸¹.

Ból występujący w kikucie często ma charakter neurogeniczny, wiąże się z uszkodzeniem nerwów i zwykle rozwija się w ciągu 7 dni od amputacji⁸². Może ustąpić samoistnie, ale często ma charakter przewlekły. Może być nieustający i silny lub przerywany⁸³.

Skurcze i ściskanie w odczuciach fantomowych mogą odzwierciedlać napięcie mięśniowe w kikucie. Leczenie zmniejszające napięcie mięśniowe w kikucie zmniejsza skurczowy ból fantomowy⁸⁴. To wskazuje, że ćwiczenia fantomowe, które zmieniają napięcie mięśniowe i pozycję w kikucie, mogą wpływać na intensywność bólu fantomowego⁸⁵.

Podsumowanie

Ból kończyny resztkowej jest powszechnym i złożonym problemem, dotykającym znaczną część pacjentów po amputacji. W przeciwieństwie do bólu fantomowego, RLP często ma identyfikowalną przyczynę anatomiczną lub mechaniczną, co może ułatwiać jego leczenie. Kluczowymi mechanizmami w patogenezie RLP są procesy obwodowe, takie jak tworzenie neurom i ektopowa aktywność nerwowa, choć nie bez znaczenia są też mechanizmy ośrodkowe i rdzeniowe.

Ważnym aspektem jest częste współistnienie bólu kończyny resztkowej z bólem fantomowym, co sugeruje wspólne elementy patogenetyczne. Zrozumienie tych powiązań może być kluczowe dla opracowania skutecznych strategii terapeutycznych.

Skuteczne leczenie bólu kończyny resztkowej wymaga kompleksowego podejścia, uwzględniającego zarówno fizyczne przyczyny bólu, jak i czynniki psychologiczne. Identyfikacja i leczenie konkretnych przyczyn, takich jak neuromy, problemy z tkankami miękkimi, infekcje czy nieodpowiednio dopasowana proteza, może znacząco poprawić jakość życia pacjentów po amputacji.

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Materiały źródłowe

#1 Pain in the Residual Limb – Special Subjects – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/special-subjects/limb-prosthetics/pain-in-the-residual-limb
Approximately 60% of individuals with an amputation have post-amputation pain in the residual limb, which can severely limit function, impair quality of life, and significantly impede rehabilitation. Residual limb pain should be evaluated and treated aggressively because some causes can be dangerous. […] Persistent residual limb pain is a chronic condition that differs from phantom limb pain and phantom limb sensation. […] Neuropathic pain is common in patients and is usually described as a shooting or burning pain and typically develops within 7 days of amputation. It can go away on its own but is often chronic. It can be unrelenting and severe, or intermittent. It often is the result of nerve damage from an injury or the severing of nerves during the amputation. […] Most patients experience phantom limb pain at some time. The phantom aspect is not the pain, which is real, but the location of the pain in a limb that has been amputated. The mechanism is believed to involve peripheral and central factors. Onset and duration typically is within days following amputation but could be delayed months to years.
#2 Residual Limb Pain – Special Subjects – Merck Manual Consumer Version
https://www.merckmanuals.com/home/special-subjects/limb-prosthetics/residual-limb-pain
After an amputation, about 60% of people have pain in the residual limb, which can severely limit function, impair quality of life, and significantly impede rehabilitation. Residual limb pain should be evaluated and treated aggressively, because some causes can be dangerous. […] Persistent residual limb pain is a chronic condition that differs from phantom limb pain and phantom limb sensation. […] Pain due to nerve damage (neuropathic pain) is common. Usually described as a shooting or burning pain, neuropathic pain typically develops within 7 days of amputation. It can go away on its own but is often long-lasting. It can be unrelenting and severe, or intermittent. Nerves may have been damaged from an injury or when they were severed during the amputation. Treatment of neuropathic pain includes psychologic treatments, physical methods, antidepressants, and antiseizure drugs.
#3 Making sense of phantom limb pain | Journal of Neurology, Neurosurgery & Psychiatry
https://jnnp.bmj.com/content/93/8/833
PLP is an umbrella term for a hugely heterogenous phenomenon. After limb amputation, most individuals experience a phantom limb and perceive painful sensations to originate from it. […] The most common factor positively associated with PLP is RLP (identified in five studies, representing a total of 920 participants). RLP is described as pain perceived to originate from the remaining portion of the limb after amputation, most often close to the site of amputation. […] Considering the high covariation between PLP and RLP, it is essential to understand whether these two pain phenomena relate to each other mechanistically. […] This close association between RLP and PLP likely points to the potential contribution of peripheral factors in the onset of PLP such as the state of the residual nerve endings after ligation and transection, molecular alterations throughout the nerve triggered by the nerve transection or ectopic nerve impulses originating from a neuroma or the dorsal root ganglion.
#4 Phantom Limb Pain – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK448188/
Phantom limb pain is the perception of pain or discomfort in a limb that is no longer there. PLP most commonly presents as a sequela of amputation. The underlying pathophysiology remains poorly understood. […] The condition should be differentiated from other related clinical conditions such as residual limb pain, which was formerly called „stump pain” and is pain that originates from the actual site of the amputated limb that tends to resolve with wound healing. […] Pain after amputation of a limb is a common symptom and is separated into two types of pain including residual limb pain (RLP) and phantom limb pain (PLP). […] The latter condition, formerly known as „stump pain”, is pain that originates from the actual site of the amputated limb. It is most common in the early post-amputation period and tends to resolve with wound healing.
#5 Phantom Limb Pain – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK448188/
Unlike PLP, RLP is often a manifestation of an underlying source, such as nerve entrapment, neuroma formation, surgical trauma, ischemia, skin breakdown, or infection. […] Of note, more than half of people with PLP also have RLP. It is important to know the difference between the two because the causes and treatments for each differ, but also be aware that both of these elements can coexist at the same time. […] The exact etiology of PLP is unclear. Multiple theories have been debated, and the only agreement is that multiple mechanisms are likely responsible. […] The predominant theory for years involved the irritation of the severed nerve endings causing phantom pain. This was enforced by evidence that almost all amputation patients will develop neuromas in the residual limb. […] Over the last few decades, advances in imaging and laboratory techniques have shown evidence of central nervous system (CNS) involvement. Imaging studies such as MRI and PET scans show activity in the areas of the brain associated with the amputated limb when the patient feels phantom pain. The pain is now thought to involve many peripheral and central nervous system factors.
#6 Phantom Limb Pain: What It Is, Causes, Treatment & Prevention
https://my.clevelandclinic.org/health/diseases/12092-phantom-limb-pain
Residual limb pain: This is pain that affects the remaining part of your limb (stump) thats still on your body after an amputation. Residual limb pain often has a medical reason, such as infection or nerve damage. […] You may also feel pain in the remaining part of your body that wasnt amputated. This is a residual limb or stump. Since this part of your body still exists, several complications can happen that may be causing the pain: […] You can experience residual limb pain at the same time as phantom limb pain. […] Residual limb pain often has a medical reason, such as infection or nerve damage.
#7 Residual limb pain – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/residual-limb-pain/symptoms-causes/syc-20541403
Residual limb pain is a type of pain felt in the part of an arm or leg that’s left after the arm or leg is removed, called amputation. More than half of people who have an amputation get this type of pain. Sometimes called stump pain, it may happen soon after the surgery, often within the first week. But the pain may last after healing. […] Residual limb pain is not the same thing as phantom pain. Phantom pain feels like it comes from the part of the arm or leg that’s no longer there after amputation. But many people have both residual limb pain and phantom pain. […] There are several causes of pain after removal of an arm or leg, called amputation. They include the following: Issues in the bone or the soft tissue, such as sores or bone spurs. Infection. Poor blood supply to the part of the arm or leg that’s left. A tumor. A tangle of nerve endings that forms after the arm or leg is removed, called a neuroma. Nerve damage. Issues with the fit or use of a replacement arm or leg, called a prosthesis.
#8 Living With Residual Limb Pain â Amputee Coalition
https://amputee-coalition.org/resources/living-with-residual-limb-pain-fs/
Residual limb pain is different from this normal postoperative pain. For example, it commonly occurs after your postoperative pain has ended. It is frequently described as sharp, aching, throbbing or burning in nature. Your entire healthcare team, including your doctors, therapists and prosthetist, will work with you to determine the cause of this pain and decide what treatments might be most effective. […] Poor tissue coverage can be caused by the bone at the end of your residual limb not being properly trimmed at the time of surgery, and this can cause pain when you wear your prosthesis. If padding and other methods are not successful, surgery may be required to revise your residual limb so as to decrease your pain and allow you to wear your prosthesis. […] A neuroma is a collection, or bundle, of nerve endings that forms under the skin of your residual limb. Think of it like a tangle of hair. It can become very sensitive, especially if the tangle is pressing against your prosthesis.
#9 Pain in the Residual Limb – Special Subjects – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/special-subjects/limb-prosthetics/pain-in-the-residual-limb
Approximately 60% of individuals with an amputation have post-amputation pain in the residual limb, which can severely limit function, impair quality of life, and significantly impede rehabilitation. Residual limb pain should be evaluated and treated aggressively because some causes can be dangerous. […] Persistent residual limb pain is a chronic condition that differs from phantom limb pain and phantom limb sensation. […] Neuropathic pain is common in patients and is usually described as a shooting or burning pain and typically develops within 7 days of amputation. It can go away on its own but is often chronic. It can be unrelenting and severe, or intermittent. It often is the result of nerve damage from an injury or the severing of nerves during the amputation. […] Most patients experience phantom limb pain at some time. The phantom aspect is not the pain, which is real, but the location of the pain in a limb that has been amputated. The mechanism is believed to involve peripheral and central factors. Onset and duration typically is within days following amputation but could be delayed months to years.
