New pathophysiological interpretation of the so-called phantom limb and phantom pain syndromes.
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Humans↗
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Psychophysical correlates of phantom limb experience.
Phantom limb phenomena were correlated with psychophysiological measures of peripheral sympathetic nervous system activity measured at the amputation stump and contralateral limb. Amputees were assigned to one of three groups depending on whether they reported phantom limb pain, non-painful phantom limb sensations, or no phantom limb at all. Skin conductance and skin temperature were recorded continuously during two 30 minute sessions while subjects continuously monitored and rated the intensity of any phantom limb sensation or pain they experienced. The results from both sessions showed that mean skin temperature was significantly lower at the stump than the contralateral limb in the groups with phantom limb pain and non-painful phantom limb sensations, but not among subjects with no phantom limb at all. In addition, stump skin conductance responses correlated significantly with the intensity of non-painful phantom limb paresthesiae but not other qualities of sensation or pain. Between-limb measures of pressure sensitivity were not significantly different in any group. The results suggest that the presence of a phantom limb, whether painful or painless, is related to the sympathetic-efferent outflow of cutaneous vasoconstrictor fibres in the stump and stump neuromas. The hypothesis of a sympathetic-efferent somatic-afferent mechanism involving both sudomotor and vasoconstrictor fibres is proposed to explain the relationship between stump skin conductance responses and non-painful phantom limb paresthesiae. It is suggested that increases in the intensity of phantom limb paresthesiae follow bursts of sympathetic activity due to neurotransmitter release onto apposing sprouts of large diameter primary afferents located in stump neuromas, and decreases correspond to periods of relative sympathetic inactivity. The results of the study agree with recent suggestions that phantom limb pain is not a unitary syndrome, but a symptom class with each class subserved by different aetiological mechanisms.
Adult↗
Is the phantom limb really a phantom?
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Humans↗
Phantom limb pain.
A phantom limb is universally experienced after a limb has been amputated or its sensory roots have been destroyed. A complete break of the spinal cord also often leads to a phantom body below the level of the break. Furthermore, phantom breasts, genitals and other body areas occur in a substantial number of people after surgical removal or denervation of the body part. The most astonishing feature of a phantom limb (or other body area) is its incredible "reality" to the person. An examination of phantom limb phenomena has led to a new theory. It is proposed that we are born with a widespread neural network--the "neuromatrix"--for the body-self, which is subsequently modified by experience. The neuromatrix imparts a pattern--the "neurosignature"--on all inputs from the body, so that experiences of one's own body have a quality of self and are imbued with affective tone and cognitive meaning. The theory is presented with supporting evidence as well as implications for research.
Humans↗
Phantom limb and multiple sclerosis.
Phantom limb phenomena are most often associated with amputations, although they may accompany many neurologic disorders. In the neurologic variety, expression of illusory limbs varies with the level at which the somesthetic pathway is interrupted, and with changes in consciousness. Phantom limb illusions are rarely reported in patients with multiple sclerosis (MS). The patient reported here complained of a supernumerary phantom limb during an exacerbation of MS. This case suggests that in neurologic diseases, phantom limb illusions may result from distorted perception of limbs that are subject to both sensory loss and such recurrent spontaneous sensations as paresthesias.
Adult↗
Pathophysiology and management of phantom limb pain.
Phantom pain phenomenon is a poorly understood but relatively common sequela of limb amputation that may result in significant psychological and physical morbidity. In this review, proposed pathoneurophysiological mechanisms for the development of phantom pain are reviewed as well as psychological mechanisms that may be involved. The authors recommend an integrated approach to management of chronic phantom pain that takes into consideration the multiple factors that may contribute to its etiology.
Adult↗
Phantom limbs and related phenomena in recent traumatic amputations.
Seventy-three soldiers who had traumatic amputations were examined from 1 to 6 months after limb loss. All experienced phantom limb sensations and 67 percent experienced phantom limb pains, usually transient. Stump pain occurred in 43 percent and was associated with phantom pain in 54 percent of these. Of the 23 percent of the entire group who had evident stump pathology, 33 percent had phantom pains only, 20 percent had stump pains only, 40 percent had both, and 7 percent were pain-free. All stump ends exhibited an area of hyperpathia with hypoesthesia. Phantom pain probably results from peripheral or spinal cord mechanisms, or both, rather then from more rostral mechanisms.
Adult↗
Phantom limb phenomenon in patients with leprosy.
The phantom limb phenomenon (PLP) was studied in 42 patients with leprosy who had limb amputation and/or digital shortening; some of the patients also had another type of limb deformity, such as claw-hand or foot-drop, which did not involve significant loss of tissue. Thirty-eight (90 per cent) of the patients reported having at least one phantom limb (PL) for a missing or deformed part. Associated with each of the three types of limb defects, two descriptively and experientially distinct types of PLs were found: the paresthetic or typical (TPL) and the painless or natural (NPL). Descriptions of the TPL and the NPL are given. The findings were compared to various reports, particularly those of Stetter and Frederiks. The leprosy TPL was similar both to the PL of amputees as frequently described in the literature, and to what Stetter and Frederiks termed the PL sensations. A close correspondence, if not identity, was noted between the NPL of leprosy patients and the equivalent categories of Stetter's PL experience and Frederiks' PL as such. Included in these three designations are aspects of the PLP that are associated with the normal, intact limb; these aspects are thought to be usual concomitants of the PLP and to constitute manifestations of the persistence of the normal body image. From our findings, we conclude that for the appearance of a PLP, the actual loss of a part of a limb, whether slow or sudden, is not required, but the loss of its sensorimotor functions is sufficient.
