8Chronic pain can be defined as pain that persists for an extended period of time (i.e., >3-6 months) and initially accompanies a disease process or bodily injury that has subsequently resolved or healed. 

Lew et al. examined the records of 340 Veterans of the Second Gulf war who had been treated at a Polytrauma clinic and found that chronic pain was extremely common (96.5%). Furthermore this chronic pain was not an isolated morbidity with Post Traumatic Stress Disorder (PTSD) and Persistent Post Concussive Symptoms co-existing. Indeed 42.1% had all three conditions. 

The chance of having any one of the disorders in isolation was much lower than two or three co-existing. The most common sites of chronic pain were back (58%) and head (55%), with shoulder, neck and knee all around 20%.

This study is consistent with other work and underlines the often-complex physical, psychological and social challenges seen in a small but important group of severely injured Veterans. It underlines the need for multidisciplinary intervention. 

In the community setting it is important that the Veteran is treated as a whole rather than focusing on pain or psychological difficulties, underscoring the need for a comprehensive assessment by a trained individual or team.

Phantom limb sensations/pain, prostheses and stump care

Nikolajsen reports that virtually all amputees experience phantom phenomena. The sensation that the limb is still present and sensing movement and posture rarely cause clinical problems. However 60-80% will experience painful sensations in the missing limb. The picture can be clouded by stump pain and indeed stump pain, phantom limb pain and phantom limb sensation often co-exist. 

Phantom limb pain tends to be episodic and is severe in between 15-25% of patients. It is more common in upper limb amputations. It may be exacerbated by stump pain. Pain is more often perceived in the missing hands or feet and often has a burning, stabbing or prickling quality although crushing or cramp type pain can also be described. 

Stump pain may be due to local factors and the stump itself should be examined for skin quality, pressure areas or local hypersensitive areas with the possibility of neuroma formation also present. Veterans should have a well-fitted high quality prosthesis and if a replacement is required the NHS is obliged to supply one of at least equivalent quality. If there is weight change then the socket of the prosthesis may require adjustment.

Treatments for phantom limb pain and stump pain are not well supported by research. The evidence base for neuropathic pain is wider and treatment strategies should follow that route with the additional local attention to the stump (good quality stump sock, use of moisturisers if needed etc.). 

The Nice guidance on neuropathic pain suggests that a choice of amitriptyline, duloxetine, gabapentin or pregabalin is the initial treatment for neuropathic pain. Then, if the initial treatment is not effective or is not tolerated, offer one of the remaining 3 drugs, and consider switching again if the second and third drugs tried are also not effective or not tolerated. They also recommend that the use of tramadol is limited to acute rescue therapy.

This patient is a military veteran. I consider that his/her current condition may be related to military service. This referral should be considered for priority treatment under Welsh Health Circular WHC (2008) 051