#10 Phantom Limb Pain – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK448188/
Unlike PLP, RLP is often a manifestation of an underlying source, such as nerve entrapment, neuroma formation, surgical trauma, ischemia, skin breakdown, or infection. […] Of note, more than half of people with PLP also have RLP. It is important to know the difference between the two because the causes and treatments for each differ, but also be aware that both of these elements can coexist at the same time. […] The exact etiology of PLP is unclear. Multiple theories have been debated, and the only agreement is that multiple mechanisms are likely responsible. […] The predominant theory for years involved the irritation of the severed nerve endings causing phantom pain. This was enforced by evidence that almost all amputation patients will develop neuromas in the residual limb. […] Over the last few decades, advances in imaging and laboratory techniques have shown evidence of central nervous system (CNS) involvement. Imaging studies such as MRI and PET scans show activity in the areas of the brain associated with the amputated limb when the patient feels phantom pain. The pain is now thought to involve many peripheral and central nervous system factors.
#11 Phantom Limb Pain: Mechanisms and Treatment Approaches
https://pmc.ncbi.nlm.nih.gov/articles/PMC3198614/
The vast amount of research over the past decades has significantly added to our knowledge of phantom limb pain. Multiple factors including site of amputation or presence of preamputation pain have been found to have a positive correlation with the development of phantom limb pain. The paradigms of proposed mechanisms have shifted over the past years from the psychogenic theory to peripheral and central neural changes involving cortical reorganization. […] Proposed mechanisms to explain phantom limb pain are shown in Table 2. However none of these theoretical constructs appears to be able to explain the phenomenon of PLP independently and many experts believe that multiple mechanism are likely responsible. […] During amputation, peripheral nerves are severed. This results in massive tissue and neuronal injury causing disruption of the normal pattern of afferent nerve input to the spinal cord. This is followed by a process called deafferentation and the proximal portion of the severed nerve sprouts to form neuromas. There is an increased accumulation of molecules enhancing the expression of sodium channels in these neuromas that results in hype-excitability and spontaneous discharges. This abnormal peripheral activity is thought to be a potential source of the stump pain, including phantom pain. […] The axonal sprouts at the proximal section of the amputated peripheral nerve form connections with the neurons in the receptive field of the spinal cord. Some neurons in the areas of spinal cord that are not responsible for pain transmission also sprout into the Lamina II of the dorsal horn of the spinal cord which is the area involved in the transmission of nociceptive afferent inputs. This is followed by increased neuronal activity, expansion of the neuronal receptive field, and hyperexcitability of other regions. This process is called central sensitization.
#12 Pathophysiology and treatment of phantom limb pain | Colombian Journal of Anesthesiology
https://www.elsevier.es/es-revista-colombian-journal-anesthesiology-342-articulo-pathophysiology-treatment-phantom-limb-pain-S2256208713000850
The onset and nature of PLP may differ depending on the cause of the amputation, although there are no clear data to reach definitive conclusions. […] There are some factors associated with the onset of phantom pain. […] After nerve sectioning, there is retrograde degeneration and shortening of afferent neurons as a result of the injury, edema and axon regeneration. This phenomenon is known as sprouting and gives rise to neuroma formation, i.e., expanded and disorganized A and C fiber endings with ectopic firing that increases during mechanical and chemical stimulus. […] An additional site of ectopic discharge is the dorsal root ganglion (DRG), which joins the ectopic activity originating in the stump neuroma and amplifies it, or produces crossed excitation, leading to the depolarization of the neighboring neurons.
#13 Pathophysiology and treatment of phantom limb pain
http://www.scielo.org.co/scielo.php?pid=S0120-33472014000100009&script=sci_arttext&tlng=en
Phantom limb pain may be present in up to 80% of patients subjected to amputation because of trauma or peripheral vascular disease. Several factors have been associated with its occurrence, including pre-amputation pain, the etiology, and the amputation level. […] The proposed pathophysiological mechanisms are still in research and include peripheral, central and psychological factors. […] PLP may be of short duration, with the presence of painful cramps, or it may be constant, associated with intense perception of the lost limb. Characteristically, it is more intense in the distal portions and it is shooting, throbbing, burning or cramp-like pain. […] After nerve sectioning, there is retrograde degeneration and shortening of afferent neurons as a result of the injury, edema and axon regeneration. This phenomenon is known as sprouting and gives rise to neuroma formation, i.e., expanded and disorganized A and C fiber endings with ectopic firing that increases during mechanical and chemical stimulus.
#14 Phantom Limb Pain: Mechanisms and Treatment Approaches
https://pmc.ncbi.nlm.nih.gov/articles/PMC3198614/
The vast amount of research over the past decades has significantly added to our knowledge of phantom limb pain. Multiple factors including site of amputation or presence of preamputation pain have been found to have a positive correlation with the development of phantom limb pain. The paradigms of proposed mechanisms have shifted over the past years from the psychogenic theory to peripheral and central neural changes involving cortical reorganization. […] Proposed mechanisms to explain phantom limb pain are shown in Table 2. However none of these theoretical constructs appears to be able to explain the phenomenon of PLP independently and many experts believe that multiple mechanism are likely responsible. […] During amputation, peripheral nerves are severed. This results in massive tissue and neuronal injury causing disruption of the normal pattern of afferent nerve input to the spinal cord. This is followed by a process called deafferentation and the proximal portion of the severed nerve sprouts to form neuromas. There is an increased accumulation of molecules enhancing the expression of sodium channels in these neuromas that results in hype-excitability and spontaneous discharges. This abnormal peripheral activity is thought to be a potential source of the stump pain, including phantom pain. […] The axonal sprouts at the proximal section of the amputated peripheral nerve form connections with the neurons in the receptive field of the spinal cord. Some neurons in the areas of spinal cord that are not responsible for pain transmission also sprout into the Lamina II of the dorsal horn of the spinal cord which is the area involved in the transmission of nociceptive afferent inputs. This is followed by increased neuronal activity, expansion of the neuronal receptive field, and hyperexcitability of other regions. This process is called central sensitization.
#15 Phantom Limb Pain – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK448188/
Despite, the phantom limb sensation was described by French military surgeon Ambroise Pare (1510-1590) in the sixteenth century, even today we do not have a clear explanation of this complex phenomenon and, therefore, the pathophysiology is explained by a wide range of mechanisms. […] During the amputation, there is a significant amount of trauma that occurs in the nerves and surrounding tissues. This damage disrupts the normal afferent and efferent signals involved with the missing limb. The proximal portions of the severed nerves start to sprout neuromas, and the nerves become hyper-excitable due to an increase in sodium-channels and resulting in spontaneous discharges. […] In the spinal cord, a process called central sensitization occurs. Central sensitization is a process where neural activity increases, the neuronal receptive field expands, and the nerves become hypersensitive.
#16
https://journals.lww.com/rca/fulltext/2014/42010/pathophysiology_and_treatment_of_phantom_limb.9.aspx
The onset and nature of PLP may differ depending on the cause of the amputation, although there are no clear data to reach definitive conclusions. […] After nerve sectioning, there is retrograde degeneration and shortening of afferent neurons as a result of the injury, edema and axon regeneration. This phenomenon is known as sprouting and gives rise to neuroma formation, i.e., expanded and disorganized A and C fiber endings with ectopic firing that increases during mechanical and chemical stimulus. […] An additional site of ectopic discharge is the dorsal root ganglion (DRG), which joins the ectopic activity originating in the stump neuroma and amplifies it, or produces crossed excitation, leading to the depolarization of the neighboring neurons. […] After peripheral nerve injury, there is evidence of central sensitization of the neurons of the posterior horn of the spinal cord. This process is characterized by long-term potentiation, where short-lasting nociceptive stimuli generate increased post-synaptic potentials during a long period of time.
#17 Pathophysiology and treatment of phantom limb pain | Colombian Journal of Anesthesiology
https://www.elsevier.es/es-revista-colombian-journal-anesthesiology-342-articulo-pathophysiology-treatment-phantom-limb-pain-S2256208713000850
The onset and nature of PLP may differ depending on the cause of the amputation, although there are no clear data to reach definitive conclusions. […] There are some factors associated with the onset of phantom pain. […] After nerve sectioning, there is retrograde degeneration and shortening of afferent neurons as a result of the injury, edema and axon regeneration. This phenomenon is known as sprouting and gives rise to neuroma formation, i.e., expanded and disorganized A and C fiber endings with ectopic firing that increases during mechanical and chemical stimulus. […] An additional site of ectopic discharge is the dorsal root ganglion (DRG), which joins the ectopic activity originating in the stump neuroma and amplifies it, or produces crossed excitation, leading to the depolarization of the neighboring neurons.
#18
https://journals.lww.com/rca/fulltext/2014/42010/pathophysiology_and_treatment_of_phantom_limb.9.aspx
The onset and nature of PLP may differ depending on the cause of the amputation, although there are no clear data to reach definitive conclusions. […] After nerve sectioning, there is retrograde degeneration and shortening of afferent neurons as a result of the injury, edema and axon regeneration. This phenomenon is known as sprouting and gives rise to neuroma formation, i.e., expanded and disorganized A and C fiber endings with ectopic firing that increases during mechanical and chemical stimulus. […] An additional site of ectopic discharge is the dorsal root ganglion (DRG), which joins the ectopic activity originating in the stump neuroma and amplifies it, or produces crossed excitation, leading to the depolarization of the neighboring neurons. […] After peripheral nerve injury, there is evidence of central sensitization of the neurons of the posterior horn of the spinal cord. This process is characterized by long-term potentiation, where short-lasting nociceptive stimuli generate increased post-synaptic potentials during a long period of time.
