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PubMed1998

The perception of phantom limbs. The D. O. Hebb lecture.

Almost everyone who has a limb amputated will experience a phantom limb--the vivid impression that the limb is not only still present, but in some cases, painful. There is now a wealth of empirical evidence demonstrating changes in cortical topography in primates following deafferentation or amputation, and this review will attempt to relate these in a systematic way to the clinical phenomenology of phantom limbs. With the advent of non-invasive imaging techniques such as MEG (magnetoencephalogram) and functional MRI, topographical reorganization can also be demonstrated in humans, so that it is now possible to track perceptual changes and changes in cortical topography in individual patients. We suggest, therefore, that these patients provide a valuable opportunity not only for exploring neural plasticity in the adult human brain but also for understanding the relationship between the activity of sensory neurons and conscious experience. We conclude with a theory of phantom limbs, some striking demonstrations of phantoms induced in normal subjects, and some remarks about the relevance of these phenomena to the question of how the brain constructs a 'body image.'

Adult↗
PubMed1999

Decrease in phantom limb pain associated with prosthesis-induced increased use of an amputation stump in humans.

The experience of phantom limb pain, non-painful phantom limb sensation and telescoping was ascertained by questionnaire in a group of upper extremity amputees wearing a functionally effective Sauerbruch prosthesis which permits extensive use of the affected limb and in a group of patients wearing a cosmetic prosthesis that did little to increase the utilization of the amputation stump. The Sauerbruch prosthesis group exhibited a significant and large decrease in amount of phantom limb pain while the cosmetic prosthesis group showed no change. Neither group experienced a decrease in non-painful phantom limb sensation or telescoping. The amount of phantom limb pain has been found to be highly correlated with the amount of injury-related, afferent-decrease cortical reorganization. It is possible that the increased use of the amputation stump induced by wearing a Sauerbruch prosthesis produced a countervailing use-dependent, afferent-increase type of cortical reorganization that reversed the phantom limb pain. These preliminary results require replication. Their therapeutic implications are discussed.

Adult↗
PubMed2000

Phantom limbs and neural plasticity.

The study of phantom limbs has received tremendous impetus from recent studies linking changes in cortical topography with perceptual experience. Systematic psychophysical testing and functional imaging studies on patients with phantom limbs provide 2 unique opportunities. First, they allow us to demonstrate neural plasticity in the adult human brain. Second, by tracking perceptual changes (such as referred sensations) and changes in cortical topography in individual patients, we can begin to explore how the activity of sensory maps gives rise to conscious experience. Finally, phantom limbs also allow us to explore intersensory effects and the manner in which the brain constructs and updates a "body image" throughout life.

Adult↗
PubMed2000

Psychophysiological stress responses in amputees with and without phantom limb pain.

The present experiment tested the hypothesis that phantom limb pain amputees show a different pattern of psychophysiological reactivity to stress compared with painfree amputees. Six phantom limb pain (PLP) and five painfree upper-extremity amputees were administered two groups of tasks: stressful and relaxing. The measured dependent variables were skin temperature recorded at both stump and intact site, heart rate, blood pressure, subjective pain and stress ratings. Phantom limb pain patients were characterized by higher stump temperature compared with phantom limb painfree patients. This effect was observed during the whole recording. Consistently with the between-subjects effect, when PLP patients exhibited higher skin temperature (during relaxation, compared with during stressful tasks), they perceived more pain. The experiment showed higher cardiovascular reactivity in PLP patients, specifically to the stressful free-speech task, which focused on recollection of the amputation event. As compared with the painfree patients, during the personal stressor, PLP patients' heart rate and systolic blood pressure increased, indicating a greater sympathetic response. Results indicate that peripheral factors, such as stump temperature reliably differentiate PLP from painfree patients. Moreover, the clear cardiovascular hyperreactivity observed in PLP patients during their report of amputation suggests that PLP is associated with a long-term emotional memory for the painful experience of that event. These results are consistent with most reports in the literature relating phantom pain development to the experience of preamputation pain.

Adult↗
PubMed1992

Psychophysiological contributions to phantom limbs.