Adult↗
Herpes zoster reactivation of phantom limb pain.
A case is reported in which a herpes zoster infection caused recurrence of phantom limb pain in a man whose left arm had been amputated 7 years previously. It is, to our knowledge, the first such case reported, and it shows the importance of peripheral mechanisms in the generation of phantom limb pain.
Herpes Zoster↗
The relation between limb dominance, acceptance of disability, and the phantom limb phenomenon.
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Adaptation, Psychological↗
Multiple phantom limbs in a child.
This case report describes multiple phantom feet in a child after amputation of a leg. The subject is a 16-year-old girl who was born with a right leg 10 cm shorter than the left and who at the age of 6 was amputated below the right knee so that she could wear a prosthesis that would give her normal mobility. The girl reports that she subsequently experienced 2 phantom feet and 3 sets of phantom toes which have persisted to the present time. Each phantom has a distinct size, length and position in relation to the others and each is also the site of vivid sensations such as heat, tickle, and fatigue as well as voluntary and involuntary movement. She also describes sensations that resemble sensations experienced before the amputation: one of her phantom feet feels flat and locked into a forward position which corresponds with the actual shape and position of her congenitally deformed amputated foot. The implications of multiple phantoms are discussed with reference to recent concepts of phantom limbs.
Adolescent↗
Phantom limb pain treated by electrical stimulation.
Twenty patients suffering from phantom limb pain were assessed for suitability for treatment by electrical stimulator implant to the peripheral nerve or the spinal cord. Twelve were so treated and seven obtained excellent and three partial relief of pain. One patient maintains excellent relief of pain by trancutaneous electrical stimulation. Factors that might influence the responsiveness of pain to electrical stimulation and the qualitative results from such treatment are discussed.
Electric Stimulation↗
A burning issue. Phantom limb pain and psychological preparation of the patient for amputation.
Fantasies concerning an amputated limb can contribute to the occurrence of persistent phantom limb pain. We report a case in which burning pain perceived as located in the amputated lower extremities was related to the patient's feelings about incineration of the removed limbs against her wishes. Hypnotherapy involving elucidation of the fantasy and suggestion was successfully employed in this case and may be a helpful approach in other such cases. Importantly, adequate preparation of the patient for amputation, including an awareness of concerns about the disposition of the limb, may help prevent pathological limb sensations.
Adolescent↗
Treatment of phantom limb pain with muscular relaxation training to disrupt the pain--anxiety--tension cycle.
Sixteen phantom limb pain patients were treated with a combination of (1) progressive muscle relaxation exercise, (2) feedback of stump and forehead muscle tension, and (3) reassurance about normal phantom sensations and the relationship between anxiety and pain. Fourteen of the patients had chronic pain (average of 12 years) and two were recent amputees (5- and 1-week). At the end of treatment, 8 of the chronic patients showed virtually complete relief from pain, 4 showed significant decreases to a point at which they no longer desired treatment and 2 showed no significant change. Both recent amputees showed complete relief from pain. These changes have been sustained for follow-up period of 6 months to 3 years. The 2 unsuccessful patients did not learn to relax and had strong psychological needs for their pain.
Anxiety↗
[Unusual use of reflexotherapeutic technics for control of pain in cases of phantom limb. Spinal and supraspinal theory].
Treatment of selected cases of amputees suffering from phantom-limbs pains by means of unusual techniques of reflexotherapy is reported. Nose, hand and foot acupuncture and classical auricolotherapy demonstrate in the patients here reported the beneficial effect of these methods. Nosologic, pathologic, clinic results and the anatomo functional mechanisms through which the therapeutic action of reflexoterapy can be explained are discussed. Spinal and trigeminal-reticulo-spinal pathways (central biasing mechanism) are postulated as inhibitory control system for somatic afferences.
Acupuncture Therapy↗
[Problems of peripheral nerve surgery in amputation stump pain and phantom limbs].
Follow-up examination of 17 patients with severe and lasting stump and phantom limb pain which could not be improved by analgetics and who then underwent surgical procedures at the neuroma. The results were discouraging. Only 2 patients showed a lasting improvement. Resection of the neuroma and injection of alcohol into the neuroma seem to be successful only if the preoperative history of pain is very short or if there is an isolated injury of a peripheral nerve and a subsequent single neuroma.
Amputation Stumps↗
The care of patients with phantom limb pain in a pain clinic.
Patients referred to the Pain Clinic at the University of Virginia Medical Center with genuine phantom pain rather than stump pain have been treated by a variety of technics. Simple revision of drug therapy has proved helpful in some instances, as has repeated injection of trigger areas or neuromata, though surgical excision has proved necessary in some patients. Mechanical stimulation by stump tapping, prosthetic application, or electrical transcutaneous stimulation also may be useful. Sympathetic nerve block is occasionally very rewarding. Most patients need some form of psychological therapy. Rarely is cordotomy or higher central nervous system surgery required. There is no single best mode of therapy for phantom limb pain, nor can patients be guaranteed a permanent cure.
Autonomic Nerve Block↗
[Stereotaxia in phantom-limb-neuralgia and causalgia (author's transl)].
Intractable pain is an important indication for stereotactic operations in deep structures of the brain. The targets are situated in primary and secondary sensomotoric regions of the thalamus, dependent or independent on cortical areas. In clinical practice it is necessary to combine two or three targets in the thalamic nuclei. In more than 25% the destruction of parts of the emotional pain-perception is necessary (ncl. dorso-medialis). The results os stereotactic operations in 32 patients with causalgia and phantom-limb-neuralgia are analysed.
Causalgia↗