#19
https://journals.lww.com/painrpts/fulltext/2021/01000/clinical_updates_on_phantom_limb_pain.7.aspx
Residual limb pain (RLP) is also associated with inappropriate preparation of the stump and can develop in the context of wound healing disorders, osteitis, osteomyelitis, local circulatory disorders, neuroma, hematoma, or seroma. Residual limb pain is also associated with inappropriate preparation of the stump (eg, unfavorable formation of the bony stump end), inaccurate alignment of bone lengths in stumps with 2 or more bones, and missing fat pad under mesh-graft after surgical treatment of soft tissue injuries resulting in improper fit of the prosthesis. Neuromas can not only trigger PLP but can also cause localized allodynia, hyperalgesia, and pain hindering prosthesis use. […] The scientific evidence for best practice is weak and contrasted by various clinical reports describing the polypragmatic use of drugs and interventional techniques. Approaches to restore the body scheme and integration of sensorimotor input are of importance. Modern techniques, including apps and virtual reality, offer an exciting supplement to already established approaches based on mirror therapy. Targeted prosthesis care helps to obtain or restore limb function and at the same time plays an important role reshaping the body scheme.
#20 Role of Potassium Ions Quantum Tunneling in the Pathophysiology of Phantom Limb Pain
https://www.mdpi.com/2076-3425/10/4/241
Potassium channels might play a major role in evoked and spontaneous hyperexcitability of the severed nerves. […] This is supported by multiple studies showing that the inhibition of potassium channels with broad spectrum potassium channel blockers induced spontaneous activity in the nerve fibers. […] This supports the idea that pain related to potassium channelopathy is largely peripheral in origin, and that downregulation of potassium channels can be a contributing factor in pain syndromes. […] The majority of current research focuses on depolarizing ion channels like sodium and calcium channels, while research on potassium channels is less abundant. […] Channelopathy that accompanies downregulation decreases trafficking across channels and renders them dormant, but measuring the exact figures of kinetics around potassium channels is difficult due to the large heterogenicity of the channels and large number of channels that might be involved.
#21 Phantom Limb Pain – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK448188/
Despite, the phantom limb sensation was described by French military surgeon Ambroise Pare (1510-1590) in the sixteenth century, even today we do not have a clear explanation of this complex phenomenon and, therefore, the pathophysiology is explained by a wide range of mechanisms. […] During the amputation, there is a significant amount of trauma that occurs in the nerves and surrounding tissues. This damage disrupts the normal afferent and efferent signals involved with the missing limb. The proximal portions of the severed nerves start to sprout neuromas, and the nerves become hyper-excitable due to an increase in sodium-channels and resulting in spontaneous discharges. […] In the spinal cord, a process called central sensitization occurs. Central sensitization is a process where neural activity increases, the neuronal receptive field expands, and the nerves become hypersensitive.
#22
https://journals.lww.com/painrpts/fulltext/2021/01000/clinical_updates_on_phantom_limb_pain.7.aspx
Although several potential mechanisms for development and maintenance of PLP have been described, the persistence of PLP most likely is a multifactorial process driven by somatic, psychological, and social factors, despite a seemingly universal cause in the unavoidable nerve injury with respective peripheral and central changes in the nervous system. Differentiating early factors might be the extent of tissue damage, edema, and disorders of the cell membrane, and damage of the perineurium. In the periphery, regenerative processes are initiated, like sprouting of damaged neurons and development of neuroma on the tail of the injured nerve with abnormal spontaneous activity generating afferent input. Central and peripheral changes are also associated with an increased expression of sodium channels and higher activity of nociceptive C fibers and spontaneous activity of dorsal root ganglion neurons.
#23 Pathophysiology and treatment of phantom limb pain | Colombian Journal of Anesthesiology
https://www.elsevier.es/es-revista-colombian-journal-anesthesiology-342-articulo-pathophysiology-treatment-phantom-limb-pain-S2256208713000850
After peripheral nerve injury, there is evidence of central sensitization of the neurons of the posterior horn of the spinal cord. […] Experiments have shown that after amputation of a digit in an adult monkey there is invasion of neuronal areas adjacent to the cortical area where the amputated digit was represented, consistent with neuroplasticity changes in the primary motor cortex (M1) and the primary somatosensory cortex (S1). […] Psychological factors, although they appear not to be part of the etiology, may affect the course and severity of pain. […] At present, there is no clear consensus about the efficacy of PLP treatment, since less than 10% of patients receiving medical treatment obtain long-term pain relief.
#24
https://journals.lww.com/rca/fulltext/2014/42010/pathophysiology_and_treatment_of_phantom_limb.9.aspx
The onset and nature of PLP may differ depending on the cause of the amputation, although there are no clear data to reach definitive conclusions. […] After nerve sectioning, there is retrograde degeneration and shortening of afferent neurons as a result of the injury, edema and axon regeneration. This phenomenon is known as sprouting and gives rise to neuroma formation, i.e., expanded and disorganized A and C fiber endings with ectopic firing that increases during mechanical and chemical stimulus. […] An additional site of ectopic discharge is the dorsal root ganglion (DRG), which joins the ectopic activity originating in the stump neuroma and amplifies it, or produces crossed excitation, leading to the depolarization of the neighboring neurons. […] After peripheral nerve injury, there is evidence of central sensitization of the neurons of the posterior horn of the spinal cord. This process is characterized by long-term potentiation, where short-lasting nociceptive stimuli generate increased post-synaptic potentials during a long period of time.
#25 Phantom Limb Pain – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK448188/
Despite, the phantom limb sensation was described by French military surgeon Ambroise Pare (1510-1590) in the sixteenth century, even today we do not have a clear explanation of this complex phenomenon and, therefore, the pathophysiology is explained by a wide range of mechanisms. […] During the amputation, there is a significant amount of trauma that occurs in the nerves and surrounding tissues. This damage disrupts the normal afferent and efferent signals involved with the missing limb. The proximal portions of the severed nerves start to sprout neuromas, and the nerves become hyper-excitable due to an increase in sodium-channels and resulting in spontaneous discharges. […] In the spinal cord, a process called central sensitization occurs. Central sensitization is a process where neural activity increases, the neuronal receptive field expands, and the nerves become hypersensitive.
#26
https://journals.lww.com/rca/fulltext/2014/42010/pathophysiology_and_treatment_of_phantom_limb.9.aspx
Nerve injury also produces a functional connection of low threshold inputs with ascending spinal projection neurons that transmit nociceptive information to supraspinal centers. […] Experiments have shown that after amputation of a digit in an adult monkey there is invasion of neuronal areas adjacent to the cortical area where the amputated digit was represented, consistent with neuroplasticity changes in the primary motor cortex (M1) and the primary somatosensory cortex (S1). […] Psychological factors, although they appear not to be part of the etiology, may affect the course and severity of pain. […] At present, there is no clear consensus about the efficacy of PLP treatment, since less than 10% of patients receiving medical treatment obtain long-term pain relief. […] The mechanism of action of calcitonin in PLP is still unknown. […] The exact mechanisms by which local anesthetic injections reduce pain are not known.
#27
https://journals.lww.com/painrpts/fulltext/2021/01000/clinical_updates_on_phantom_limb_pain.7.aspx
At the spinal cord level, sensitization has been described, while the activity of inhibitory interneurons has been shown to be reduced. Also, an increased activity of spinal pronociceptive excitatory systems, with increased activity of glutamate and the N-methyl-D-aspartate receptor system, has been indicated. Neuronal plasticity and reorganization of the somatosensory cortex have been demonstrated after amputation. Cortical reorganization is a process by which neighboring regions of the area representing the lost limb expand along the cortical map thereby coactivating neurons formerly receiving and processing peripheral input from this limb. This is accompanied by the expansion of neuronal receptive fields. Importantly, the degree of cortical reorganization correlates with severity of PLP. Therapy focusing on limb perception (such as mirror therapy and prosthesis use) could prevent, reduce, and even reverse these changes in cortical reorganization.
#28
https://journals.lww.com/painrpts/fulltext/2021/01000/clinical_updates_on_phantom_limb_pain.7.aspx
At the spinal cord level, sensitization has been described, while the activity of inhibitory interneurons has been shown to be reduced. Also, an increased activity of spinal pronociceptive excitatory systems, with increased activity of glutamate and the N-methyl-D-aspartate receptor system, has been indicated. Neuronal plasticity and reorganization of the somatosensory cortex have been demonstrated after amputation. Cortical reorganization is a process by which neighboring regions of the area representing the lost limb expand along the cortical map thereby coactivating neurons formerly receiving and processing peripheral input from this limb. This is accompanied by the expansion of neuronal receptive fields. Importantly, the degree of cortical reorganization correlates with severity of PLP. Therapy focusing on limb perception (such as mirror therapy and prosthesis use) could prevent, reduce, and even reverse these changes in cortical reorganization.
#29 Phantom Limb Pain: Mechanisms and Treatment Approaches
https://pmc.ncbi.nlm.nih.gov/articles/PMC3198614/
Cortical reorganization is perhaps the most cited reason for the cause of PLP in recent years. During reorganization, the cortical areas representing the amputated extremity are taken over by the neighboring representational zones in both the primary somatosensory and the motor cortex. The extent of cortical reorganization has been found to be directly related to the degree of pain and the size of the deafferentiated region. […] The assumption that PLP is of psychogenic origin has not been supported in the recent literature even though stress, anxiety, exhaustion, and depression are believed to exacerbate PLP.
