History

Fact Explanation
Introduction This syndrome is the persistent sensation of an amputated limb or an organ including the pain which is mostly suffering. Around 60-70% of patients who are amputees suffers from phantom limb. Additionally other parts like breast, tooth and eyes also causes phantom pain following removal. The incidence of phantom limb would be higher and more severe when the amputation is traumatic or with pre-exciting than in elective amputation.[1][2]
Sensation as the amputated limb is existing including the pain. The perception could be pleasurable, numb or painful (Shooting, stabbing, piercing, or burning pain). Just after weaning of the anesthesia 70-75% of amputees will feel the limb is still there. Remaining will feel it in few weeks. The somato-sensory cortex is mapped according to the body parts, so after the amputation the cortex will be reorganized substantially. So the currently accepted mechanism of phantom limb is reorganization of the somato-sensory cortex located in the post central gurus which is also named as the plasticity of central nerves system. Initial hypothesis were related to the local inflammation, irritation and neuroma formation at the amputation stump, which is currently proven as incorrect.[1][3][4]
Perception of different parts of the missing limb is being touched when stroking other parts. This is also secondary to the reorganization of somato sensory cortex.[5]
Attempting to mobilize as usual after the amputation. When the patient feels the limb is still existing they tries to keep the leg on ground and walk. So there may be falls on ground unexpectedly.[1][6]
Trying to scratch the parts of amputated limb. Patients feel as some parts of the amputated limb itchy.[1][7]
The incidence which led for amputation. During traumatic amputation the phantom limb pain is commoner, more vivid, longer and more severe than in elective amputation. This may be due to the greater attention paid to the mutilated limb and existence of pain memories. [2]
Degree of pain before amputation. When the pre-amputaion pain management is poor patients will suffer with more severe phantom limb pain again due to greater attention and pain memories.[1][8]
Warmness, redness, swelling or discharges from the stump. Other than phantom limb pain, local inflammation, cellulitis or trauma of the stump can cause pain and have to be excluded before labeling as phantom pain.[9]
References
  1. SUBEDI B, GROSSBERG GT. Phantom Limb Pain: Mechanisms and Treatment Approaches Pain Res Treat [online] 2011:864605 [viewed 30 September 2014] Available from: doi:10.1155/2011/864605
  2. HOUGHTON AD, NICHOLLS G, HOUGHTON AL, SAADAH E, MCCOLL L. Phantom pain: natural history and association with rehabilitation. Ann R Coll Surg Engl [online] 1994 Jan, 76(1):22-25 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502176
  3. MACIVER K, LLOYD DM, KELLY S, ROBERTS N, NURMIKKO T. Phantom limb pain, cortical reorganization and the therapeutic effect of mental imagery Brain [online] 2008 Aug, 131(8):2181-2191 [viewed 30 September 2014] Available from: doi:10.1093/brain/awn124
  4. RAMACHANDRAN VS. Consciousness and body image: lessons from phantom limbs, Capgras syndrome and pain asymbolia. Philos Trans R Soc Lond B Biol Sci [online] 1998 Nov 29, 353(1377):1851-1859 [viewed 30 September 2014] Available from: doi:10.1098/rstb.1998.0337
  5. SCHMALZL L, THOMKE E, RAGNö C, NILSERYD M, STOCKSELIUS A, EHRSSON HH. "Pulling Telescoped Phantoms Out of the Stump": Manipulating the Perceived Position of Phantom Limbs Using a Full-Body Illusion Front Hum Neurosci [online] :121 [viewed 30 September 2014] Available from: doi:10.3389/fnhum.2011.00121
  6. HSU E, COHEN SP. Postamputation pain: epidemiology, mechanisms, and treatment J Pain Res [online] :121-136 [viewed 30 September 2014] Available from: doi:10.2147/JPR.S32299
  7. HELMCHEN C, PALZER C, MüNTE TF, ANDERS S, SPRENGER A. Itch Relief by Mirror Scratching. A Psychophysical Study PLoS One [online] , 8(12):e82756 [viewed 30 September 2014] Available from: doi:10.1371/journal.pone.0082756
  8. KNOTKOVA H, CRUCIANI RA, TRONNIER VM, RASCHE D. Current and future options for the management of phantom-limb pain J Pain Res [online] :39-49 [viewed 30 September 2014] Available from: doi:10.2147/JPR.S16733
  9. FALCONER MA. Surgical Treatment of Intractable Phantom-limb Pain Br Med J [online] 1953 Feb 7, 1(4805):299-304 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2015794

