LCCH News Autumn / Winterr 2001

Clinical Hypnosis in Amputee Rehabilitation
(NHS Experience)

By: Dr I. Al-Khawaja, Consultant Physician in Rehabilitation Medicine, Brighton General Hospital, Brighton, East Sussex.

One of the major problems in amputee rehabilitation is the management of different types of painful conditions usually experienced by patients who lost their limbs in traumatic incidents or as a result of vascular problems. These patients require a great deal of attention from a multidisciplinary team including medical, nursing, counselling and physical therapy in order to overcome their painful conditions and improve the quality of their lives.

The painful syndrome could be a recent experience in the days or weeks after amputation, but sometimes could be months or years afterwards. In addition to the pain in the residual limb (stump), there could be what is known as a phantom pain. These symptoms are usually treated by simple pain killers (analgesia), non-steriodal anti-inflammatory drugs, narcotics such as morphine derivatives, anti-epileptic agents or anti-depressant drugs. All these have side effects and can be dangerous, especially in patients who have other medical conditions. It is sometimes impossible to control these pain conditions without large doses of medications which would leave the patient heavily sedated and drowsy. More invasive treatments such as lumbar sympathectomy, or even deep brain stimulation, have been tried without any significant benefit.

This has led the author to explore the use of clinical hypnosis in the management of a range of clinical syndromes in amputee patients who have experienced severe pain that has not responded to standard medical therapy. He was supported and encouraged by his employer (SOUTH DOWN HEALTH NHS TRUST, Brighton) to make all the necessary arrangements including the medical time, appropriate training, patients' education, information leaflets and consent forms.

We report here four cases which have been treated successfully with clinical hypnosis, and compare the outcome using the Visual Analogue Scale (VAS). The first case was a 79 years old gentleman who lost his leg above the knee during the Second World War in a landmine accident. He was troubled with both stump pain and phantom pain for over 50 years. He was on a combination of regular pain killers (Co-proxamol) and anti-epileptic agent (carbamazepine). He agreed to undergo clinical hypnosis with Visual Analogue Scale (VAS) of 8/10. Trance was established using a standard approach employing a permissive technique. Regression in time and Glove anaesthesia were employed in a single session, which resulted in his VAS improving to 2/10 with an occasional need for pain killers. He stopped the anti-epileptic agent which he took for nearly 20 years.

The second patient was a 56-years-old lady who has experienced intolerable phantom pain which has affected the quality of her life, disturbed her sleep, and ability to use the lower limb prosthesis for nearly 4 years. She has tried all type of pain killers and was maintained on Co-dydramol (a strong opiate derivative) and Gabapentin as well as a strong anti-depressant (Amitriptyline) which was started after further deterioration when she lost her husband. Her VAS was 10/10 prior to treatment. She consented to hypnosis but was unable to relax and concentrate. Induction was then carried out with hand levitation and by using Glove anaesthesia and pseudo-orientation in time, her symptoms improved significantly and her VAS was 6/10 at the end of the first session. Reinforcement was carried out a week later with similar techniques and other metaphors.