#30 Phantom Limb Pain: Mechanisms and Treatment Approaches
https://pmc.ncbi.nlm.nih.gov/articles/PMC3198614/
Cortical reorganization is perhaps the most cited reason for the cause of PLP in recent years. During reorganization, the cortical areas representing the amputated extremity are taken over by the neighboring representational zones in both the primary somatosensory and the motor cortex. The extent of cortical reorganization has been found to be directly related to the degree of pain and the size of the deafferentiated region. […] The assumption that PLP is of psychogenic origin has not been supported in the recent literature even though stress, anxiety, exhaustion, and depression are believed to exacerbate PLP.
#31 Phantom Limb Pain – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK448188/
Over the past few years, there has been significant research into cortical reorganization and is a commonly cited factor in phantom limb pain. […] Cortical reorganization partially explains why nociceptive stimulation of the nerves in the residual limb and surrounding area can cause pain and sensation in the missing limb. […] Chronic pain has been shown to be multi-factorial with a strong psychological component. Phantom limb pain can often develop into chronic pain syndrome and for treatment to have a higher chance of success the patient’s pain behaviors and pain processing should be addressed.
#32 Pathophysiology and treatment of phantom limb pain | Colombian Journal of Anesthesiology
https://www.elsevier.es/es-revista-colombian-journal-anesthesiology-342-articulo-pathophysiology-treatment-phantom-limb-pain-S2256208713000850
After peripheral nerve injury, there is evidence of central sensitization of the neurons of the posterior horn of the spinal cord. […] Experiments have shown that after amputation of a digit in an adult monkey there is invasion of neuronal areas adjacent to the cortical area where the amputated digit was represented, consistent with neuroplasticity changes in the primary motor cortex (M1) and the primary somatosensory cortex (S1). […] Psychological factors, although they appear not to be part of the etiology, may affect the course and severity of pain. […] At present, there is no clear consensus about the efficacy of PLP treatment, since less than 10% of patients receiving medical treatment obtain long-term pain relief.
#33
https://journals.lww.com/rca/fulltext/2014/42010/pathophysiology_and_treatment_of_phantom_limb.9.aspx
Nerve injury also produces a functional connection of low threshold inputs with ascending spinal projection neurons that transmit nociceptive information to supraspinal centers. […] Experiments have shown that after amputation of a digit in an adult monkey there is invasion of neuronal areas adjacent to the cortical area where the amputated digit was represented, consistent with neuroplasticity changes in the primary motor cortex (M1) and the primary somatosensory cortex (S1). […] Psychological factors, although they appear not to be part of the etiology, may affect the course and severity of pain. […] At present, there is no clear consensus about the efficacy of PLP treatment, since less than 10% of patients receiving medical treatment obtain long-term pain relief. […] The mechanism of action of calcitonin in PLP is still unknown. […] The exact mechanisms by which local anesthetic injections reduce pain are not known.
#34 Making sense of phantom limb pain | Journal of Neurology, Neurosurgery & Psychiatry
https://jnnp.bmj.com/content/93/8/833
PLP is an umbrella term for a hugely heterogenous phenomenon. After limb amputation, most individuals experience a phantom limb and perceive painful sensations to originate from it. […] The most common factor positively associated with PLP is RLP (identified in five studies, representing a total of 920 participants). RLP is described as pain perceived to originate from the remaining portion of the limb after amputation, most often close to the site of amputation. […] Considering the high covariation between PLP and RLP, it is essential to understand whether these two pain phenomena relate to each other mechanistically. […] This close association between RLP and PLP likely points to the potential contribution of peripheral factors in the onset of PLP such as the state of the residual nerve endings after ligation and transection, molecular alterations throughout the nerve triggered by the nerve transection or ectopic nerve impulses originating from a neuroma or the dorsal root ganglion.
#35 Making sense of phantom limb pain | Journal of Neurology, Neurosurgery & Psychiatry
https://jnnp.bmj.com/content/93/8/833
PLP is an umbrella term for a hugely heterogenous phenomenon. After limb amputation, most individuals experience a phantom limb and perceive painful sensations to originate from it. […] The most common factor positively associated with PLP is RLP (identified in five studies, representing a total of 920 participants). RLP is described as pain perceived to originate from the remaining portion of the limb after amputation, most often close to the site of amputation. […] Considering the high covariation between PLP and RLP, it is essential to understand whether these two pain phenomena relate to each other mechanistically. […] This close association between RLP and PLP likely points to the potential contribution of peripheral factors in the onset of PLP such as the state of the residual nerve endings after ligation and transection, molecular alterations throughout the nerve triggered by the nerve transection or ectopic nerve impulses originating from a neuroma or the dorsal root ganglion.
#36 Making sense of phantom limb pain | Journal of Neurology, Neurosurgery & Psychiatry
https://jnnp.bmj.com/content/93/8/833
PLP is an umbrella term for a hugely heterogenous phenomenon. After limb amputation, most individuals experience a phantom limb and perceive painful sensations to originate from it. […] The most common factor positively associated with PLP is RLP (identified in five studies, representing a total of 920 participants). RLP is described as pain perceived to originate from the remaining portion of the limb after amputation, most often close to the site of amputation. […] Considering the high covariation between PLP and RLP, it is essential to understand whether these two pain phenomena relate to each other mechanistically. […] This close association between RLP and PLP likely points to the potential contribution of peripheral factors in the onset of PLP such as the state of the residual nerve endings after ligation and transection, molecular alterations throughout the nerve triggered by the nerve transection or ectopic nerve impulses originating from a neuroma or the dorsal root ganglion.
#37 Residual limb pain – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/residual-limb-pain/symptoms-causes/syc-20541403
Some studies have found that risk factors for residual limb pain may include: How high on the body the arm or leg was removed, called amputation. How much pain there was before amputation. The reason for the amputation. Older age at the time of amputation. […] Emotional stress, such as fear and lack of emotional support, may make the pain worse. […] Residual limb pain affects quality of life and may get in the way of using a replacement arm or leg, called a prosthesis. People with residual limb pain may be more likely to be depressed or anxious than people who don’t have the pain. […] A replacement limb, called a prothesis, that fits well can ease pressure between the residual limb and the prothesis. This can help prevent residual limb pain. Taking good care of the skin that comes into contact with the prothesis also can help prevent residual limb pain. […] Researchers are studying other ways to prevent residual limb pain after amputation.
#38 Residual limb pain – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/residual-limb-pain/symptoms-causes/syc-20541403
Some studies have found that risk factors for residual limb pain may include: How high on the body the arm or leg was removed, called amputation. How much pain there was before amputation. The reason for the amputation. Older age at the time of amputation. […] Emotional stress, such as fear and lack of emotional support, may make the pain worse. […] Residual limb pain affects quality of life and may get in the way of using a replacement arm or leg, called a prosthesis. People with residual limb pain may be more likely to be depressed or anxious than people who don’t have the pain. […] A replacement limb, called a prothesis, that fits well can ease pressure between the residual limb and the prothesis. This can help prevent residual limb pain. Taking good care of the skin that comes into contact with the prothesis also can help prevent residual limb pain. […] Researchers are studying other ways to prevent residual limb pain after amputation.
#39 Making sense of phantom limb pain | Journal of Neurology, Neurosurgery & Psychiatry
https://jnnp.bmj.com/content/93/8/833
According to the meta-analysis by Limakatso and colleagues, preamputation pain was the second most common factor positively associated with PLP. […] In the meta-analysis, non-painful phantom sensations comprised the third most common factor positively associated with PLP. […] While certain cross-sectional and retrospective studies have suggested there is a gradual decrease in PLP over time, this evidence relies on retrospective recall of pain intensity, which is known to be unreliable. […] To summarise, PLP is clearly a highly prevalent and heterogenous phenomenon in amputees. Developing a better understanding (and quantification) of PLP covariates is necessary for better handling of this heterogeneity in future research and for providing valuable clues as to the underlying mechanism(s) of PLP.
#40 Residual limb pain – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/residual-limb-pain/symptoms-causes/syc-20541403
Some studies have found that risk factors for residual limb pain may include: How high on the body the arm or leg was removed, called amputation. How much pain there was before amputation. The reason for the amputation. Older age at the time of amputation. […] Emotional stress, such as fear and lack of emotional support, may make the pain worse. […] Residual limb pain affects quality of life and may get in the way of using a replacement arm or leg, called a prosthesis. People with residual limb pain may be more likely to be depressed or anxious than people who don’t have the pain. […] A replacement limb, called a prothesis, that fits well can ease pressure between the residual limb and the prothesis. This can help prevent residual limb pain. Taking good care of the skin that comes into contact with the prothesis also can help prevent residual limb pain. […] Researchers are studying other ways to prevent residual limb pain after amputation.
#41 Residual limb pain – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/residual-limb-pain/symptoms-causes/syc-20541403
Some studies have found that risk factors for residual limb pain may include: How high on the body the arm or leg was removed, called amputation. How much pain there was before amputation. The reason for the amputation. Older age at the time of amputation. […] Emotional stress, such as fear and lack of emotional support, may make the pain worse. […] Residual limb pain affects quality of life and may get in the way of using a replacement arm or leg, called a prosthesis. People with residual limb pain may be more likely to be depressed or anxious than people who don’t have the pain. […] A replacement limb, called a prothesis, that fits well can ease pressure between the residual limb and the prothesis. This can help prevent residual limb pain. Taking good care of the skin that comes into contact with the prothesis also can help prevent residual limb pain. […] Researchers are studying other ways to prevent residual limb pain after amputation.