Examination

Fact Explanation
Absence of features of inflammation, trauma, infection or neuroma formation at the site of stump. The local pathologies causing pain at amputation stump first has to be excluded. Redness, warmness, wound dehisence, purulent discharges usually excludes features of inflammation and infection. Evidence of trauma has to be excluded by inspection and palpation. Neuroma formation at the nerve endings has to excluded. Tapping over the suspected neuroma may aggravate the pain and that sign would be beneficial in detecting a neuroma.[1][2]
Pulse has to examined proximal to the stump. Ischaemia of the could cause pain and has to be excluded before labeling as phantom limb.[3]
Sensory examination of the amputation stump and above body parts. Nerve entrapment, nerve plexus involvement and progressive neuropathy can cause neuropathic pain of the stump and has to be excluded[4].
Contractures of the proximal joints. Contractures proximal to the stump may cause painful postures and has to be excluded[5].
Stroking the other parts of body may cause the perception of sensory modalities as in some parts of amputated limb. This is generally due to the reorganization of somatosensory cortex.[6]
Mental state examination To see the associated psychological stress due to the condition.[7]
Fundoscopic examination To see the changes of such as diabetic retinopathy or vasculitis which may be concurrent with limb amputation.[8]
References
  1. BERGER SM. Conservative management of phantom-limb and amputation-stump pain. Ann R Coll Surg Engl [online] 1980 Mar, 62(2):102-105 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC249231
  2. HSU E, COHEN SP. Postamputation pain: epidemiology, mechanisms, and treatment J Pain Res [online] :121-136 [viewed 30 September 2014] Available from: doi:10.2147/JPR.S32299
  3. O'DWYER KJ, EDWARDS MH. The association between lowest palpable pulse and wound healing in below knee amputations. Ann R Coll Surg Engl [online] 1985 Jul, 67(4):232-234 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2497832
  4. BRAUNE S, SCHADY W. Changes in sensation after nerve injury or amputation: the role of central factors. J Neurol Neurosurg Psychiatry [online] 1993 Apr, 56(4):393-399 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1014957
  5. GHOLIZADEH H, ABU OSMAN NA, ESHRAGHI A, ALI S, ARIFIN N, WAN ABAS WA. Evaluation of new suspension system for limb prosthetics Biomed Eng Online [online] :1 [viewed 30 September 2014] Available from: doi:10.1186/1475-925X-13-1
  6. SCHMALZL L, THOMKE E, RAGNö C, NILSERYD M, STOCKSELIUS A, EHRSSON HH. "Pulling Telescoped Phantoms Out of the Stump": Manipulating the Perceived Position of Phantom Limbs Using a Full-Body Illusion Front Hum Neurosci [online] :121 [viewed 30 September 2014] Available from: doi:10.3389/fnhum.2011.00121
  7. FISHER K, HANSPAL RS. Phantom pain, anxiety, depression, and their relation in consecutive patients with amputated limbs: case reports BMJ [online] 1998 Mar 21, 316(7135):903-904 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC28494
  8. VISWANATH K, MCGAVIN DD. Diabetic Retinopathy: Clinical Findings and Management Community Eye Health [online] 2003, 16(46):21-24 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1705856