Recent studies of amputees reveal a remarkable diversity in the qualities of experiences that define the phantom limb, whether painless or painful. This paper selectively reviews evidence of peripheral, central and psychological processes that trigger or modulate a variety of phantom limb experiences. The data show that pain experienced prior to amputation may persist in the form of a somatosensory memory in the phantom limb. It is suggested that the length and size of the phantom limb may be a perceptual marker of the extent to which sensory input from the amputation stump have re-occupied deprived cortical regions originally subserving the amputated limb. A peripheral mechanism involving a sympathetic-efferent somatic-afferent cycle is presented to explain fluctuations in the intensity of paresthesias referred to the phantom limb. While phantom pain and other sensations are frequently triggered by thoughts and feelings, there is no evidence that the painful or painless phantom limb is a symptom of a psychological disorder. It is concluded that the experience of a phantom limb is determined by a complex interaction of inputs from the periphery and widespread regions of the brain subserving sensory, cognitive, and emotional processes.

Amputation, Surgical↗
PubMed1996

Pain memories in phantom limbs: a case study.

Pain experienced in a limb prior to amputation may influence the course of phantom limb pain many months later. Katz and Melzack (1990) found that 42% of their sample reported a 'somatosensory pain memory' which resembled the quality and location of a painful, or non-painful pre-amputation sensation. For many amputees, pain memories are vivid experiences which incorporate both emotional and sensory aspects of the pre-amputation pain (Katz 1992). Katz and Melzack (1990) suggest that sensory input will 'trigger' somatosensory pain memories while the affective component of a pain memory is generated by the intensity, quality and location of the current experience of phantom limb pain. The present case study used a diary design to examine whether 'triggers' could be identified for somatosensory pain memories. Over a 9-month period, the patient reported daily experience of ongoing phantom limb pain, generally confined to the distal part of the limb, and 5 episodes of injury-related phantom limb pain, primarily experienced in the calf of the missing limb. A 'trigger' was identified for each of the episodes of injury-related phantom limb pain, and a significant finding in this study was that two episodes of injury-related phantom limb pain were associated with cognitive and/or emotional, rather than sensory 'triggers'.

Abscess↗
PubMed2003

[Phantom limb pain: aspects of neuroplasticity and intervention].

Phantom-limb pain is a common sequel of amputation, occurring in up to 80 % of the amputee population. It must be differentiated from non-painful phantom phenomena, residual-limb pain, and non-painful residual-limb phenomena. A comprehensive model of phantom-limb pain is presented that assigns a major role to pain occurring before the amputation and to central as well as peripheral changes related to it. Special emphasis is put on the role of cortical reorganization in the development of phantom limb pain. Finally, new approaches to the prevention and treatment of phantom limb pain are presented that have a positive influence on phantom limb pain by preventing or reversing cortical reorganization.

Clinical Trials as Topic↗
PubMed2003

Five early accounts of phantom limb in context: Paré, Descartes, Lemos, Bell, and Mitchell.

PHANTOM LIMB WAS described long before American physician and surgeon Silas Weir Mitchell coined the term and drew attention to the disorder in the 1860s. The early descriptions of Ambroise Paré, René Descartes, Aaron Lemos, Charles Bell, and then Mitchell of this strange consequence of amputation are presented in historical and cultural context. These five men described phantom limbs for various reasons. They also differed when it came to explaining and dealing with these illusory sensations. The rich history of phantom limbs can begin to be appreciated by viewing the contributions of these individuals in perspective and by realizing that their writings represent only a fraction of what was published about phantom limbs more than 130 years ago.

History, 16th Century↗
PubMed1984

Increasing phantom limb pain as a symptom of cancer recurrence.