#42 Making sense of phantom limb pain | Journal of Neurology, Neurosurgery & Psychiatry
https://jnnp.bmj.com/content/93/8/833
According to the meta-analysis by Limakatso and colleagues, preamputation pain was the second most common factor positively associated with PLP. […] In the meta-analysis, non-painful phantom sensations comprised the third most common factor positively associated with PLP. […] While certain cross-sectional and retrospective studies have suggested there is a gradual decrease in PLP over time, this evidence relies on retrospective recall of pain intensity, which is known to be unreliable. […] To summarise, PLP is clearly a highly prevalent and heterogenous phenomenon in amputees. Developing a better understanding (and quantification) of PLP covariates is necessary for better handling of this heterogeneity in future research and for providing valuable clues as to the underlying mechanism(s) of PLP.
#43 Residual limb pain – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/residual-limb-pain/symptoms-causes/syc-20541403
Some studies have found that risk factors for residual limb pain may include: How high on the body the arm or leg was removed, called amputation. How much pain there was before amputation. The reason for the amputation. Older age at the time of amputation. […] Emotional stress, such as fear and lack of emotional support, may make the pain worse. […] Residual limb pain affects quality of life and may get in the way of using a replacement arm or leg, called a prosthesis. People with residual limb pain may be more likely to be depressed or anxious than people who don’t have the pain. […] A replacement limb, called a prothesis, that fits well can ease pressure between the residual limb and the prothesis. This can help prevent residual limb pain. Taking good care of the skin that comes into contact with the prothesis also can help prevent residual limb pain. […] Researchers are studying other ways to prevent residual limb pain after amputation.
#44 Residual limb pain | UM Health-Sparrow
https://www.uofmhealthsparrow.org/departments-conditions/conditions/residual-limb-pain
Emotional stress, such as fear and lack of emotional support, may make the pain worse. […] Residual limb pain affects quality of life and may get in the way of using a replacement arm or leg, called a prosthesis. […] Researchers are studying other ways to prevent residual limb pain after amputation. […] Treatment for residual limb pain depends on the cause. […] Nerve blocks. These shots, called injections, block or turn off a nerve’s pain signals. They can help ease residual limb pain. […] Regenerative peripheral nerve interface. Also called RPNI, this newer procedure helps prevent neuroma, a tangle of nerve endings that often forms after an amputation. It also helps prevent pain from neuromas that have formed. Neuromas are a major cause of residual limb pain.
#45 Residual limb pain – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/residual-limb-pain/symptoms-causes/syc-20541403
Some studies have found that risk factors for residual limb pain may include: How high on the body the arm or leg was removed, called amputation. How much pain there was before amputation. The reason for the amputation. Older age at the time of amputation. […] Emotional stress, such as fear and lack of emotional support, may make the pain worse. […] Residual limb pain affects quality of life and may get in the way of using a replacement arm or leg, called a prosthesis. People with residual limb pain may be more likely to be depressed or anxious than people who don’t have the pain. […] A replacement limb, called a prothesis, that fits well can ease pressure between the residual limb and the prothesis. This can help prevent residual limb pain. Taking good care of the skin that comes into contact with the prothesis also can help prevent residual limb pain. […] Researchers are studying other ways to prevent residual limb pain after amputation.
#46 Pathophysiology and treatment of phantom limb pain | Colombian Journal of Anesthesiology
https://www.elsevier.es/es-revista-colombian-journal-anesthesiology-342-articulo-pathophysiology-treatment-phantom-limb-pain-S2256208713000850
After peripheral nerve injury, there is evidence of central sensitization of the neurons of the posterior horn of the spinal cord. […] Experiments have shown that after amputation of a digit in an adult monkey there is invasion of neuronal areas adjacent to the cortical area where the amputated digit was represented, consistent with neuroplasticity changes in the primary motor cortex (M1) and the primary somatosensory cortex (S1). […] Psychological factors, although they appear not to be part of the etiology, may affect the course and severity of pain. […] At present, there is no clear consensus about the efficacy of PLP treatment, since less than 10% of patients receiving medical treatment obtain long-term pain relief.
#47 Pathophysiology and treatment of phantom limb pain
http://www.scielo.org.co/scielo.php?pid=S0120-33472014000100009&script=sci_arttext&tlng=en
Psychological factors, although they appear not to be part of the etiology, may affect the course and severity of pain. […] The mechanisms by which local anesthetic injections reduce pain are not known. […] At present, there is no clear consensus about the efficacy of PLP treatment, since less than 10% of patients receiving medical treatment obtain long-term pain relief.
#48 Pain in the Residual Limb – Special Subjects – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/special-subjects/limb-prosthetics/pain-in-the-residual-limb
Phantom limb pain is often more severe soon after the amputation, then decreases over time. […] Some patients with a socket-secured prosthesis (SSP) experience chronic, recurring residual limb pain caused by chronic skin irritation from sweating and pressure/friction ulcers. […] Persistent pain can affect sleep, increase stress levels, and increase mental health problems (eg. anxiety, depression, substance use disorders). Persistent pain is more common in patients with short remaining skeletal structures and/or soft-tissue deformities of the residual limb. […] The diagnosis of a neuroma is suggested by history and physical examination. Pain from a neuroma may have neurogenic characteristics such as feeling electrical, shooting, tingling, sharp and stabbing, or prickly sensations. The pain is typically localized to the residual limb. […] Successful osseointegration requires a multidisciplinary team including the surgeon, prosthetist, and physical therapist. Candidates follow a comprehensive screening procedure.
#49 Phantom Limb Pain – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK448188/
Over the past few years, there has been significant research into cortical reorganization and is a commonly cited factor in phantom limb pain. […] Cortical reorganization partially explains why nociceptive stimulation of the nerves in the residual limb and surrounding area can cause pain and sensation in the missing limb. […] Chronic pain has been shown to be multi-factorial with a strong psychological component. Phantom limb pain can often develop into chronic pain syndrome and for treatment to have a higher chance of success the patient’s pain behaviors and pain processing should be addressed.
#50 Phantom Limb Pain – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK448188/
Unlike PLP, RLP is often a manifestation of an underlying source, such as nerve entrapment, neuroma formation, surgical trauma, ischemia, skin breakdown, or infection. […] Of note, more than half of people with PLP also have RLP. It is important to know the difference between the two because the causes and treatments for each differ, but also be aware that both of these elements can coexist at the same time. […] The exact etiology of PLP is unclear. Multiple theories have been debated, and the only agreement is that multiple mechanisms are likely responsible. […] The predominant theory for years involved the irritation of the severed nerve endings causing phantom pain. This was enforced by evidence that almost all amputation patients will develop neuromas in the residual limb. […] Over the last few decades, advances in imaging and laboratory techniques have shown evidence of central nervous system (CNS) involvement. Imaging studies such as MRI and PET scans show activity in the areas of the brain associated with the amputated limb when the patient feels phantom pain. The pain is now thought to involve many peripheral and central nervous system factors.
#51 Living With Residual Limb Pain â Amputee Coalition
https://amputee-coalition.org/resources/living-with-residual-limb-pain-fs/
Residual limb pain is different from this normal postoperative pain. For example, it commonly occurs after your postoperative pain has ended. It is frequently described as sharp, aching, throbbing or burning in nature. Your entire healthcare team, including your doctors, therapists and prosthetist, will work with you to determine the cause of this pain and decide what treatments might be most effective. […] Poor tissue coverage can be caused by the bone at the end of your residual limb not being properly trimmed at the time of surgery, and this can cause pain when you wear your prosthesis. If padding and other methods are not successful, surgery may be required to revise your residual limb so as to decrease your pain and allow you to wear your prosthesis. […] A neuroma is a collection, or bundle, of nerve endings that forms under the skin of your residual limb. Think of it like a tangle of hair. It can become very sensitive, especially if the tangle is pressing against your prosthesis.
#52 Pain in the Residual Limb – Special Subjects – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/special-subjects/limb-prosthetics/pain-in-the-residual-limb
Phantom limb pain is often more severe soon after the amputation, then decreases over time. […] Some patients with a socket-secured prosthesis (SSP) experience chronic, recurring residual limb pain caused by chronic skin irritation from sweating and pressure/friction ulcers. […] Persistent pain can affect sleep, increase stress levels, and increase mental health problems (eg. anxiety, depression, substance use disorders). Persistent pain is more common in patients with short remaining skeletal structures and/or soft-tissue deformities of the residual limb. […] The diagnosis of a neuroma is suggested by history and physical examination. Pain from a neuroma may have neurogenic characteristics such as feeling electrical, shooting, tingling, sharp and stabbing, or prickly sensations. The pain is typically localized to the residual limb. […] Successful osseointegration requires a multidisciplinary team including the surgeon, prosthetist, and physical therapist. Candidates follow a comprehensive screening procedure.
#53 Residual Limb Pain – Special Subjects – Merck Manual Consumer Version
https://www.merckmanuals.com/home/special-subjects/limb-prosthetics/residual-limb-pain
Painful neuromas (noncancerous overgrowths of nerve tissue) can occur in any severed nerve (from surgery or trauma) and may cause pain that feels electrical, shooting, tingling, sharp and stabbing, or prickly. […] Some people with a traditional socket-secured prosthesis experience chronic, recurring residual limb pain caused by chronic skin irritation from sweating and pressure/friction ulcers. This results in having less control over the prosthesis, a loss of function, reduced independence, and a decreased quality of life. Persistent pain can affect sleep, increase stress levels, and increase mental health problems (for example. anxiety, depression, and substance use disorders). Some people with persistent residual limb pain may benefit from replacing the traditional socket prosthesis through transcutaneous osseointegration, which involves surgically implanting a prosthetic anchor into the residual limbs bone.