Differential Diagnoses

Fact Explanation
Psychogenic phantom limb pain A rare entity and is characterized by manifestations of mental and emotional problems[1]. Mental status and emotional status would be non significant in phantom limb unless patient is severely suffering from the condition causing distress[2].
Stump pain As mentioned previously pathologies related to the stump can cause pain and unusual perception of the limb. So the inflammation, infection, neuroma formation, trauma and contracture formation has to excluded or managed appropriately if present[3]. So above manifestations would be absent and inflammatory markers (CRP/ESR) will be normal in phantom limb[4].
Lesions in the nerve roots or nerve plexuses Preexisting or new pathologies at nerve roots, plexuses such as lumbar radicularpathy, plexus inflammation could give rise to neoropathic pain[5]. In phantom limb there want be any neurological deficit and nerve conduction studies should be normal[6].
Ischaemic pain Preexisting or new occlusive arterial disease occurring proximal to the stump may cause ischaemic pain in the stump[7]. In pure phantom limb pain arterial pulsation and arterial duplex findings are normal[1].
References
  1. SUBEDI B, GROSSBERG GT. Phantom Limb Pain: Mechanisms and Treatment Approaches Pain Res Treat [online] 2011:864605 [viewed 28 September 2014] Available from: doi:10.1155/2011/864605
  2. FISHER K, HANSPAL RS. Phantom pain, anxiety, depression, and their relation in consecutive patients with amputated limbs: case reports BMJ [online] 1998 Mar 21, 316(7135):903-904 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC28494
  3. RUSSELL WR, SPALDING JM. Treatment of Painful Amputation Stumps Br Med J [online] 1950 Jul 8, 2(4670):68-73 [viewed 01 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2038293
  4. WOOLF CJ. Central sensitization: Implications for the diagnosis and treatment of pain Pain [online] 2011 Mar, 152(3 Suppl):S2-15 [viewed 01 October 2014] Available from: doi:10.1016/j.pain.2010.09.030
  5. TIPTON JS. Obturator neuropathy Curr Rev Musculoskelet Med [online] , 1(3-4):234-237 [viewed 01 October 2014] Available from: doi:10.1007/s12178-008-9030-7
  6. KNOTKOVA H, CRUCIANI RA, TRONNIER VM, RASCHE D. Current and future options for the management of phantom-limb pain J Pain Res [online] :39-49 [viewed 01 October 2014] Available from: doi:10.2147/JPR.S16733
  7. BEARD JD. Chronic lower limb ischemia West J Med [online] 2000 Jul, 173(1):60-63 [viewed 01 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1070983

Investigations - for Diagnosis

Fact Explanation
Usually the diagnosis is clinically. In post amputation patients the classical symptoms of phantom limb and exclusion of differential diagnosis clinically can justify the diagnosis of phantom limb[4].
Inflammatory markers such as CRP, ESR and WBC/DC to exclude stump inflammation and infection. When there is an ongoing inflammation or infection of the stump the inflammatory markers would be high, whereas in pure phantom limb those are normal[1][2].
Nerve conduction studies to exclude regional nerve pathologies. In root lesions, plexus lesions and nerve entrapment cases the nerve conduction findings will be useful to diagnose the lesion. In pure phantom limb pain there should not be a neurological deficit[3].
Imaging such as CECT or MRI to exclude spinal and root lesions. Imaging would be normal in phantom limb whereas spinal and root lesions will show the changes in imaging[3][5].
Arterial duplex to exclude proximal arterial occlusion. When the clinical picture is suggestive of an ischaemic pain duplex studies would be beneficial[6].
Magnetoencephalogram for research purposes can be used though not practiced in clinical management. It shows the mapping of the cerebral cortex and presents the findings after the reorganization of the somatosensory cortex[7].
References
  1. WOOLF CJ. Central sensitization: Implications for the diagnosis and treatment of pain Pain [online] 2011 Mar, 152(3 Suppl):S2-15 [viewed 01 October 2014] Available from: doi:10.1016/j.pain.2010.09.030
  2. HSU E, COHEN SP. Postamputation pain: epidemiology, mechanisms, and treatment J Pain Res [online] :121-136 [viewed 01 October 2014] Available from: doi:10.2147/JPR.S32299
  3. KNOTKOVA H, CRUCIANI RA, TRONNIER VM, RASCHE D. Current and future options for the management of phantom-limb pain J Pain Res [online] :39-49 [viewed 01 October 2014] Available from: doi:10.2147/JPR.S16733
  4. SUBEDI B, GROSSBERG GT. Phantom Limb Pain: Mechanisms and Treatment Approaches Pain Res Treat [online] 2011:864605 [viewed 01 October 2014] Available from: doi:10.1155/2011/864605
  5. ERGUN T, LAKADAMYALI H. CT and MRI in the evaluation of extraspinal sciatica Br J Radiol [online] 2010 Sep, 83(993):791-803 [viewed 01 October 2014] Available from: doi:10.1259/bjr/76002141
  6. BEARD JD. Chronic lower limb ischemia West J Med [online] 2000 Jul, 173(1):60-63 [viewed 01 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1070983
  7. CONNOLLY AT, BAJWA JA, JOHNSON MD. Cortical magnetoencephalography of deep brain stimulation for the treatment of postural tremor Brain Stimul [online] 2012 Oct, 5(4):616-624 [viewed 01 October 2014] Available from: doi:10.1016/j.brs.2011.11.006