Previous studies have shown that phantom limb pain following major amputation reaches its greatest severity 2 to 3 weeks following amputation; it then gradually diminishes over subsequent months and years. Transient episodes of severe phantom limb pain are sometimes temporally related to specific activities such as urination, sexual intercourse, or local pressure applied to the amputation stump. Also, neuroma formation may be associated with transient episodes of increased discomfort usually associated with the application of local pressure. Phantom limb pain progressively increasing over an extended period of time has not been previously reported. The authors observed phantom limb pain of increasing severity to be associated with locally recurrent extremity sarcoma in two patients. In both patients increasing phantom limb pain was the first indication of recurrent cancer and led to radiologic studies and biopsy which confirmed the diagnosis of recurrent disease. It is suggested that phantom limb pain of progressive increasing severity may be a symptom of locally recurrent cancer in an amputation stump.

Adult↗
PubMed2006

Can immersive virtual reality reduce phantom limb pain?

This paper describes the design and implementation of a case-study based investigation using immersive virtual reality as a treatment for phantom limb pain. The authors' work builds upon prior research which has found the use of a mirror box (where the amputee sees a mirror image of their remaining anatomical limb in the phenomenal space of their amputated limb) can reduce phantom limb pain and voluntary movement to paralyzed phantom limbs for some amputees. The present project involves the transposition of movements made by amputees' anatomical limb into movements of a virtual limb which is presented in the phenomenal space of their phantom limb. The three case studies presented here provide qualitative data which provide tentative support for the use of this system for phantom pain relief. The authors suggest the need for further research using control trials.

Amputees↗
PubMed2006

Surgical treatment of chronic phantom limb sensation and limb pain after lower limb amputation.

BACKGROUND: Therapy for phantom sensation and phantom limb pain following amputation is still difficult, because pathophysiologic mechanisms have not been clarified. This report illustrates a simple and useful surgical intervention. The authors propose that changes at the peripheral nerve site can influence the central feeling of phantom sensation and pain. METHODS: Fifteen patients (mean age, 56 years) with lower limb amputation were included in the study. In all patients, the sciatic nerve was split at a point approximately 3 cm proximal to the popliteal fossa, and the two parts were reconnected in a sling fashion using an epiperineurial technique under microscopic vision. The nerves were covered with a fibrin patch and anesthetics were applied by means of a local pain catheter. Frequency, duration, intensity, and quality of phantom pain were compared preoperatively and 1 week, 3 months, 6 months, and 1 year postoperatively. RESULTS: Fourteen of 15 patients defined the procedure as very helpful. Average, maximum, and minimum pain intensity were significantly reduced 1 week, 3 months, 6 months, and 1 year postoperatively (p < 0.001). Pain intensity scores decreased significantly over the long term after surgical intervention (median visual analogue scale score: preoperatively, 7; 1 year postoperatively, 4) (p < 0.001). The duration of pain attack shortened from approximately 120 minutes to 5 to 10 minutes. CONCLUSIONS: This study shows that accurate treatment of the peripheral nerve can help to successfully reduce phantom limb pain. The authors feel encouraged to perform future investigations to test their operative method in a prospective, randomized, matched control study including electrophysiologic tests for more objective pain assessment.

Adult↗
PubMed2006

Self-reported treatments used for lower-limb phantom pain: descriptive findings.

OBJECTIVE: To examine the types and relative frequency of treatments used for lower-limb phantom limb pain (PLP), including both pharmacologic and rehabilitative interventions. DESIGN: Cross-sectional survey. SETTING: Community-based survey from clinical databases. PARTICIPANTS: Community-based sample (N=255) of persons with lower-limb amputations. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Intensity of PLP and type and helpfulness of treatments (both past and present) used for PLP. RESULTS: Although 72% of the sample (n=183) reported current PLP, 53% of the respondents with PLP (and 38% of those with severe PLP) had never used treatment for PLP. Those who had used treatment reported greater pain severity and interference. The most commonly used treatment modality was analgesic medication, including acetaminophen, opioids, and nonsteroidal anti-inflammatory drugs. Of the treatments surveyed, only opioids and chiropractic care were rated as moderately to extremely helpful by the majority of those who had tried them, and many pain interventions had been discontinued. CONCLUSIONS: As hypothesized, a significant proportion of persons with PLP have not used treatment for this pain, and, among those who have used pain treatments, few treatments are perceived as substantially helpful. More research is needed to identify effective management strategies for PLP and to examine further patient perceptions of pain treatment.