#54 Living With Residual Limb Pain â Amputee Coalition
https://amputee-coalition.org/resources/living-with-residual-limb-pain-fs/
Unfortunately, surgery to remove neuromas is not usually successful, because they often just reform. […] As your incision begins to heal, your doctor will let you know when you can start massaging your residual limb. This will help to prevent nerves from being âcaughtâ in scar tissue. You will also be taught how to wrap your limb using elastic wraps. This not only helps to prevent scarring but also helps with prosthesis fit. […] No matter the cause of residual limb pain, there are some principles that can be followed to help you manage your pain.
#55 Residual limb pain – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/residual-limb-pain/symptoms-causes/syc-20541403
Residual limb pain is a type of pain felt in the part of an arm or leg that’s left after the arm or leg is removed, called amputation. More than half of people who have an amputation get this type of pain. Sometimes called stump pain, it may happen soon after the surgery, often within the first week. But the pain may last after healing. […] Residual limb pain is not the same thing as phantom pain. Phantom pain feels like it comes from the part of the arm or leg that’s no longer there after amputation. But many people have both residual limb pain and phantom pain. […] There are several causes of pain after removal of an arm or leg, called amputation. They include the following: Issues in the bone or the soft tissue, such as sores or bone spurs. Infection. Poor blood supply to the part of the arm or leg that’s left. A tumor. A tangle of nerve endings that forms after the arm or leg is removed, called a neuroma. Nerve damage. Issues with the fit or use of a replacement arm or leg, called a prosthesis.
#56 Residual limb pain | UM Health-Sparrow
https://www.uofmhealthsparrow.org/departments-conditions/conditions/residual-limb-pain
Residual limb pain is a type of pain felt in the part of an arm or leg that’s left after the arm or leg is removed, called amputation. More than half of people who have an amputation get this type of pain. Sometimes called stump pain, it may happen soon after the surgery, often within the first week. But the pain may last after healing. […] Residual limb pain is not the same thing as phantom pain. Phantom pain feels like it comes from the part of the arm or leg that’s no longer there after amputation. But many people have both residual limb pain and phantom pain. […] There are several causes of pain after removal of an arm or leg, called amputation. They include the following: Issues in the bone or the soft tissue, such as sores or bone spurs. […] A tangle of nerve endings that forms after the arm or leg is removed, called a neuroma.
#57 Residual limb pain – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/residual-limb-pain/symptoms-causes/syc-20541403
Residual limb pain is a type of pain felt in the part of an arm or leg that’s left after the arm or leg is removed, called amputation. More than half of people who have an amputation get this type of pain. Sometimes called stump pain, it may happen soon after the surgery, often within the first week. But the pain may last after healing. […] Residual limb pain is not the same thing as phantom pain. Phantom pain feels like it comes from the part of the arm or leg that’s no longer there after amputation. But many people have both residual limb pain and phantom pain. […] There are several causes of pain after removal of an arm or leg, called amputation. They include the following: Issues in the bone or the soft tissue, such as sores or bone spurs. Infection. Poor blood supply to the part of the arm or leg that’s left. A tumor. A tangle of nerve endings that forms after the arm or leg is removed, called a neuroma. Nerve damage. Issues with the fit or use of a replacement arm or leg, called a prosthesis.
#58 Residual limb pain – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/residual-limb-pain/symptoms-causes/syc-20541403
Residual limb pain is a type of pain felt in the part of an arm or leg that’s left after the arm or leg is removed, called amputation. More than half of people who have an amputation get this type of pain. Sometimes called stump pain, it may happen soon after the surgery, often within the first week. But the pain may last after healing. […] Residual limb pain is not the same thing as phantom pain. Phantom pain feels like it comes from the part of the arm or leg that’s no longer there after amputation. But many people have both residual limb pain and phantom pain. […] There are several causes of pain after removal of an arm or leg, called amputation. They include the following: Issues in the bone or the soft tissue, such as sores or bone spurs. Infection. Poor blood supply to the part of the arm or leg that’s left. A tumor. A tangle of nerve endings that forms after the arm or leg is removed, called a neuroma. Nerve damage. Issues with the fit or use of a replacement arm or leg, called a prosthesis.
#59 Residual limb pain – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/residual-limb-pain/symptoms-causes/syc-20541403
Residual limb pain is a type of pain felt in the part of an arm or leg that’s left after the arm or leg is removed, called amputation. More than half of people who have an amputation get this type of pain. Sometimes called stump pain, it may happen soon after the surgery, often within the first week. But the pain may last after healing. […] Residual limb pain is not the same thing as phantom pain. Phantom pain feels like it comes from the part of the arm or leg that’s no longer there after amputation. But many people have both residual limb pain and phantom pain. […] There are several causes of pain after removal of an arm or leg, called amputation. They include the following: Issues in the bone or the soft tissue, such as sores or bone spurs. Infection. Poor blood supply to the part of the arm or leg that’s left. A tumor. A tangle of nerve endings that forms after the arm or leg is removed, called a neuroma. Nerve damage. Issues with the fit or use of a replacement arm or leg, called a prosthesis.
#60 Residual limb pain – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/residual-limb-pain/symptoms-causes/syc-20541403
Residual limb pain is a type of pain felt in the part of an arm or leg that’s left after the arm or leg is removed, called amputation. More than half of people who have an amputation get this type of pain. Sometimes called stump pain, it may happen soon after the surgery, often within the first week. But the pain may last after healing. […] Residual limb pain is not the same thing as phantom pain. Phantom pain feels like it comes from the part of the arm or leg that’s no longer there after amputation. But many people have both residual limb pain and phantom pain. […] There are several causes of pain after removal of an arm or leg, called amputation. They include the following: Issues in the bone or the soft tissue, such as sores or bone spurs. Infection. Poor blood supply to the part of the arm or leg that’s left. A tumor. A tangle of nerve endings that forms after the arm or leg is removed, called a neuroma. Nerve damage. Issues with the fit or use of a replacement arm or leg, called a prosthesis.
#61 Living With Residual Limb Pain â Amputee Coalition
https://amputee-coalition.org/resources/living-with-residual-limb-pain-fs/
Residual limb pain is different from this normal postoperative pain. For example, it commonly occurs after your postoperative pain has ended. It is frequently described as sharp, aching, throbbing or burning in nature. Your entire healthcare team, including your doctors, therapists and prosthetist, will work with you to determine the cause of this pain and decide what treatments might be most effective. […] Poor tissue coverage can be caused by the bone at the end of your residual limb not being properly trimmed at the time of surgery, and this can cause pain when you wear your prosthesis. If padding and other methods are not successful, surgery may be required to revise your residual limb so as to decrease your pain and allow you to wear your prosthesis. […] A neuroma is a collection, or bundle, of nerve endings that forms under the skin of your residual limb. Think of it like a tangle of hair. It can become very sensitive, especially if the tangle is pressing against your prosthesis.
#62 Residual limb pain – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/residual-limb-pain/symptoms-causes/syc-20541403
Residual limb pain is a type of pain felt in the part of an arm or leg that’s left after the arm or leg is removed, called amputation. More than half of people who have an amputation get this type of pain. Sometimes called stump pain, it may happen soon after the surgery, often within the first week. But the pain may last after healing. […] Residual limb pain is not the same thing as phantom pain. Phantom pain feels like it comes from the part of the arm or leg that’s no longer there after amputation. But many people have both residual limb pain and phantom pain. […] There are several causes of pain after removal of an arm or leg, called amputation. They include the following: Issues in the bone or the soft tissue, such as sores or bone spurs. Infection. Poor blood supply to the part of the arm or leg that’s left. A tumor. A tangle of nerve endings that forms after the arm or leg is removed, called a neuroma. Nerve damage. Issues with the fit or use of a replacement arm or leg, called a prosthesis.
#63 Residual Limb Pain – Special Subjects – Merck Manual Consumer Version
https://www.merckmanuals.com/home/special-subjects/limb-prosthetics/residual-limb-pain
Painful neuromas (noncancerous overgrowths of nerve tissue) can occur in any severed nerve (from surgery or trauma) and may cause pain that feels electrical, shooting, tingling, sharp and stabbing, or prickly. […] Some people with a traditional socket-secured prosthesis experience chronic, recurring residual limb pain caused by chronic skin irritation from sweating and pressure/friction ulcers. This results in having less control over the prosthesis, a loss of function, reduced independence, and a decreased quality of life. Persistent pain can affect sleep, increase stress levels, and increase mental health problems (for example. anxiety, depression, and substance use disorders). Some people with persistent residual limb pain may benefit from replacing the traditional socket prosthesis through transcutaneous osseointegration, which involves surgically implanting a prosthetic anchor into the residual limbs bone.
#64 Pain in the Residual Limb – Special Subjects – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/special-subjects/limb-prosthetics/pain-in-the-residual-limb
Phantom limb pain is often more severe soon after the amputation, then decreases over time. […] Some patients with a socket-secured prosthesis (SSP) experience chronic, recurring residual limb pain caused by chronic skin irritation from sweating and pressure/friction ulcers. […] Persistent pain can affect sleep, increase stress levels, and increase mental health problems (eg. anxiety, depression, substance use disorders). Persistent pain is more common in patients with short remaining skeletal structures and/or soft-tissue deformities of the residual limb. […] The diagnosis of a neuroma is suggested by history and physical examination. Pain from a neuroma may have neurogenic characteristics such as feeling electrical, shooting, tingling, sharp and stabbing, or prickly sensations. The pain is typically localized to the residual limb. […] Successful osseointegration requires a multidisciplinary team including the surgeon, prosthetist, and physical therapist. Candidates follow a comprehensive screening procedure.