Investigations - Fitness for Management

Fact Explanation
Fasting blood sugar or HbA1c To see the glycaemic control or occurrence of diabetes in amputees[1].
Full blood count To see the anaemia with Haemoglobin count and WBC count to see any ongoing infection[2][3].
Arterial duplex of the proximal arteries To assess the perfusion of the stump[4].
Serum creatinine and electrolytes To assess the renal status especially if the patient is having complicated diabetes mmellitus[5].
2D echo cardiogram To assess the cardiac status of the amputee for patient's functional capacity as well as for any invasive procedures[6].
Ultra sound scan of the abdomen To exclude abdominal aortic aneurysm, if suspected to be the(pheripheral arterial disease) cause for amputation[7].
Imaging such as lumbar spine X ray To occurrence of deformities due to changing of the gait pattern[8].
References
  1. GHAZANFARI Z, HAGHDOOST AA, ALIZADEH SM, ATAPOUR J, ZOLALA F. A Comparison of HbA1c and Fasting Blood Sugar Tests in General Population Int J Prev Med [online] 2010, 1(3):187-194 [viewed 01 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3075530
  2. ZHU A, KANESHIRO M, KAUNITZ JD. Evaluation and Treatment of Iron Deficiency Anemia: A Gastroenterological Perspective Dig Dis Sci [online] 2010 Mar, 55(3):548-559 [viewed 01 October 2014] Available from: doi:10.1007/s10620-009-1108-6
  3. NIXON DF, PARSONS AJ, EGLIN RP. Routine full blood counts as indicators of acute viral infections. J Clin Pathol [online] 1987 Jun, 40(6):673-675 [viewed 01 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1141060
  4. BEARD JD. Chronic lower limb ischemia West J Med [online] 2000 Jul, 173(1):60-63 [viewed 01 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1070983
  5. SAKA W, AKHIGBE R, POPOOLA O, OYEKUNLE O. Changes in Serum Electrolytes, Urea, and Creatinine in Aloe Vera-treated Rats J Young Pharm [online] 2012, 4(2):78-81 [viewed 01 October 2014] Available from: doi:10.4103/0975-1483.96620
  6. SPETHMANN S, RIEPER K, RIEMEKASTEN G, BORGES AC, SCHATTKE S, BURMESTER GR, HEWING B, BAUMANN G, DREGER H, KNEBEL F. Echocardiographic follow-up of patients with systemic sclerosis by 2D speckle tracking echocardiography of the left ventricle Cardiovasc Ultrasound [online] :13 [viewed 01 October 2014] Available from: doi:10.1186/1476-7120-12-13
  7. GRAHAM M, CHAN A. Ultrasound screening for clinically occult abdominal aortic aneurysm. CMAJ [online] 1988 Apr 1, 138(7):627-629 [viewed 01 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1267741
  8. ALLAN GM, SPOONER GR, IVERS N. X-ray scans for nonspecific low back pain: A nonspecific pain? Can Fam Physician [online] 2012 Mar, 58(3):275 [viewed 01 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3303649

