Skip to main content
Egyptian Rheumatology and Rehabilitation
Download PDF
  • Original Article
  • Open access
  • Published:

Treatment of phantom pain with contralateral injection into tender points: a new method of treatment

Egyptian Rheumatology and Rehabilitation volume 42, pages 103–110 (2015)Cite this article

Abstract

Objective

The aim of this study was to ascertain the existence of contralateral painful muscle areas mirroring phantom pain and to evaluate the short-term effects of anaesthetics versus saline, injected contralaterally to control phantom and phantom limb pain.

Design

This was a double-blinded cross-over study.

Participants

This study included eight lower-limb amputees with phantom limb pain in the past 6 months.

Interventions

Either 1 ml of 0.25% bupivacaine or 0.9% saline was injected alternately in each point with a 28-G needle, with 72 h between injections. The main outcomes measured were phantom sensation modification and the intensity of phantom limb pain (visual analogue scale) before and after injections.

Results

Painful muscle areas in the healthy limb do not mirror the topographical distribution of phantom limb pain. At 60 min after the injection, a statistically significantly greater relief of phantom limb pain was observed after using a local anaesthetic compared with that when using saline injection (P = 0.003). Bupivacaine consistently reduced/abolished the phantom sensation in six out of eight patients. These effects on phantom sensation were not observed after saline injections.

Conclusion

Contralateral injections of 1 ml of 0.25% bupivacaine in the myofascial hyperalgesic areas attenuated phantom limb pain and affected phantom limb sensation. Our study gives a basis of a new method of management of that kind of severe pain to improve the method of rehabilitation of amputee. However, further longitudinal studies with larger number of patients are needed to confirm our study.

References

  1. Hsu E, Cohen SP. Postamputation pain: epidemiology, mechanisms, and treatment. J Pain Res 2013; 6:121–36.

    PubMed  PubMed Central  Google Scholar 

  2. Casale R, Maini M, Bettinardi O, Labeeb A, Rosati V, Damiani C, Mallik M. Motor and sensory rehabilitation after lower limb amputation: state of art and perspective of change. G Ital Med Lav Ergon 2013; 35:51–60.

    PubMed  Google Scholar 

  3. Subedi B, Grossberg GT. Phantom limb pain: mechanisms and treatment approaches. Pain Res Treat 2011; 2011:864605.

    Google Scholar 

  4. Zheng Z, Hu Y, Tao W, Zhang X, Li Y. Dorsal root entry zone lesions for phantom limb pain with brachial plexus avulsion: a study of pain and phantom limb sensation. Stereotact Funct Neurosurg 2009; 87:249–55.

    PubMed  Google Scholar 

  5. Viswanathan A, Phan PC, Burton AW. Use of spinal cord stimulation in the treatment of phantom limb pain: case series and review of the literature. Pain Pract 2010; 10:479–84.

    PubMed  Google Scholar 

  6. Mulvey MR, Radford HE, Fawkner HJ, Hirst L, Neumann V, Johnson MI. Transcutaneous electrical nerve stimulation for phantom pain and stump pain in adult amputees. Pain Pract 2013; 13:289–96.

    PubMed  Google Scholar 

  7. Davies A. Acupuncture treatment of phantom limb pain and phantom limb sensation in a primary care setting. Acupunct Med 2013; 31:101–4.

    PubMed  Google Scholar 

  8. Ilfeld BM, Moeller-Bertram T, Hanling SR, Tokarz K, Mariano ER, Loland VJ, et al. Treating intractable phantom limb pain with ambulatory continuous peripheral nerve blocks: a pilot study. Pain Med 2013; 14:935–42.

    PubMed  Google Scholar 

  9. Bradbrook D. Acupuncture treatment of phantom limb pain and phantom limb sensation in amputees. Acupunct Med 2004; 22:93–7.

    PubMed  Google Scholar 

  10. Jacobs M, Niemtzow R. Treatment of phantom limb pain with laser and needle auricular acupuncture: a case report. Med Acupunct 2011; 23:57–60.

    Google Scholar 

  11. Mannix S, O’Sullivan C, Kelly G. Acupuncture for managing phantom-limb syndrome: a systematic review. Med Acupunct 2013; 25:23–42.

    Google Scholar 

  12. Gross D. Contralateral local anaesthesia in the treatment of postamputation pain. In: Siegfried J, Zimmermann M, editors Phantom and stump pain Berlin: Springer-Verlag 1981;107–107.