#65 Residual Limb Pain – Special Subjects – Merck Manual Consumer Version
https://www.merckmanuals.com/home/special-subjects/limb-prosthetics/residual-limb-pain
Painful neuromas (noncancerous overgrowths of nerve tissue) can occur in any severed nerve (from surgery or trauma) and may cause pain that feels electrical, shooting, tingling, sharp and stabbing, or prickly. […] Some people with a traditional socket-secured prosthesis experience chronic, recurring residual limb pain caused by chronic skin irritation from sweating and pressure/friction ulcers. This results in having less control over the prosthesis, a loss of function, reduced independence, and a decreased quality of life. Persistent pain can affect sleep, increase stress levels, and increase mental health problems (for example. anxiety, depression, and substance use disorders). Some people with persistent residual limb pain may benefit from replacing the traditional socket prosthesis through transcutaneous osseointegration, which involves surgically implanting a prosthetic anchor into the residual limbs bone.
#66 Residual limb pain – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/residual-limb-pain/symptoms-causes/syc-20541403
Some studies have found that risk factors for residual limb pain may include: How high on the body the arm or leg was removed, called amputation. How much pain there was before amputation. The reason for the amputation. Older age at the time of amputation. […] Emotional stress, such as fear and lack of emotional support, may make the pain worse. […] Residual limb pain affects quality of life and may get in the way of using a replacement arm or leg, called a prosthesis. People with residual limb pain may be more likely to be depressed or anxious than people who don’t have the pain. […] A replacement limb, called a prothesis, that fits well can ease pressure between the residual limb and the prothesis. This can help prevent residual limb pain. Taking good care of the skin that comes into contact with the prothesis also can help prevent residual limb pain. […] Researchers are studying other ways to prevent residual limb pain after amputation.
#67 Residual limb pain – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/residual-limb-pain/symptoms-causes/syc-20541403
Some studies have found that risk factors for residual limb pain may include: How high on the body the arm or leg was removed, called amputation. How much pain there was before amputation. The reason for the amputation. Older age at the time of amputation. […] Emotional stress, such as fear and lack of emotional support, may make the pain worse. […] Residual limb pain affects quality of life and may get in the way of using a replacement arm or leg, called a prosthesis. People with residual limb pain may be more likely to be depressed or anxious than people who don’t have the pain. […] A replacement limb, called a prothesis, that fits well can ease pressure between the residual limb and the prothesis. This can help prevent residual limb pain. Taking good care of the skin that comes into contact with the prothesis also can help prevent residual limb pain. […] Researchers are studying other ways to prevent residual limb pain after amputation.
#68 Pain in the Residual Limb – Special Subjects – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/special-subjects/limb-prosthetics/pain-in-the-residual-limb
Phantom limb pain is often more severe soon after the amputation, then decreases over time. […] Some patients with a socket-secured prosthesis (SSP) experience chronic, recurring residual limb pain caused by chronic skin irritation from sweating and pressure/friction ulcers. […] Persistent pain can affect sleep, increase stress levels, and increase mental health problems (eg. anxiety, depression, substance use disorders). Persistent pain is more common in patients with short remaining skeletal structures and/or soft-tissue deformities of the residual limb. […] The diagnosis of a neuroma is suggested by history and physical examination. Pain from a neuroma may have neurogenic characteristics such as feeling electrical, shooting, tingling, sharp and stabbing, or prickly sensations. The pain is typically localized to the residual limb. […] Successful osseointegration requires a multidisciplinary team including the surgeon, prosthetist, and physical therapist. Candidates follow a comprehensive screening procedure.
#69 Pain in the Residual Limb – Special Subjects – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/special-subjects/limb-prosthetics/pain-in-the-residual-limb
Approximately 60% of individuals with an amputation have post-amputation pain in the residual limb, which can severely limit function, impair quality of life, and significantly impede rehabilitation. Residual limb pain should be evaluated and treated aggressively because some causes can be dangerous. […] Persistent residual limb pain is a chronic condition that differs from phantom limb pain and phantom limb sensation. […] Neuropathic pain is common in patients and is usually described as a shooting or burning pain and typically develops within 7 days of amputation. It can go away on its own but is often chronic. It can be unrelenting and severe, or intermittent. It often is the result of nerve damage from an injury or the severing of nerves during the amputation. […] Most patients experience phantom limb pain at some time. The phantom aspect is not the pain, which is real, but the location of the pain in a limb that has been amputated. The mechanism is believed to involve peripheral and central factors. Onset and duration typically is within days following amputation but could be delayed months to years.
#70 Making sense of phantom limb pain | Journal of Neurology, Neurosurgery & Psychiatry
https://jnnp.bmj.com/content/93/8/833
PLP is an umbrella term for a hugely heterogenous phenomenon. After limb amputation, most individuals experience a phantom limb and perceive painful sensations to originate from it. […] The most common factor positively associated with PLP is RLP (identified in five studies, representing a total of 920 participants). RLP is described as pain perceived to originate from the remaining portion of the limb after amputation, most often close to the site of amputation. […] Considering the high covariation between PLP and RLP, it is essential to understand whether these two pain phenomena relate to each other mechanistically. […] This close association between RLP and PLP likely points to the potential contribution of peripheral factors in the onset of PLP such as the state of the residual nerve endings after ligation and transection, molecular alterations throughout the nerve triggered by the nerve transection or ectopic nerve impulses originating from a neuroma or the dorsal root ganglion.
#71 Phantom Limb Pain – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK448188/
Unlike PLP, RLP is often a manifestation of an underlying source, such as nerve entrapment, neuroma formation, surgical trauma, ischemia, skin breakdown, or infection. […] Of note, more than half of people with PLP also have RLP. It is important to know the difference between the two because the causes and treatments for each differ, but also be aware that both of these elements can coexist at the same time. […] The exact etiology of PLP is unclear. Multiple theories have been debated, and the only agreement is that multiple mechanisms are likely responsible. […] The predominant theory for years involved the irritation of the severed nerve endings causing phantom pain. This was enforced by evidence that almost all amputation patients will develop neuromas in the residual limb. […] Over the last few decades, advances in imaging and laboratory techniques have shown evidence of central nervous system (CNS) involvement. Imaging studies such as MRI and PET scans show activity in the areas of the brain associated with the amputated limb when the patient feels phantom pain. The pain is now thought to involve many peripheral and central nervous system factors.
#72 Residual limb pain – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/residual-limb-pain/symptoms-causes/syc-20541403
Residual limb pain is a type of pain felt in the part of an arm or leg that’s left after the arm or leg is removed, called amputation. More than half of people who have an amputation get this type of pain. Sometimes called stump pain, it may happen soon after the surgery, often within the first week. But the pain may last after healing. […] Residual limb pain is not the same thing as phantom pain. Phantom pain feels like it comes from the part of the arm or leg that’s no longer there after amputation. But many people have both residual limb pain and phantom pain. […] There are several causes of pain after removal of an arm or leg, called amputation. They include the following: Issues in the bone or the soft tissue, such as sores or bone spurs. Infection. Poor blood supply to the part of the arm or leg that’s left. A tumor. A tangle of nerve endings that forms after the arm or leg is removed, called a neuroma. Nerve damage. Issues with the fit or use of a replacement arm or leg, called a prosthesis.
#73 Residual Limb Pain – Special Subjects – Merck Manual Consumer Version
https://www.merckmanuals.com/home/special-subjects/limb-prosthetics/residual-limb-pain
After an amputation, about 60% of people have pain in the residual limb, which can severely limit function, impair quality of life, and significantly impede rehabilitation. Residual limb pain should be evaluated and treated aggressively, because some causes can be dangerous. […] Persistent residual limb pain is a chronic condition that differs from phantom limb pain and phantom limb sensation. […] Pain due to nerve damage (neuropathic pain) is common. Usually described as a shooting or burning pain, neuropathic pain typically develops within 7 days of amputation. It can go away on its own but is often long-lasting. It can be unrelenting and severe, or intermittent. Nerves may have been damaged from an injury or when they were severed during the amputation. Treatment of neuropathic pain includes psychologic treatments, physical methods, antidepressants, and antiseizure drugs.
#74 Phantom Limb Pain: What It Is, Causes, Treatment & Prevention
https://my.clevelandclinic.org/health/diseases/12092-phantom-limb-pain
Residual limb pain: This is pain that affects the remaining part of your limb (stump) thats still on your body after an amputation. Residual limb pain often has a medical reason, such as infection or nerve damage. […] You may also feel pain in the remaining part of your body that wasnt amputated. This is a residual limb or stump. Since this part of your body still exists, several complications can happen that may be causing the pain: […] You can experience residual limb pain at the same time as phantom limb pain. […] Residual limb pain often has a medical reason, such as infection or nerve damage.
#75 Residual limb pain – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/residual-limb-pain/symptoms-causes/syc-20541403
Residual limb pain is a type of pain felt in the part of an arm or leg that’s left after the arm or leg is removed, called amputation. More than half of people who have an amputation get this type of pain. Sometimes called stump pain, it may happen soon after the surgery, often within the first week. But the pain may last after healing. […] Residual limb pain is not the same thing as phantom pain. Phantom pain feels like it comes from the part of the arm or leg that’s no longer there after amputation. But many people have both residual limb pain and phantom pain. […] There are several causes of pain after removal of an arm or leg, called amputation. They include the following: Issues in the bone or the soft tissue, such as sores or bone spurs. Infection. Poor blood supply to the part of the arm or leg that’s left. A tumor. A tangle of nerve endings that forms after the arm or leg is removed, called a neuroma. Nerve damage. Issues with the fit or use of a replacement arm or leg, called a prosthesis.