Investigations - Followup

Fact Explanation
Fasting blood sugar or HbA1c To see the ongoing glycaemic control or occurrence of diabetes mellitus[1].
Inflammatory markers such as ESR or CRP To screen for any ongoing inflammation or infection which may affect the healthiness of the stump[2][3].
Full blood count To see the anaemia which may impede the healthiness of the stump as well as the general well being. WBC cout will be increase during an infection[4][5].
X ray of lumbar and cervical spine The deformities in the spine are possible due to altered postures and gait pattern following amputation[6][7].
2D echocardiogram The cardiac status should be in an optimal status for the patient to be mobilized adequetly with the amputation, thereforee the cardiac assessment should be there in the follow up[8].
References
  1. GHAZANFARI Z, HAGHDOOST AA, ALIZADEH SM, ATAPOUR J, ZOLALA F. A Comparison of HbA1c and Fasting Blood Sugar Tests in General Population Int J Prev Med [online] 2010, 1(3):187-194 [viewed 01 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3075530
  2. WOOLF CJ. Central sensitization: Implications for the diagnosis and treatment of pain Pain [online] 2011 Mar, 152(3 Suppl):S2-15 [viewed 01 October 2014] Available from: doi:10.1016/j.pain.2010.09.030
  3. HSU E, COHEN SP. Postamputation pain: epidemiology, mechanisms, and treatment J Pain Res [online] :121-136 [viewed 01 October 2014] Available from: doi:10.2147/JPR.S32299
  4. ZHU A, KANESHIRO M, KAUNITZ JD. Evaluation and Treatment of Iron Deficiency Anemia: A Gastroenterological Perspective Dig Dis Sci [online] 2010 Mar, 55(3):548-559 [viewed 01 October 2014] Available from: doi:10.1007/s10620-009-1108-6
  5. NIXON DF, PARSONS AJ, EGLIN RP. Routine full blood counts as indicators of acute viral infections. J Clin Pathol [online] 1987 Jun, 40(6):673-675 [viewed 01 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1141060
  6. PARIZEL PM, VAN DER ZIJDEN T, GAUDINO S, SPAEPEN M, VOORMOLEN MH, VENSTERMANS C, DE BELDER F, VAN DEN HAUWE L, VAN GOETHEM J. Trauma of the spine and spinal cord: imaging strategies Eur Spine J [online] 2010 Mar, 19(Suppl 1):8-17 [viewed 01 October 2014] Available from: doi:10.1007/s00586-009-1123-5
  7. ALLAN GM, SPOONER GR, IVERS N. X-ray scans for nonspecific low back pain: A nonspecific pain? Can Fam Physician [online] 2012 Mar, 58(3):275 [viewed 01 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3303649
  8. SPETHMANN S, RIEPER K, RIEMEKASTEN G, BORGES AC, SCHATTKE S, BURMESTER GR, HEWING B, BAUMANN G, DREGER H, KNEBEL F. Echocardiographic follow-up of patients with systemic sclerosis by 2D speckle tracking echocardiography of the left ventricle Cardiovasc Ultrasound [online] :13 [viewed 01 October 2014] Available from: doi:10.1186/1476-7120-12-13

Management - General Measures

Fact Explanation
Health education and improve the awareness about the syndrome in patients. The education and improving the awareness regarding the phantom limb phenomena is utmost important pre-operatively. Patient should be advised about the possibility and features of amputation so then the occurrence of that will be an expected one for the patient. Other than that the patient should be emphasized about the risk of getting phatom limb syndrome such as having falls while trying to get up thinking the amputated limb is still there. Not only above patient should be thoroughly aware regarding the options which are there to minimize the phantom limb syndrome[1][2].
Prevention of falls following immediate and early post operative periods. High risk of falls should be expected and prevented. Methods available would be keeping the by stander, keeping on a bar bed][3][4].
Psychological support. Having an amputated limb and feeling of it's existence would be depressing with the background of limb loss and disability. So it should be properly addressed. Family support also should be in hand to hand[2][5].
Arrange early rehabilitation. Rehabilitation such as physio therapy, arranging walking aids or prosthesis should be addressed[6][7].
Pre operative optimal pain management. When the pre and peri operative pain management is poor there is a high incidence of getting a more severe phantom limb pain. So the maximum pain management during pre and perioperative period would be more important.[5][6]
References
  1. SUBEDI B, GROSSBERG GT. Phantom Limb Pain: Mechanisms and Treatment Approaches Pain Res Treat [online] 2011:864605 [viewed 30 September 2014] Available from: doi:10.1155/2011/864605
  2. DE ROOS C, VEENSTRA A, DE JONGH A, DEN HOLLANDER-GIJSMAN M, VAN DER WEE N, ZITMAN F, VAN ROOD Y. Treatment of chronic phantom limb pain using a trauma-focused psychological approach Pain Res Manag [online] 2010, 15(2):65-71 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886995
  3. HSU E, COHEN SP. Postamputation pain: epidemiology, mechanisms, and treatment J Pain Res [online] :121-136 [viewed 30 September 2014] Available from: doi:10.2147/JPR.S32299
  4. BURGOYNE LL, BILLUPS CA, JIRóN JL JR, KADDOUM RN, WRIGHT BB, BIKHAZI GB, PARISH ME, PEREIRAS LA. Phantom limb pain in young cancer-related amputees: Recent experience at St. Jude Children's Research Hospital Clin J Pain [online] 2012, 28(3):222-225 [viewed 30 September 2014] Available from: doi:10.1097/AJP.0b013e318227ce7a
  5. SUBEDI B, GROSSBERG GT. Phantom Limb Pain: Mechanisms and Treatment Approaches Pain Res Treat [online] 2011:864605 [viewed 30 September 2014] Available from: doi:10.1155/2011/864605
  6. KNOTKOVA H, CRUCIANI RA, TRONNIER VM, RASCHE D. Current and future options for the management of phantom-limb pain J Pain Res [online] :39-49 [viewed 30 September 2014] Available from: doi:10.2147/JPR.S16733
  7. KNOTKOVA H, CRUCIANI RA, TRONNIER VM, RASCHE D. Current and future options for the management of phantom-limb pain J Pain Res [online] :39-49 [viewed 30 September 2014] Available from: doi:10.2147/JPR.S16733
  8. BHUVANESWAR CG, EPSTEIN LA, STERN TA. Reactions to Amputation: Recognition and Treatment Prim Care Companion J Clin Psychiatry [online] 2007, 9(4):303-308 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2018851

