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Level II). No preventive effect of perioperative ketamine given by the epidural route was
reported in another study (Wilson et al, 2008 Level II).
Perioperative gabapentin was ineffective in reducing incidence and severity of phantom limb
pain (Nikolajsen et al, 2006 Level II).
Infusions of local anaesthetics via peripheral nerve sheath catheters, usually inserted by the
surgeon at the time of amputation, are a safe method of providing excellent analgesia in the
immediate postoperative period (Pinzur et al, 1996 Level II; Lambert et al, 2001 Level II). However,
they are of no proven benefit in preventing phantom pain or stump pain (Halbert et al, 2002
Level I).
Therapy
A survey in 1980 identified over 50 different therapies used for the treatment of phantom limb
pain (Sherman et al, 1980), suggesting limited evidence for effective treatments. This was
confirmed by a systematic review (Halbert et al, 2002).
Calcitonin by IV infusion is effective in the treatment of acute phantom limb pain (Jaeger &
Maier, 1992 Level II). Calcitonin may also be given subcutaneously or intranasally (Wall &
Heyneman, 1999). It was not effective for chronic phantom limb pain (Eichenberger et al, 2008
Level II).
• Ketamine, an NMDA‐receptor antagonist (see Section 4.3.2), provided short‐term relief of
stump and phantom limb pain (Nikolajsen et al, 1996 Level II; Eichenberger et al, 2008 Level II).
• Oral controlled‐release (CR) morphine (Huse et al, 2001 Level II) and IV infusions of morphine
reduced phantom limb pain (Wu et al, 2002 Level II). Morphine was superior to mexiletine
(53% vs 30% pain relief) in treating postamputation pain; the NNT for 50% pain relief was
5.6 (Wu et al, 2008 Level II).
• Gabapentin was effective in reducing phantom limb pain (Bone et al, 2002 Level II).
• IV lignocaine (lidocaine) significantly reduced stump pain but had no effect on phantom
pain (Wu et al, 2002 Level II).
• Amitriptyline and tramadol provided good control of phantom limb and stump pain in
amputees (Wilder‐Smith et al, 2005 Level II).
• Injections of local anaesthetic into painful myofascial areas of the contralateral limb
reduced phantom limb pain and sensations (Casale et al, 2009 Level II).
Non‐pharmacological treatment options for phantom limb pain are also effective. These CHAPTER 9
include sensory discrimination training (Flor et al, 2001 Level II), mental imagery of limb
movement (MacIver et al, 2008 Level IV; Ulger et al, 2009 Level IV) and motor imagery, consisting
of 2 weeks each of limb laterality recognition, imagined movements and mirror movements
(Moseley, 2006 Level II).

Acute pain management: scientific evidence 235