Common Cares

Phantom Pain-Amputation Part III

Introduction

Over the years scientists have noted many complaints of a strange form of pain called phantom limb pain. This pain is strange because it is located in an appendage that no longer exists. By many of the amputees, the pain is described as totally unbearable. Phantom limb pain has even driven some victims crazy. For the amputees this is a very real problem that definitely needs to be solved.

Phantom Sensation

Phantom sensation is a term used to mean any type of sensation, which the amputee experiences in the portion of the limb that has been removed. It can include: tingling, warmth, cold, pain, cramping, constriction, and any other imaginable sensation. Essentially, any sensation that the limb could have experienced prior to the amputation can be experienced in the amputated "phantom" limb.

Virtually all amputees who are old enough to talk have reported phantom sensations of some sort. Some amputees will not voluntarily mention it since they think that it indicates that their mind is unhinged! It is actually not crazy thinking at all. Instead, it simply means the part of the brain, which has always felt that limb, is still reporting some sensations to the rest of the brain. What the thinking part of the brain knows (that the limb is gone) may be different from what the feeling part of the brain reports.

Some children born without a limb even report that they can feel the part that they never have had present. So long as the sensation is not unpleasant, there should be no real problem once the reality of phantom sensation is explained. It is usually only when the phantom sensation is unpleasant, noxious, painful, that the phantom sensation is a problem that needs specific treatment.

Phantom Pain

One of the really difficult part of post-amputation pain is to manage is phantom pain. It is defined as pain in the missing or amputated part of the limb(s) or some part of it. It is important, from a treatment standpoint, to differentiate between phantom pain and pain in the residual limb (stump). They are very different problems with totally different causes and very different treatments. Phantom pain is never experienced in the residual limb (stump) even though it can be triggered by something happening to the residual limb.

Unfortunately, phantom pain is experienced by 60-70% of new amputees and after a year as many as 40% of them may still be bothered by it in a significant way. Often it diminishes a lot in its severity over time. Many amputees report that it becomes much less frequent as time goes along; however, when it recurs it may be just as bothersome as when it was first experienced.

There is tremendous variability of this phantom pain. It can be extremely unpleasant and even disabling for some amputees. It is complex, resistant to treatment and very frustrating to amputee and caregivers alike. It is really this part of post-amputation pain that this series of articles will focus on since it is the most severe part of the problem.

A pain experienced after any surgical procedure where skin, muscle, bone and nerves are cut is called immediate post-op pain. Essentially everyone experiences some degree of post-op pain following an amputation. It can usually be controlled with pain medication and subsides fairly rapidly as swelling goes down, tissues begin to heal, and the wound stabilizes. This is simply part of the natural healing process.

Reasons known to cause

Many scientists have studied amputees to determine the cause of this mysterious pain. Sussman (1995) concluded that the trouble starts in a part of the brain known as the sensory cortex. The sensory cortex carries a rough map of the body, called a homunculus or "little man." Each body part in the homunculus is wired to its corresponding portion of the real anatomy. When a body part is lost the corresponding part of the brain is not able to handle the loss and rewires its circuitry to make up for the signals it was no longer receiving from the missing digit. The rewiring might occur in one of two ways. Perhaps nerve impulses in the sensory cortex begin to course down previously untraveled pathways. The second theory is that neighboring neurons in the cortex may actually invade the territory left fallow because sensations are no longer received from the missing limb.

Birbaumer, Lutzenberger, Montoya, and Wolfgang (1997) examined the functional relationship between cortical reorganization and phantom limb pain. Neuroelectric source imaging was used to determine changes in cortical reorganization in the somatosensory cortex after anesthesia of an amputation stump produced by brachial plexus blockage in six phantom limb pain patients and four pain-free amputees. This cortical reorganization was studied to examine whether the neurons rewired after the loss of an appendage.

The area of the brain for the foot is adjacent to the area for genitalia. Because of this connection Finnegan-Lingís missing limb aches when one makes a move.

There are also other reasons that can contribute to phantom pain.

Reasons believed

Incorrect surgical procedure

Unless you live in a heavily populated area or in a part of the world that has a high population of amputees, chances are your surgeon may not be wholly experienced in post-traumatic amputations.

It is somewhat unfair to point the finger for such things at the inexperienced surgeon (at least your life was saved); incorrect surgical procedures have caused some amputees problems for many years after the original trauma.

Climatic conditions

Changes in weather, particularly related to changes in air pressure and temperature can dramatically affect levels of phantom pain. Other than moving to a different climate this is a hard one to avoid.