Adult↗
PubMed2002

Continuous brachial plexus analgesia and NMDA-receptor blockade in early phantom limb pain: a report of two cases.

OBJECTIVE: To provide a mechanism-based acute pain management strategy for early phantom limb pain following traumatic amputations and to collect first evidence of its acute and potentially preventative effects on the formation and maintenance of phantom limb pain. The combination of continuous brachial plexus analgesia and prolonged block of N-methyl-D-aspartate (NMDA) receptors over 4 weeks aimed to attenuate peripheral and central sensitization, currently thought to be substantially involved in establishing and maintaining phantom limb pain. CASE REPORT: Two patients, after traumatic upper limb amputations and early phantom limb pain, were treated on the second and fifth day following amputation by continuous brachial plexus analgesia with ropivacaine 0.375% (30 ml for the initial block, continuous infusion rate = 5 ml/h) for 5 (Patient 1) and 9 days (Patient 2). Both patients received oral memantine (a noncompetitive NMDA-receptor antagonist) in increasing doses from 10 to 30 mg/d over a 4-week period. Ropivacaine only produced minor motor block, with almost unimpaired motor function. Memantine was well tolerated and no relevant side effects were observed. In both patients the treatment prevented the establishment of phantom limb pain, which did not reappear during follow-up of 1 year. CONCLUSIONS: The combination of long-term regional analgesia with prolonged block of NMDA receptors might be effective for treatment and prevention of phantom limb pain following traumatic amputations. The absence of clinically relevant side effects, together with maintained motor function suggests this treatment to be a promising preventive strategy for phantom limb pain following traumatic amputations.

Journal Article↗
PubMed2001

Chronic motor cortex stimulation for phantom limb pain: a functional magnetic resonance imaging study: technical case report.

OBJECTIVE AND IMPORTANCE: Chronic motor cortex stimulation has provided satisfactory control of pain in patients with central or neuropathic trigeminal pain. We used this technique in a patient who experienced phantom limb pain. Functional magnetic resonance imaging (fMRI) was used to guide electrode placement and to assist in understanding the control mechanisms involved in phantom limb pain. CLINICAL PRESENTATION: A 45-year-old man whose right arm had been amputated 2 years previously experienced phantom limb pain and phantom limb phenomena, described as the apparent possibility of moving the amputated hand voluntarily. He was treated with chronic motor cortex stimulation. INTERVENTION: Data from fMRI were used pre- and postoperatively to detect shoulder and stump cortical activated areas and the "virtual" amputated hand cortical area. These sites of preoperative fMRI activation were integrated in an infrared-based frameless stereotactic device for surgical planning. Phantom limb virtual finger movement caused contralateral primary motor cortex activation. Satisfactory pain control was obtained; a 70% reduction in the phantom limb pain was achieved on a visual analog scale. Postoperatively and under chronic stimulation, inhibiting effects on the primary sensorimotor cortex as well as on the contralateral primary motor and sensitive cortices were detected by fMRI studies. CONCLUSION: Chronic motor cortex stimulation can be used to relieve phantom limb pain and phantom limb phenomena. Integrated by an infrared-based frameless stereotactic device, fMRI data are useful in assisting the neurosurgeon in electrode placement for this indication. Pain control mechanisms and cortical reorganization phenomena can be studied by the use of fMRI.

Electric Stimulation Therapy↗
PubMed1991

Auricular transcutaneous electrical nerve stimulation (TENS) reduces phantom limb pain.

The present paper evaluates the efficacy of low frequency, high intensity auricular transcutaneous electrical nerve stimulation (TENS) for the relief of phantom limb pain. Auricular TENS was compared with a no-stimulation placebo condition using a controlled crossover design in a group of amputees with (1) phantom limb pain (Group PLP), (2) nonpainful phantom limb sensations (Group PLS), and (3) no phantom limb at all (Group No PL). Small, but significant, reductions in the intensity of nonpainful phantom limb sensations were found for Group PLS during the TENS but not the placebo condition. In addition, 10 min after receiving auricular TENS, Group PLP demonstrated a modest, yet statistically significant decrease in pain as measured by the McGill Pain Questionnaire. Ratings of mood, sleepiness, and anxiety remained virtually unchanged across test occasions and sessions, indicating that the decrease in pain was not mediated by emotional factors. Further placebo-controlled trials of auricular TENS in patients with phantom limb pain are recommended in order to evaluate the importance of electrical stimulation parameters such as pulse width and rate, and to establish the duration of pain relief.