Management - Specific Treatments

Fact Explanation
Pharmacological management with analgesic effect Analgesics should be added according to the analgesics ladder. 1) Paracetamol and NSAIDs : widely used over the counter drugs and simple pain could be managed. They decreases the the nociception in central and peripheral nervous system. Side effect profile mainly would be gastric irritation and renal impairment in long term use. 2) Antidepressants : mainly tricyclic anti depressants such as amitriptyllin are widely used. Side effects of them mainly the drowsiness will be beneficial in managing pain at nigh causing sleep deprivation. Other anti depressants would be serotonin-norepinephrine re-uptake inhibitors such as duloxetine. 3) Anti-convulsants : Anti-convulsants such as gabapentin and lamotrigine is beneficial in managing neuropathic pains including phantom limb pain. 4) Opioid and tramadol also has evidence in managing phantom limb pain[1][2].
Non invasive treatment options Other than pharmacological options there are non invasive treatment modalities which could be supportive. Those are repetitive transcranial magnetic stimulation, visual feedback, or motor imagery[3][4].
Invasive treatment modalities In resistant cases there are invasive modalities which can be beneficial. Those are Surgical destructive interventions and nerve blocks, Invasive neuromodulation, Deep brain stimulation, Motor cortex stimulation and Spinal cord stimulation[3][5].
References
  1. DE ROOS C, VEENSTRA A, DE JONGH A, DEN HOLLANDER-GIJSMAN M, VAN DER WEE N, ZITMAN F, VAN ROOD Y. Treatment of chronic phantom limb pain using a trauma-focused psychological approach Pain Res Manag [online] 2010, 15(2):65-71 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886995
  2. SUBEDI B, GROSSBERG GT. Phantom Limb Pain: Mechanisms and Treatment Approaches Pain Res Treat [online] 2011:864605 [viewed 30 September 2014] Available from: doi:10.1155/2011/864605
  3. KNOTKOVA H, CRUCIANI RA, TRONNIER VM, RASCHE D. Current and future options for the management of phantom-limb pain J Pain Res [online] :39-49 [viewed 30 September 2014] Available from: doi:10.2147/JPR.S16733
  4. VUCKOVIC A, HASAN MA, FRASER M, CONWAY BA, NASSEROLESLAMI B, ALLAN DB. Dynamic Oscillatory Signatures of Central Neuropathic Pain in Spinal Cord Injury J Pain [online] 2014 Jun, 15(6):645-655 [viewed 30 September 2014] Available from: doi:10.1016/j.jpain.2014.02.005
  5. KIM SY, KIM YY. Mirror Therapy for Phantom Limb Pain Korean J Pain [online] 2012 Oct, 25(4):272-274 [viewed 30 September 2014] Available from: doi:10.3344/kjp.2012.25.4.272