Stress

The cause of just about every ailment known. Stressful lifestyles lead to kinds of ailments and if your an amputee, phantom pain is just another to add to the list.

Inactivity

Remaining in a relatively same position for long periods of time. Office workers especially, poor posture really helps bring on those phantoms. Make sure you are sat in the best possible position to keep blood flow to the amputated limb to a maximum.

Periodic illness

Colds, flu, strep throat, infections, virus'es can increase the level of phantom sensation, sometimes to unbearable levels. This is particularly noticeable for people who only notice phantom pain when ill. Not much you can do except either pump yourself full of drugs and sit this out. But don't wait too long, 48 hours of constant phantom pain needs prescription medication. More often than not phantom pain will cause you to tense/tighten up therefore perpetrating even more phantom pain. In cases such as this usually a onetime shot of morphine or other significant painkiller will do the trick. See a doctor either way.

Known treatment methods

Unfortunately, even now, understanding of the way at the brain handles pain and other sensations are still fairly crude. A lot of guesswork is still involved. One can observe many things that we do not truly understand. That makes a reasonable discussion of pain much more difficult. It also makes devising a rational plan of treatment very difficult.

Several relief approaches for phantom limb pain have been investigated including biofeedback, hypnosis, and relaxation. All three of these reliefs were found helpful. Arena et al., (1990) examined uses of biofeedback as a relief tactic. Tsushima (1982) used EMG and temperature biofeedback to treat phantom limb pain in a 51yr old man. Nine EMG biofeedback sessions were effective in eliminating headache and reducing neck and chest pain excluding phantom limb pain. Four subsequent sessions involving temperature biofeedback and autogenic training were successful in eliminating phantom limb pain, which remained absent at a two-month follow-up.

Wain (1986) tested how efficiently hypnosis treats phantom limb pain. Wain suggests that hypnosis bridges the gap between physiological and psychological conceptualizations of pain. The treatment of the pain sufferer is considered in terms of the therapeutic relationship and hypnotic trance, diagnosis, assessment of hypnotizability, induction procedures, and the development of a hypnotic strategy. It is emphasized that hypnosis promotes a milieu in which effective strategies can be integrated and the hypnotic techniques can give patients the needed impetus to recognize their ability to regain control.

McKechnie(1975) experimented with relaxation as a treatment for phantom limb pain. McKechnie reports observing relief from phantom limb pain in a young male adult patient with a nine-year history of such pain. Relief occurred during and after relaxation exercises focused on the phantom limb and was facilitated by practice. Six-month follow-up revealed continued relief. The relaxation technique is related to the hypnosis treatment by use the use of mind and body to control the pain in both techniques.

Although many studies point to cortical reorganization of the neurons as the result of this phantom limb pain, we have still not found a major way to extinguish this pain. In addition to cortical reorganization, scientists have studied psychosocial factors and stress as related to phantom limb pain. In the future, methods designed to alter cortical reorganization should be examined along with stress releasers, relaxation techniques, and pharmaceutical agents for their efficacy in the treatment of phantom limb pain.

New Studies

It appears from recent research that it is critically important to adequately treat immediate post-op amputation pain because adequate early control decreases the chances of severe problems later. Surgeons are being encouraged to be much more liberal with pain medication in the immediate post-op period. Continuous post-op epidural analgesia is being recommended for pain management since it can be very effective. Adequate doses of narcotic and non-narcotic analgesics (pain medicines) should be prescribed in a fairly rapidly decreasing program to fit the decrease expected in the pain itself.

For amputees who are experiencing an unusually great amount of post-op pain or pain in the phantom limb, (which has been removed), early referral to a comprehensive pain management program is extremely important. Early referral for expert management can remarkably decrease long-term problems with post-amputation pain. Here, an ounce of early treatment can be worth a pound of late treatment.

The problems of management are made much more complex by the differences between amputees. All of the issues of accidents or other for limb removal underline the fact that management of pain is a major problem.

Drug dependency can actually cause phantom pain to increase, rather than decrease. The easiest and worst way to combat phantom pain to fill yourself full of medication. There are MANY alternatives; medication (especially the heavy addictive types) should be a LAST RESORT, not the first option.

Increased blood flow to the amputated area will (in many cases) reduce the amount of pain. Therefore constant exercise, whether stretching, running, walking, bike riding or lifting weights can provide relief from phantom pain. Any other supplement or product that increases blood flow will have similar effects.