Adult↗
PubMed2005

Dissociation of phantom limb phenomena from stump tactile spatial acuity and sensory thresholds.

Most amputees experience phantom limb sensations and/or phantom limb pain as well as residual limb (stump) pain that are resistant to treatment. Phantom phenomena are not homogeneous; each patient presents with a unique combination of spontaneous or evoked sensations, pain, and/or awareness. In an effort to understand the underlying mechanisms, postamputation pain has been subclassified based on the perceived sensory qualities reported by the individual. However, little is known about the relationship between subjective phantom phenomena and sensory function of the residual stump. The aim of the present study was to determine if sensory processing, as measured psychophysically, reflected subjective reports of specific qualities of phantom and/or stump sensory phenomena. Twelve individuals who had recently (within 6 months) undergone traumatic unilateral upper extremity amputation participated in the study. Limb temperature, thermal thresholds, tactile sensory thresholds and tactile spatial acuity were compared between the residual limb and the intact limb, and related to patient reports of specific stump and phantom sensory phenomena. All but one subject reported phantom sensations and/or phantom pain. The remaining subject reported only stump pain. Mean skin temperature of the residual limb was significantly lower than that of the intact contralateral limb by approximately 0.9 degrees C in the proximal portion of the stump and 1.7 degrees C at the stump tip. However, the temperature of the stump (compared with the intact limb) did not reflect subjective reports of stump or phantom limb thermal characteristics. Thermal threshold abnormalities differed among patients, and did not suggest any pattern of small fibre loss of function or generalized hyperexcitability. Other than within grafted tissue or near the scar area, skin areas that the patient described as abnormally sensitive or tender to touch were not accompanied by corresponding abnormalities in static tactile thresholds or tactile spatial acuity. Tactile spatial acuity was heightened near the scar area only. The proportion of subjects who had decreased two-point discrimination thresholds at the stump did not differ significantly according to the reporting or non-reporting of dual percepts. Thus, despite a common injury, the sensory abnormalities varied within this cohort of subjects. In addition, psychophysical threshold measures of sensory function did not reflect, in any simple way, subjective phantom phenomena. Therefore, classification of phantom phenomena based on peripheral sensory function may be a misleading step in the search for specific mechanisms underlying postamputation sensory phenomena.

Adult↗
PubMed1995

Phantom-limb pain as a perceptual correlate of cortical reorganization following arm amputation.

Although phantom-limb pain is a frequent consequence of the amputation of an extremity, little is known about its origin. On the basis of the demonstration of substantial plasticity of the somatosensory cortex after amputation or somatosensory deafferentation in adult monkeys, it has been suggested that cortical reorganization could account for some non-painful phantom-limb phenomena in amputees and that cortical reorganization has an adaptive (that is, pain-preventing) function. Theoretical and empirical work on chronic back pain has revealed a positive relationship between the amount of cortical alteration and the magnitude of pain, so we predicted that cortical reorganization and phantom-limb pain should be positively related. Using non-invasive neuromagnetic imaging techniques to determine cortical reorganization in humans, we report a very strong direct relationship (r = 0.93) between the amount of cortical reorganization and the magnitude of phantom limb pain (but not non-painful phantom phenomena) experienced after arm amputation. These data indicate that phantom-limb pain is related to, and may be a consequence of, plastic changes in primary somatosensory cortex.

Adult↗
PubMed2005

Supernumerary phantom limb after stroke.

The perception of a phantom limb is commonly reported after amputations. However, only a few cases have been described after a stroke. This article presents a patient who reported a supernumerary phantom limb (pseudopolymelia) after spontaneous intracerebral haemorrhage and discusses the possible underlying mechanisms for this rare phenomenon.

Aged↗