Case of the month #10: Phantom pain following trauma

The specialist physiotherapist addressed Mr S worries about phantom pain, explaining the underlying mechanism.  Mr S admitted to being worried about his mental state in particular why he could still feel his amputated limb and why it still hurt. Explanations about the underlying pathophysiology helped to alleviate some of these anxieties.  Mr S was taken through a “return to fitness and confidence” exercise programme.  Desensitisation techniques were used to try and reduce and help manage stump pain.  Graded motor imagery was used to try and improve the impact of the phantom pain.

The specialist occupational therapist helped Mr S in day-to-day practical requirements, ensuring that his home environment was suitable to his needs. Home assessments and improvement were made.  Mr S was put into contact with a charity that helps patients with a disability return back to driving. He lived in a very rural environment and despite the impact of the trauma did express a wish to return back to driving in order to return his life back to as normal as possible.

The Clinical Psychologist started sessions to try and help address the impact the accident had had on Mr S.  They used a combination of Acceptance and Commitment Therapy, bereavement therapy and EMDR (Eye movement, desensitisation and reprocessing therapy) to address this.  Therapy was given in parallel with support from the Well Being (Mental Health) Service and conjoint working by the two services helped to address the post traumatic stress disorder, grief and resulted in a significant reduction in levels of anxiety and depression, better sleep and improved sense of well being and function. After several individual sessions, Mr S was enrolled on a pain management programme which further helped to reinforce his pain management strategies and level of functioning.

Mr S was also reviewed in a medicines optimisation clinic by one of the Pain Medicine consultants.  It was evident that despite the high dose of opioids that he was on, Mr S’s pain was not controlled.  The opioids had escalated rapidly during his prolonged in patient stay and he had been discharged on this dose and remained on it despite no subjective report of any benefit. He was experiencing significant sided effects and after a frank discussion about the risks of opioids and their ineffectiveness in his pain management, he agreed to reduce the dose slowly by 5mg twice daily every fortnight.  He successfully and steadily managed to wean off without experiencing any significant withdrawal symptoms.

Once his mood was stabilised with ongoing multimodal therapy, he was advised to wean off Fluoxetine and introduce Duloxetine.  This was to see whether he would benefit from the anti-neuropathic pain effect of this drug, whilst also benefiting from its antidepressant effect.  The dose of Duloxetine was increased up to 60mg twice daily and did help to reduce some of the pain in his stump.  Prior to this Lidocaine 5% plasters had been used in an unlicensed indication to help with the stump pain and this together with the desensitization therapy had helped Mr S to be fitted with and start wearing a prosthesis. Wearing a prosthesis is recognised as being contributory towards reducing phantom pain.

Later in his journey through the Pain Service, Mr S was also helped to return to work with support provided through the specialist occupational therapist with modifications made by his employer to allow safe access to work in accordance with legislation requirements.