04/12/2013 // Concord, CA, USA // LifeCare123 // Greg A. Vigna, M.D., J.D. // (press release)
Medical Perspective:
Sixteen percent of the 185,000 upper-or lower extremity amputations are a result of trauma. A majority of these patients will have post-amputation pain. Historically post-amputation pain has either been characterized as phantom limb pain, residual leg pain or more commonly referred to as stump pain. Reflex sympathetic dystrophy (RSD) is a horrible pain syndrome, which may contribute to both phantom limb pain and residual leg pain. Clinicians need to consider RSD as a cause of pain in patients with disabling chronic pain following an amputation who have failed to improve with standard medication and physical therapy. Further studies are needed to develop best practices in preventing or decreasing the incidence of post-amputation pain in the traumatically injured patient. Phantom limb pain is pain that is in the distribution of the lost extremity. It may be characterized in many different ways. It can be sharp, dull, cramping, shooting. It may be localized to a part of the lost extremity or in its entirety. Phantom limb pain is often constant and is present in up to 50-85% of patients following amputation. Phantom limb pain is very resistant to treatment and its mechanism is not understood. Anesthetic blocks to the affected extremity (a peripheral nerve block) have provided limited improvement because it is believed to be both a central nervous system (brain and spinal cord) and peripheral nervous system problem. Doing regional blocks to the amputated extremity for 72 hours following an operation have been shown to decrease the severity of phantom pain but not the frequency of its occurrence.
Stump pain or residual leg pain can be sharp, dull, burning, and shock like. It many include the stump itself or the entire residual extremity. The clinician must determine the source of the residual leg pain. It may be related to normal post-surgical pain, pain from a joint in the residual extremity, pain from abnormal tissue in the stump, infection, pain referred from the spine, or ischemic pain from a lack of oxygen from impaired circulation. There may also be allodynia which is pain with normal touching which is consistent with sympathetic nervous system mediated pain or RSD. Stump pain may also be caused by a poorly fitting prosthesis. As with phantom limb pain, residual leg pain is also believed to be caused by peripheral nervous system and central nervous system mechanisms.
Pain physicians have recognized that chronic pain is often caused by the sympathetic nervous system. RSD now referred to as Complex Regional Pain Syndrome (CRPS) is a result of a sympathetic nervous system dysfunction. CRPS is subdivided into CRPS Type I that results from soft tissue injury and CRPS Type II which is the result from an identifiable nerve injury. Clearly amputation potentially causes both. A recent study comparing the response to sympathetic nerve blocks in phantom limb pain patients and residual leg pain patients showed a transient improvement in both the phantom limb pain and residual leg pain groups. This suggests that this sympathetic mediated pain mechanism may in some part contribute to both residual leg pain and phantom limb pain.
Standard physical therapy for a patient following an amputation and physical therapy in a patient with CRPS are generally similar. There is an effort in both to facilitate range of motion, desensitize the affected tissue, early and progressive weight-bearing, and increased mobility. Treatment pre-operatively into the early post-amputation period, with regional anesthetic blocks, may allow for more aggressive mobilization that may in fact decrease the severity and the incidence of phantom limb pain and residual leg pain. Certainly further studies are necessary.
What does this mean in clinical practice for the acute traumatically injured patient looks at the possibility of an amputation?
Early regional blocks to the injured extremity pre-operatively with continued use post-operatively for 72 hours, should be considered in a traumatically injured patient. The data is not overwhelming but is supportive that it may decrease the severity of phantom limb pain. Improved pain control in the amputated patient will facilitate early weight-bearing thru the residual extremity with a total contact cast, rapid progression of range of motion, and progressive ambulation which may decrease sympathetically mediated pain.
Life Care Planner Perspective:
A Life Care Plan should include the current and future needs for those whom have suffered a catastrophic injury. It is my experience from 15 years of clinical practice that it is unfortunate when life care planners are not involved early in the medical course of a patient when critical decisions regarding discharge planning, rehabilitation options, and plans for follow up are being made. A life care planner’s role is both as an expert in case management of present and future needs of a patient and as an educator to ensure that the injured patient receives the state of the art care, to ensure the best possible outcome and the prevention of complications. At this early stage it is necessary to provide the family and patient with the frame work for future care which will include the best available acute rehabilitation care, psychological support, future vocational options, equipment needs, and future rehabilitation management. From my experience, it is imperative that a patient be referred to the most skilled and experienced in prosthetics to meet the needs and the mobility and functional goals of a specific patient. A life care planner will also need the plan to take into account issues of aging with a disability and the increase in care that will be necessary as the client ages.
Attorney Prospective:
At an early stage, medical and family support will take precedent over lawsuit related issues. However, it is necessary for a patient and their family to do the following to preserve their rights going forward: 1) Avoid any potentially damaging admissions, 2) Preserve evidence (such as crash scene evidence) for further evaluation, 3) Verify the accuracy of police reports, 4) Obtain contact information from witnesses, and 5) Discuss your situation with an attorney who is experienced in dealing with the complexity of the medical diagnoses and can provide competent representation in the matter.
Media Contact:
Catastrophic Injury Lawyers of Life Care Solutions Group
888.990.9410
Media Information:
Address: 1401 Willow Pass Road, Concord, CA 94520
Phone: 888-990-9410
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