    Google Scholar 

  13. Moseley GL, Gallace A, Spence C. Bodily illusions in health and disease: physiological and clinical perspectives and the concept of a cortical ‘body matrix’. Neurosci Biobehav Rev 2012; 36:34–46.

    PubMed  Google Scholar 

  14. Carabelli RA, Kellerman WC. Phantom limb pain: relief by application of TENS to contralateral extremity. Arch Phys Med Rehabil 1985; 66:466–7.

    CAS  PubMed  Google Scholar 

  15. Gross D. Contralateral local anaesthesia in the treatment of phantom limb and stump pain. Pain 1982; 13:313–20.

    CAS  PubMed  Google Scholar 

  16. Gross D. Contralateral local anesthesia in stump, phantom and post-traumatic pain. Reg Anaesth 1984; 7:65–73.

    CAS  PubMed  Google Scholar 

  17. Flöter T. Pain management by contralateral local anaesthesia. Acupunct Electrother Res 1983; 8:139–42.

    PubMed  Google Scholar 

  18. Koltzenburg M, Wall PD, McMahon SB. Does the right side know what the left is doing? Trends Neurosci 1999; 22:122–7.

    CAS  PubMed  Google Scholar 

  19. Dostrovsky JO. Ascending spinal and trigeminal nociceptive pathways. In: Justins DM, editor Pain 2005 – an updated review: refresher course syllabus. Seattle: IASP Press; 2005. 43–48.

    Google Scholar 

  20. Sindrup SH, Jensen TS. Efficacy of pharmacological treatments of neuropathic pain: an update and effect related to mechanism of drug action. Pain 1999; 83:389–400.

    CAS  PubMed  Google Scholar 

  21. Iacono RP, Sandyk R, Baumford CR, Awerbuch G, Malone JM. Post– amputation phantom pain and autonomous stump movements responsive to doxepin. Funct Neurol 1987; 2:343–8.

    CAS  PubMed  Google Scholar 

  22. Bartusch SL, Sanders BJ, D’Alessio JG, Jernigan JR. Clonazepam for the treatment of lancinating phantom limb pain. Clin J Pain 1996; 12:59–62.

    CAS  PubMed  Google Scholar 

  23. Elliott F, Little A, Milbrandt W. Carbamazepine for phantom-limb phenomena. N Engl J Med 1976; 295:678.

    CAS  PubMed  Google Scholar 

  24. Patterson JF. Carbamazepine in the treatment of phantom limb pain. South Med J 1988; 81:1100–2.

    CAS  PubMed  Google Scholar 

  25. Rasmussen KG, Rummans TA. Electroconvulsive therapy for phantom limb pain. Pain 2000; 85:297–9.

    CAS  PubMed  Google Scholar 

  26. Saris SC, Iacono RP, Nashold BS Jr. Successful treatment of phantom pain with dorsal root entry zone coagulation. Appl Neurophysiol 1988; 51:188–97.

    CAS  PubMed  Google Scholar 

  27. Travell J. Myofascial trigger points: a clinical view. In: Bonica JJ, Albe-Fessard D, editors Advances in pain research and therapy New York: Raven Press 1976;919–26.

    Google Scholar 

  28. Kazemi H, Ghassemi S, Fereshtehnejad SM, Amini A, Kolivand PH, Doroudi T. Anxiety and depression in patients with amputated limbs suffering from phantom pain: a comparative study with non-phantom chronic pain. Int J Prev Med 2013; 4:218–25.

    PubMed  PubMed Central  Google Scholar 

  29. Kooijman CM, Dijkstra PU, Geertzen JH, Elzinga A, van der Schans CP. Phantom pain and phantom sensations in upper limb amputees: an epidemiological study. Pain 2000; 87:33–41.

    CAS  PubMed  Google Scholar 

  30. Malavera Angarita M, Carrillo Villa S, Gomezese Ribero O, García R, Silva Sieger F. Pathophysiology and treatment of phantom limb pain. Colomb J Anesthesiol 2014; 42:40–46.

    Google Scholar 

  31. Sunderland S. The treatment of pain and related abnormal sensory phenomena associated with amputation stump. In: Sunderland S, editors. Nerves and nerve injuries. 2nd ed. Baltimore: William & Wilkins 1978; 448–458.

    Google Scholar 

  32. Henderson WR, Smyth GE. Phantom limbs. J Neurol Neurosurg Psychiatry 1948; 11:88–112.

    CAS  PubMed  PubMed Central  Google Scholar 

  33. Frost FA, Jessen B, Siggaard-Andersen J. A control, double-blind comparison of mepivacaine injection versus saline injection for myofascial pain. Lancet 1980; 1:499–500.

