Letters to the Editor
Calcitonin Treatment for Phantom Limb Pain
Dear Editor:
Phantom limb pain (PLP) and phantom limb sensation (PLS) describe sensation that is localized to a paralyzed or amputated appendage; PLP is painful, whereas PLS is not (1,2). There is little evidence from randomized controlled trials (RCTs) to guide treatment (3), and the management of phantom limb continues to challenge clinicians. Traditionally, combined tricyclic antidepressants (TCAs) and opioids have been used effectively in the management of PLP, but increasing attention is being focused on the role of calcitonin (4–7). In a small, double-blind RCT, Jaeger and Maier reported complete resolution of PLP in 76% of amputees at 1 week and and 71% of amputees at 2 years after treatment with intravenous calcitonin (6). Related studies have shown that intranasal calcitonin is an effective analgesic agent in bone pain owing to osteoporosis and malignancy (8–10). We describe the use of intranasal calcitonin for the treatment of PLS after spinal cord injury, which has not been previously described in the literature.
Case Report
Mr S, aged 60 years, with no psychiatric history, was the pedestrian victim of a hit-and- run accident that rendered him quadraplegic owing to a C5 lesion. Five days after admission, he complained of paresthesias and feelings of uncontrolled movement in his arms. Over the next 17 days, the symptoms interfered with his sleep and made him anxious, despite routine administration of diazepam and immovane. The psychiatric team was consulted and suggested that Mr S take a moderate dosage of clomipramine. The team was unable to give an opioid in combination with the TCA because he had experienced visual hallucinations on morphine earlier that week. Mr S complained that his PLS worsened, and the clomipramine was discontinued.
A trial of calcitonin was subsequently administered, initiated slowly owing to the potential for anaphylaxis as well as for less deleterious side effects such as nausea and vomiting. Intravenous calcitonin was not available at our centre, so intranasal calcitonin was started instead. After a trial of 1 IU calcitonin intradermally, Mr S was given 200 IU of intranasal calcitonin and reported an alleviation of PLS symptoms for several hours, during which he slept. Two days later, he received 400 IU of intranasal calcitonin, with only a transient improvement in symptoms.
Discussion
This case report on PLS does not support the beneficial effects of calcitonin on PLP reported in previous studies (2). Our report differs from the literature in 2 important respects. First, intranasal administration has not been studied, and it is likely that the optimal dosage was not used in this patient’s care. Further, previous studies all involve patients experiencing PLP symptoms after amputation, not PLS after spinal cord injury. This case report does highlight that intranasal calcitonin is well tolerated and convenient and may be effective as an acute pain reliever in patients who cannot tolerate traditional PLP or PLS pain medications. There continues to be a need for additional research to define the role of intranasal calcitonin in PLP pain management.
References
1. Merskey H, Bogduk N. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Seattle (WA): IASP Press; 1994.
2. Bartusch SL, Sanders BJ, D’Alessio JG, Jernigan JR. Clonazepam for the treatment of lancinating phantom limb pain. Clin J Pain 1996;12:59–62.
3. Halbert J, Crotty M, Cameron ID. Evidence for the optimal management of acute and chronic phantom pain: a systematic review. Clin J Pain 2002;18:84–92.
4. Iacono RP, Linford J, Sandyk R. Pain management after lower extremity amputation. Neurosurgery 1987;20:496–500.
5. Wu CL, Tella P, Staats PS, Vaslav R, Kazim DA, Wesselmann U, and others. Anesthesiology 2002;96:841–8.
6. Jaeger H, Maier C. Calcitonin in phantom limb pain: a double-blind study. Pain 1992;48:21–7.
7. Fiddler DS, Hindman BJ. Intravenous calcitonin alleviates spinal anesthesia-induced phantom limb pain. Anesthesiology 1991;74:187–9.
8. Blau LA, Hoehns JD. Analgesic efficacy of calcitonin for vertebral fracture pain. Ann Pharmacother 2003;37:564–70.
9. Gennari C. Analgesic effect of calcitonin in osteoporosis. Bone 2002;30(5 Suppl):67S–70S.
10. Mystakidou K, Befon S, Hondros K, Kouskouni E, Vlahos L. Continuous subcutaneous administration of high-dose salmon calcitonin in bone metastasis: pain control and beta-endorphin plasma levels.
J Pain Symptom Manage 1999;18:323–30.
S Shapiro, MD
P Kundhal, BSc
M Barua
R Shahani, BSc
S Sockalingam, BA, BSc, MD
S Bhalerao, BSc, BA, PgD, MD, FRCPC
Toronto, Ontario
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