#76 Phantom Limb Pain – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK448188/
Unlike PLP, RLP is often a manifestation of an underlying source, such as nerve entrapment, neuroma formation, surgical trauma, ischemia, skin breakdown, or infection. […] Of note, more than half of people with PLP also have RLP. It is important to know the difference between the two because the causes and treatments for each differ, but also be aware that both of these elements can coexist at the same time. […] The exact etiology of PLP is unclear. Multiple theories have been debated, and the only agreement is that multiple mechanisms are likely responsible. […] The predominant theory for years involved the irritation of the severed nerve endings causing phantom pain. This was enforced by evidence that almost all amputation patients will develop neuromas in the residual limb. […] Over the last few decades, advances in imaging and laboratory techniques have shown evidence of central nervous system (CNS) involvement. Imaging studies such as MRI and PET scans show activity in the areas of the brain associated with the amputated limb when the patient feels phantom pain. The pain is now thought to involve many peripheral and central nervous system factors.
#77 Phantom limb sensation / pain following amputation – University Hospitals Sussex NHS Foundation Trust
https://www.uhsussex.nhs.uk/resources/phantom-limb-sensation-pain-following-amputation/
The causes of phantom limb are unclear. There are three main theories: The Peripheral theory: phantom limb sensation / pain may be the result of nerve endings around the stump forming into clusters, known as neuromas. These may generate abnormal electrical impulses that the brain interprets as pain. […] The Spinal theory: the lack of sensory input from the amputated limb causes chemical changes in the central nervous system. This leads to âconfusionâ in certain regions of the brain, triggering the symptoms. […] The Central theory: the brain has a âmemoryâ of the amputated leg and its link to nerve signals. The symptoms are due to the brain trying to recreate this memory but failing because it is not receiving the feedback. […] For some amputees, the phantom limb may feel shortened or in an awkward position and can feel painful. This is sometimes described as a burning, aching, itching, cramping, sharp, stabbing or shooting pain.
#78 Amputation pain
https://www.neuromodulation.com/amputation-pain
Stump pain and phantom pain are interconnected. For instance, lingering stump problems such as scars, neuromas (a post-amputation growth containing nervous-system tissue), or bone spurs can directly influence the intensity and duration of phantom pain. A significant association has been found between stump pain and phantom limb pain. […] In 2015, dorsal root ganglion (DRG) stimulation in eight patients with amputation pain was reported to reduce phantom limb and residual limb pain by 53%; one individual reported a complete resolution of pain at 9 months. […] Potential newer neurostimulation treatments have been studied in recent years. For example, in 2015, pilot-study results were reported for high-frequency electrical nerve block in post-amputation pain.
#79 Residual Limb Pain – The Nerve Surgery Centre
https://nervesurgery.uk/residual-limb-pain/
Residual Limb PainTomas Madura2024-11-02T18:02:31+00:00 […] Pain after limb amputation is a common complication that affects many people who have undergone amputation. […] During the standard amputation, the nerves which served the amputated limb are cut and left freely in the tissues of the stump. Following the amputation the brain stops receiving signals from the amputated limb and a complex process of brain to deal with this lack of feedback starts. […] Phantom limb pain is a pain felt in the missing part of the limb after it has been amputated. About 75-80% of amputees experience this type of pain at some point after the amputation. The pain may be severe enough to disrupt sleep, cause low mood and decrease the quality of life. […] The exact cause of phantom limb pain is not well understood, but it is thought to be related to changes in the brain and nervous system that occur after amputation. Factors that may contribute to the development of phantom limb pain include the type and location of the amputation, the amount of pain experienced before the amputation, and the individuals emotional and psychological state. […] It has been observed that problematic neuromas in the amputation stump can contribute to developing of phantom limb pain, as after treatment of the neuromas the phantom limb pain improved as well. […] The neuroma pain is different from the phantom limb pain in that it is commonly felt in the stump rather than in the missing part of the limb. There may be areas on the stump when pressed or touched bring on the pain or worsen it and make the pain propagate up the remaining part of the limb or down to the missing part of the limb. The character of the pain is electric-shock-like, burning, tingling or shooting. […] It is important to note that neuroma pain and phantom limb pain often exist together and neuroma pain may be driving the phantom limb pain.
#80 An Algorithm Approach to Phantom Limb Pain | JPR
https://www.dovepress.com/an-algorithm-approach-to-phantom-limb-pain-peer-reviewed-fulltext-article-JPR
Phantom limb pain (PLP) is a common condition that occurs following both upper and lower limb amputation. […] To date, however, there is little consensus regarding the optimal management of phantom limb pain. […] Phantom limb pain (PLP), defined as pain in the missing limb, is thought to occur in 60-85% of adult amputees. […] While the association between pre-amputation pain and phantom pain remains unclear, studies consistently demonstrate an association between phantom pain, phantom sensations and residual limb pain. […] Residual limb pain, or stump pain, is pain at the amputation site, typically near the incision site. […] Neuroma formation is thought to contribute to residual limb pain and can sometimes be felt during examination of the residual limb. […] Neuromas may also be a source of abnormal impulses to the central nervous system, where such input may contribute to central reorganization, which may contribute to the later development of PLP.
#81 An Algorithm Approach to Phantom Limb Pain | JPR
https://www.dovepress.com/an-algorithm-approach-to-phantom-limb-pain-peer-reviewed-fulltext-article-JPR
Phantom limb pain (PLP) is a common condition that occurs following both upper and lower limb amputation. […] To date, however, there is little consensus regarding the optimal management of phantom limb pain. […] Phantom limb pain (PLP), defined as pain in the missing limb, is thought to occur in 60-85% of adult amputees. […] While the association between pre-amputation pain and phantom pain remains unclear, studies consistently demonstrate an association between phantom pain, phantom sensations and residual limb pain. […] Residual limb pain, or stump pain, is pain at the amputation site, typically near the incision site. […] Neuroma formation is thought to contribute to residual limb pain and can sometimes be felt during examination of the residual limb. […] Neuromas may also be a source of abnormal impulses to the central nervous system, where such input may contribute to central reorganization, which may contribute to the later development of PLP.
#82 Residual Limb Pain – Special Subjects – Merck Manual Consumer Version
https://www.merckmanuals.com/home/special-subjects/limb-prosthetics/residual-limb-pain
After an amputation, about 60% of people have pain in the residual limb, which can severely limit function, impair quality of life, and significantly impede rehabilitation. Residual limb pain should be evaluated and treated aggressively, because some causes can be dangerous. […] Persistent residual limb pain is a chronic condition that differs from phantom limb pain and phantom limb sensation. […] Pain due to nerve damage (neuropathic pain) is common. Usually described as a shooting or burning pain, neuropathic pain typically develops within 7 days of amputation. It can go away on its own but is often long-lasting. It can be unrelenting and severe, or intermittent. Nerves may have been damaged from an injury or when they were severed during the amputation. Treatment of neuropathic pain includes psychologic treatments, physical methods, antidepressants, and antiseizure drugs.
#83 Residual Limb Pain – Special Subjects – Merck Manual Consumer Version
https://www.merckmanuals.com/home/special-subjects/limb-prosthetics/residual-limb-pain
After an amputation, about 60% of people have pain in the residual limb, which can severely limit function, impair quality of life, and significantly impede rehabilitation. Residual limb pain should be evaluated and treated aggressively, because some causes can be dangerous. […] Persistent residual limb pain is a chronic condition that differs from phantom limb pain and phantom limb sensation. […] Pain due to nerve damage (neuropathic pain) is common. Usually described as a shooting or burning pain, neuropathic pain typically develops within 7 days of amputation. It can go away on its own but is often long-lasting. It can be unrelenting and severe, or intermittent. Nerves may have been damaged from an injury or when they were severed during the amputation. Treatment of neuropathic pain includes psychologic treatments, physical methods, antidepressants, and antiseizure drugs.
#84 Journal of Rehabilitation Medicine – Effectiveness of phantom exercises for phantom limb pain: A pilot study – HTML
https://www.medicaljournals.se/jrm/content/html/10.2340/16501977-0380
Flor et al. stated that surveys of amputees indicate the ineffectiveness of treatments for PLP that fail to address its underlying mechanisms. Mechanism-based treatments were found to be relatively effective in a few small studies. […] Some researchers have reported that cramping and squeezing phantom sensations reflect muscle tension in the residual limb. Treatments that reduce muscle tension in the residual limb diminish cramping phantom pain. […] A diminishing activation of input from the residual limb might reduce cortical reorganization and so the phantom pain intensity decreases, as stated in some previous studies. […] We can conclude that the ongoing stimulation, muscular training of the stump, and visual feedback from the prosthesis might have a beneficial effect on both cortical reorganization and PLP.
#85 Journal of Rehabilitation Medicine – Effectiveness of phantom exercises for phantom limb pain: A pilot study – HTML
https://www.medicaljournals.se/jrm/content/html/10.2340/16501977-0380
The outcome of our study showed that the phantom exercises that we used for PLP reduced phantom pain intensity. PLP intensity was also diminished in the other group, in which routine prosthetic training was given. […] This indicates that phantom exercises that alter muscle tension and position in the residual limb can influence the intensity of phantom pain. […] In conclusion, phantom exercises appear to be effective in reducing PLP, although there is insufficient evidence about them. The results of this study show that phantom exercises can be used safely to alleviate PLP in lower and upper limb amputees.