MEDICAL NEWS

Clinical Hypnosis in Amputee Rehabilitation (NHS Experience) By: Dr I. Al-Khawaja, Consultant Physician in Rehabilitation Medicine, Brighton General Hospital, Brighton, East Sussex. One of the major problems in amputee rehabilitation is the management of different types of painful conditions usually experienced by patients who lost their limbs in traumatic incidents or as a result of vascular problems. These patients require a great deal of attention from a multidisciplinary team including medical, nursing, counselling and physical therapy in order to overcome their painful conditions and improve the quality of their lives. The painful syndrome could be a recent experience in the days or weeks after amputation, but sometimes could be months or years afterwards. In addition to the pain in the residual limb (stump), there could be what is known as a phantom pain. These symptoms are usually treated by simple pain killers (analgesia), non-steriodal anti-inflammatory drugs, narcotics such as morphine derivatives, anti-epileptic agents or anti-depressant drugs. All these have side effects and can be dangerous, especially in patients who have other medical conditions. It is sometimes impossible to control these pain conditions without large doses of medications which would leave the patient heavily sedated and drowsy. More invasive treatments such as lumbar sympathectomy, or even deep brain stimulation, have been tried without any significant benefit. This has led the author to explore the use of clinical hypnosis in the management of a range of clinical syndromes in amputee patients who have experienced severe pain that has not responded to standard medical therapy. He was supported and encouraged by his employer (SOUTH DOWN HEALTH NHS TRUST, Brighton) to make all the necessary arrangements including the medical time, appropriate training, patients' education, information leaflets and consent forms. We report here four cases which have been treated successfully with clinical hypnosis, and compare the outcome using the Visual Analogue Scale (VAS). The first case was a 79 years old gentleman who lost his leg above the knee during the Second World War in a landmine accident. He was troubled with both stump pain and phantom pain for over 50 years. He was on a combination of regular pain killers (Co-proxamol) and anti-epileptic agent (carbamazepine). He agreed to undergo clinical hypnosis with Visual Analogue Scale (VAS) of 8/10. Trance was established using a standard approach employing a permissive technique. Regression in time and Glove anaesthesia were employed in a single session, which resulted in his VAS improving to 2/10 with an occasional need for pain killers. He stopped the anti-epileptic agent which he took for nearly 20 years. The second patient was a 56-years-old lady who has experienced intolerable phantom pain which has affected the quality of her life, disturbed her sleep, and ability to use the lower limb prosthesis for nearly 4 years. She has tried all type of pain killers and was maintained on Co-dydramol (a strong opiate derivative) and Gabapentin as well as a strong anti-depressant (Amitriptyline) which was started after further deterioration when she lost her husband. Her VAS was 10/10 prior to treatment. She consented to hypnosis but was unable to relax and concentrate. Induction was then carried out with hand levitation and by using Glove anaesthesia and pseudo-orientation in time, her symptoms improved significantly and her VAS was 6/10 at the end of the first session. Reinforcement was carried out a week later with similar techniques and other metaphors.			At the end of the second session, her VAS was 3/6 and she voluntarily stopped all her oral medication against medical advice. The third case was a 72-years-old man who underwent an above knee amputation for poor circulation and diabetic ulcers 16 days prior to the initial consultation. He was already on long acting Morphine Sulphate tablets twice daily, additional morphine liquid in between doses, anti-epileptic agent, sleeping tablets, tranquillisers, and in possession of TENS machine for continuous use. He was crying of pain, unable to sleep at night, and intolerant of food due to severe sickness resulting from adverse drug reaction. He consented to undergo hypnotherapy and his VAS was 10/10 prior to therapy. Using progressive relaxation, an adequate trance was achieved. Glove anaesthesia, and time regression were used in the first session. After 24 hours, he required reinforcement with similar techniques but further therapy using dissociation was thought to be useful. This has reduced his pain significantly and VAS was 7/10. S further session one week later with pseudo-orientation in time was successful in reducing his pain to 3/10. He started his rehabilitation programme and was able to use an artificial limb to walk home. The fourth case was a 14-years-old girl who had a congenital limb deformity. She underwent an amputation of the deformed limb and was able to walk with a prosthesis. The skin of her stump was sensitive and she developed a skin rash similar to eczema. It was painful and caused a lot of irritation and itching. Contact dermatitis was diagnosed but this has failed to respond to standard therapy. After several consultations with skin specialists, her condition did not resolve and she started to have difficulties in walking. She needed to take off her prosthesis to allow the skin to settle but within an hour of wearing the artificial limb the condition was recurring and caused her more discomfort. She was offered the opportunity to try hypnosis and both the girl and her mother consented to this. After a suitable induction with eye fixation, Glove anaesthesia, and one part dissociation were employed with pseudo-orientation in time. Within 30 minutes, her skin colour changed, with complete resolution of colour, absence of the need to scratch and normal sensation. The skin gradually dried up with scaly appearance. She was able to wear her artificial limb and walk with no discomfort or irritation. The VAS was 8/10 and after treatment she confirmed that it would not be any more than 1/10. The lesson from these cases is that Clinical hypnosis has an important role in the management of painful conditions especially in this group of patients. More research is required in order to characterize and define a standard protocol. In the new NHS culture, evidence based practice is required and mandatory. The safety of these techniques is proven and the health economics have to be illustrated. Implementing similar approaches on a wider scale would have a great impact on releasing resources to other aspects of health care due to the significant saving on expensive medicinal therapies. South Down Health NHS Trust has been open minded and innovative in providing Clinical Hypnosis in the context of Rehabilitation Medicine. Editor Note: We at LCCH congratulate South Down Health NHS Trust and Sussex Rehabilitation Centre, Brighton on their efforts to integrate Clinical Hypnosis in routine NHS services, and would encourage other Trusts to consider making such a useful clinical tool available for the benefit of their patients. Well done South Downs Health!.
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