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Following combat trauma, there is a high prevalence of phantom and residual limb pain, which is similar to rates reported by civilian or mixed cohorts, a recent study suggests.¹

鈥淲e undertook a systematic review of studies of combat injury to establish the prevalence of chronic neuropathic and postamputation pain following combat trauma,鈥� co-first authors Alexander Kumar, PhD, and Nadia Soliman, PhD, Department of Surgery and Cancer, Pain Research Group, Imperial College, London, United Kingdom, and colleagues noted in the journal Pain. 鈥淎 secondary objective was to review the definitions used for chronic neuropathic pain and postamputation pain, and the types of assessment and tools used to explore pain in these conditions.鈥�

Study design and population

This systematic review included a total of 31 studies following an original search in May 2021, an updated search on November 15, 2022, and hand searching of references. From these studies, there were 14,738 participants from six national militaries, with injuries reported from 2 World Wars (1914-1918 and 1939-1945), the Vietnam War (1955-1975), the Falklands War (1982), the Iran-Iraq War (1980-1988), and Afghanistan and Iraq (2001-2015). 

At study inclusion, the median participant age was 30.2 years, with 98.2% men. Among 19 studies reporting active service or veteran status at the time of assessment, 873 remained in active service and 3381 were veterans. At assessment, the median time since injury was 17.4 years. Blast injuries comprised 68.5% of all injuries and 30.8% were due to penetrating trauma. From three studies reporting data on traumatic brain injury, an average of 23.5% of respondents reported injury concurrent with other combat trauma. 

Pain prevalence

The prevalence of residual limb pain was 61% (95% CI 50%-71%); phantom limb pain, 57% (95% CI 46%-68%); and phantom limb sensation, 73% (95% CI 61%-82%). Chronic neuropathic pain classified as 鈥渙ther鈥� was reported in 26% (95% CI 10%-54%). Between-study heterogeneity was high for each type of pain, with pain type suggested to account for a significant proportion of heterogeneity. 

Only 10 studies explicitly used a definition or descriptor of phantom limb pain, with a variety of descriptors used among studies. Phantom limb pain severity was assessed in nine studies with inconsistent reports using categorical verbal descriptor scales, numerical rating scales, and visual analog scales. There were 12 studies that defined residual limb pain, and pain severity was assessed using verbal descriptors and numerical rating scales. Among studies describing neuropathic pain, no formal diagnostic criteria were reported in 5 studies. 

The prevalence of phantom limb pain was 50% from the Iraq/Afghanistan conflict and 57% from the Iran-Iraq war. The prevalence of residual limb pain was 70% from the Iraq/Afghanistan conflict and 58% from the Iran-Iraq war. A significant amount of heterogeneity for residual limb pain was attributed to conflict. 

Among studies reporting pain six months to two years following the injury, the prevalence of phantom limb pain was 56% and the prevalence of residual limb pain was 67%. Among studies reporting pain more than 10 years following the injury, the prevalence of phantom limb pain was 64% and the prevalence of residual limb pain was 58%. The time from injury was found to account for a significant amount of heterogeneity for both types of pain. 

鈥淥ur exploratory analyses suggest that a longer time since injury is associated with a slightly lower prevalence of residual limb pain and that the most recent conflict is associated with a higher prevalence,鈥� the authors noted in Pain. 鈥淗owever, the differences in prevalence between the groups is small and with overlapping confidence intervals.鈥�

Factors associated with postamputation and neuropathic pain were investigated in eight studies that were related to participant, characteristics, injury, and rehabilitation characteristics. There were limited reports of quality of life and psychological measures.

Associations were found between phantom limb pain and the presence of residual limb pain, phantom limb sensation, more distal upper limb amputation, anxiety, depression, and post-traumatic stress disorder. An association was found between residual limb pain and higher-intensity low back pain. Neuropathic pain was associated with lower quality of life and increased questionnaire-based scores for anxiety, depression, post-traumatic stress disorder, and pain catastrophizing. 

Moving forward

In this study, the authors demonstrated a 57% prevalence of phantom limb pain and a 61% prevalence of residual lib pain after combat trauma. There were less frequent reports of other types of neuropathic pain. 

鈥淭o our knowledge, this is the first systematic review to quantify the prevalence of chronic neuropathic pain and postamputation pain (including phantom limb pain and residual limb pain) after combat trauma in military personnel,鈥� the authors noted in Pain.

Limitations of this study include the high level of heterogeneity among studies, the lack of longitudinal data, and minimal information provided to inform how questions regarding painful symptoms were posed to participating individuals. Results from this systematic review will be used to inform the ADVANCE study, which was designed to investigate long-term outcomes of combat trauma among British soldiers who were injured between 2002 and 2014 in Afghanistan. 

鈥淎lthough there are potentially many etiological, psychological, treatment, and social differences between military and civilian cohorts that may influence pain prevalence, this prevalence appears similar to rates reported in systematic reviews of civilian or mixed cohorts,鈥� the authors concluded. 鈥淭he inconsistency in the case definitions, terminology, and measurement of pain impact indicate a need for consensus case definitions and core pain outcome domains in the evaluation of similar cohorts in future research.鈥� 

Published: May 01, 2024