    CAS  PubMed  Google Scholar 

  34. Tashani O, Johnson M. Transcutaneous electrical nerve stimulation (TENS). A possible aid for pain relief in developing countries?. Libyan J Med 2009; 4:62–5.

    CAS  PubMed  PubMed Central  Google Scholar 

  35. DeSantana JM, Walsh DM, Vance C, Rakel BA, Sluka KA. Effectiveness of transcutaneous electrical nerve stimulation for treatment of hyperalgesia and pain. Curr Rheumatol Rep 2008; 10:492–9.

    Google Scholar 

  36. Buonocore M, Camuzzini N, Cecini M, Dalla Toffola E. High-frequency transcutaneous peripheral nerve stimulation induces a higher increase of heat pain threshold in the cutaneous area of the stimulated nerve when confronted to the neighbouring areas. Biomed Res Int 2013; 2013:464207.

    Google Scholar 

  37. Pfab F, Kirchner MT, Huss-Marp J, Schuster T, Schalock PC, Fuqin J, et al. Acupuncture compared with oral antihistamine for type I hypersensitivity itch and skin response in adults with atopic dermatitis: a patient- and examiner-blinded, randomized, placebo-controlled, crossover trial. Allergy 2012; 67:566–73.

    CAS  PubMed  Google Scholar 

  38. Gorenberg M, Schwartz K. Imaging-guided hyperstimulation analgesia in low back pain. J Pain Res 2013; 6:487-91.

    PubMed  PubMed Central  Google Scholar 

  39. Saris SC, Iacono RP, Nashold BS Jr. Dorsal root entry zone lesions for post-amputation pain. J Neurosurg 1985; 62:72–6.

    CAS  PubMed  Google Scholar 

  40. Martin G, Grant SA, Macleod DB, Breslin DS, Brewer RP. Severe phantom leg pain in an amputee after lumbar plexus block. Reg Anesth Pain Med 2003; 28:475–8.

    PubMed  Google Scholar 

  41. Nathan PW, Noordenbos W, Wall PD Ongoing activity in peripheral nerve: interactions between electrical stimulation and ongoing activity. Exp Neurol 1973; 38:90–8.

    CAS  PubMed  Google Scholar 

  42. Acerra NE, Souvlis T, Moseley GL. Stroke, complex regional pain syndrome and phantom limb pain: can commonalities direct future management?. J Rehabil Med 2007; 39:109–14.

    PubMed  Google Scholar 

  43. Acerra NE, Moseley GL. Dysynchiria: watching the mirror image of the unaffected limb elicits pain on the affected side. Neurology 2005; 65:751–3.

    PubMed  Google Scholar 

  44. Bausbaum A, Bushnell MC, Devor M. Pain: basic mechanisms. In: Justins DM, editor Pain 2005 – an updated review. Seattle: IASP Press 2005; 3–9.

    Google Scholar 

  45. McLachlan EM, Janig W, Devor M, Michaelis M. Peripheral nerve injury triggers noradrenergic sprouting within dorsal root ganglia. Nature 1993; 363:543–6.

    CAS  PubMed  Google Scholar 

  46. Milligan ED, Twining C, Chacur M, Biedenkapp J, O’Connor K, Poole S, et al. Spinal glia and proinflammatory cytokines mediate mirror-image neuropathic pain in rats. J Neurosci 2003; 23:1026–40.

    CAS  PubMed  PubMed Central  Google Scholar 

  47. Watkins LR, Maier SF. Beyond neurons: evidence that immune and glial cells contribute to pathological pain states. Physiol Rev 2002; 82:981–1011.

    CAS  PubMed  Google Scholar 

  48. Fukumoto M, Ushida T, Zinchuk VS, Yamamoto H, Yoshida S. Contralateral thalamic perfusion in patients with reflex sympathetic dystrophy syndrome. Lancet 1999; 354:1790–1.

    CAS  PubMed  Google Scholar 

  49. Flor H, Elbert T, Knecht S, Wienbruch C, Pantev C, Birbaumer N, et al. Phantom-limb pain as a perceptual correlate of cortical reorganization following arm amputation. Nature 1995; 375:482–4.

    CAS  PubMed  Google Scholar 

  50. Grüsser SM, Mühlnickel W, Schaefer M, Villringer K, Christmann C, Koeppe C, Flor H. Remote activation of referred phantom sensation and cortical reorganization in human upper extremity amputees. Exp Brain Res 2004; 154:97–102.

    PubMed  Google Scholar 

  51. Ramachandran VS. A brief tour of human consciousness: from impostor poodles to purple numbers. New York: PI Press; 2004.

    Google Scholar 

  52. Knecht S, Henningsen H, Elbert T, Flor H, Höhling C, Pantev C, Taub E Reorganizational and perceptional changes after amputation. Brain 1996; 119:1213–9.

    Google Scholar 

  53. Gandevia SC, Phegan CM. Perceptual distortions of the human body image produced by local anaesthesia, pain and cutaneous stimulation. J Physiol 1999; 514:609–16.

    CAS  PubMed  PubMed Central  Google Scholar 

  54. Melzack R. Evolution of the neuromatrix theory of pain. The Prithvi Raj lecture: presented at the third world congress of world institute of pain, Barcelona 2005. Pain Pract 2005; 5:85–94.

    PubMed  Google Scholar 

  55. Giummarra MJ, Gibson SJ, Georgiou-Karistianis N, Bradshaw JL. Central mechanisms in phantom limb perception: the past, present and future. Brain Res Rev 2007; 54:219–32.

    PubMed  Google Scholar 

  56. Iannetti GD, Mouraux A. From the neuromatrix to the pain matrix (and back). Exp Brain Res 2010; 205:1–12.

    CAS  PubMed  Google Scholar 

  57. Derbyshire SW. Exploring the pain ‘neuromatrix’. Curr Rev Pain 2000; 4:467–77.

    CAS  PubMed  Google Scholar 

  58. Bileviciute-Ljungar I, Biella G, Bellomi P, Sotgiu ML. Contralateral treatment with lidocaine reduces spinal neuronal activity in mononeuropathic rats. Neurosci Lett 2001; 311:157–60.

    CAS  PubMed  Google Scholar 

  59. Sotgiu ML, Biella GE. NMDA and strychnine diversely modulate spinal dorsal horn noxious responsiveness in normal rats: potential significance to sensory disorders in neuropathic pain. Somatosens Mot Res 2002; 19:18–23.

    PubMed  Google Scholar 

  60. Sotgiu ML, Biella G. Contribution of central sensitization to the pain-related abnormal activity in neuropathic rats. Somatosens Mot Res 2000; 17:32–8.

    CAS  PubMed  Google Scholar 

  61. Ji RR, Kohno T, Moore KA, Woolf CJ. Central sensitization and LTP: do pain and memory share similar mechanisms? Trends Neurosci 2003; 26:696–705.

    CAS  PubMed  Google Scholar 

  62. Collingridge GL, Isaac JTR, Wang YT. Receptor trafficking and synaptic plasticity. Nat Rev 2004; 5:952–62.

    CAS  Google Scholar 

  63. Verley R. Reorganization of the somatosensory cerebral cortex after peripheral damage. NIPS 1986; 1:15–9.

    Google Scholar 

  64. Frot M, Mauguière F. Dual representation of pain in the operculo-insular cortex in humans. Brain 2003; 126 (Pt 2):438–50.

    PubMed  Google Scholar 

  65. Won R, Jung SJ, Park YG, Chung SS, Lee BH. Crossed-withdrawal reflex in a rat model of neuropathic pain: implications in neural plasticity. Neurosci Lett 369:2004; 239–44.

    CAS  PubMed  Google Scholar 

  66. Friel KM, Martin JH. Bilateral activity-dependent interactions in the developing corticospinal system. J Neurosci 2007; 27:11083–90.

    CAS  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Physical Medicine and Rehabilitation, Menoufia University, Menoufia, Egypt

    Alaa A. El Aziz Labeeb PhD

  2. Pain Unit, Department of Neurorehabilitation, Scientific Institute of Montescano, Salvatore Maugeri Foundation, Montescano, Pavia, Italy

    Roberto Casale

Authors
  1. Alaa A. El Aziz Labeeb PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Roberto Casale
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Alaa A. El Aziz Labeeb PhD.

Additional information

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

Rights and permissions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

El Aziz Labeeb, A.A., Casale, R. Treatment of phantom pain with contralateral injection into tender points: a new method of treatment. Egypt Rheumatol Rehabil 42, 103–110 (2015). https://doi.org/10.4103/1110-161X.163929

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.4103/1110-161X.163929

Keywords