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PHANTHOM LIMB PAIN
Definitions
Phantom sensation: non painful sensation of the
missing limb
Phantom pains:is a noxious sensation where the
limb existed
Stump pain:is the pain that is restrictedto the
amputated site
Phantom Pain coined by Silas Weir Michel in 1892
Common descriptions of phantom pain
Incidence
50-80% of amputees feel pain in the missing limb.
begins immediately after the arm or leg has been removed and it may last for years.
In over half of the cases, the phantom limb sensations decrease gradually.
not related to age, sex, location of the amputation, or reason for the amputation (e.g. trauma vs. disease).
Onset and Duration
Several studies have shown that 75% of patients with PLP develop pain within the first few days after amputation.
One study of 58 amputees found incidence of PLP to be 72%, 65% and 59% after 1 week, 6 months and 2 years. (Jensen, et al 1985)
Another study of 56 amputees showed that although the incidence and intensity of pain remained constant, the frequency and duration of pain attacks decreased significantly. (Nikolajsen, et al 1997)
Phanthom Phenomena
Phanthom Limb Phanthom Pain Stump Pain Super added Phanthom Referred Phanthom
Sensation
60% and 80% of amputees experience PLP (Nikolajsen and Jensen., 2000)
Stump Pain
Somatic stump pain usually resolves as the wound heals
Can trigger Phantom painProlonged stump pain usually attributable to local
pathology – delayed wound healing, infection, surgical complications, poor prosthetic fit, neuromas, adherent scars
Late onset stump pain - neuromas, prosthetic fit, claudication, bony overgrowth, osteoarthritis , tumour recurrence
Phantom Pain vs Sensation
Phantom limb Sensation – almost universaldoesn’t correlate with pain reports
Non-painful phantom sensations of 3 types:Kinetic senstations (movement)Kinesthetic (size,shape,position)Exteroceptive (touch, pressure, temperature, itch,
vibration)
Refferred Phantom Sensation
Telescoping of the Phantom Limb
PLP Onset
Mostly onset immediately after amputation, some at two weeks. Rarely months later
1/3 maximal immediately post-op and generally resolved by 100 days
½ slowly peaked then improved within 100 days¼ slower rise toward maximal pain
(Weinstein, 1996)
Prognosis
When PLP persists 6 months, prognosis for spontaneous improvement is poor
Probably <10% have persistent severe pain
Sensations felt by an amputee
A Little Man on the top
Mechanisms of Phantom Pain
Following a nerve cut, formation of neuromas are seen, which show spontaneous and abnormal evoked activity following mechanical and chemical stimulation. (Amir, et al 1993)
Percussion of stump/neuromas induces stump and PLP; increased activity of afferent C fibers (Nystrom, et al 1981)
Spinal Plasticity
After nerve injury, C-fibers and A delta-afferents gain access to secondary pain signaling neurons . This is manifested by mechanical hyperalgesia and expansion of peripheral receptive fields. (Doubell, et al 1999)
Increased activity of NMDA receptor; central sensitization can be reduced by NMDA antagonists such as ketamine. (Eichenberger, et al 2008)
Anatomical reorganization
Peripheral nerve damage can lead to degeneration of C-fiber afferent terminals in laminae II.
As a result, central terminals of Aβ-mechanoreceptive afferents (which normally terminate in laminae III and IV) sprout into laminae I and II. (Woolf, et al 1992)
Ultimately, this results in increased general excitability of spinal cord neurons.
Sympathetic nervous system role
Application of norepinephrine or activation of post-ganglionic sympathetic fibers excites and sensitizes damaged (not normal) nerve fibers. (Devor, et al 1994)
Sympatholytic block can abolish neuropathic pain, but pain can be rekindled by injection of norepinephrine under the skin. (Torebjork et al 1995)
Cerebral reorganization
One study of adult monkeys revealed cortical reorganization in which the mouth and chin invade cortices corresponding to arm and digits. (Dotrovsky, et al 1999)
In humans, similar reorganization has been observed using magnetoencephalographic techniques and there was a linear relationship between pain and degree of reorganization (flor, et al 1998)
Sussman (1995)
Assessment Tools
Visual Analoque ScaleUniversal Pain ScoreMacgill Pain QuestionaireFunctional Independence Measure
Treatment: A Multidisciplinary Approach
Treatment Approach
Non-Medical and Medical/SurgicalPrevent contracturesLimit oedemaAdequate Post-op AnalgesiaDesensitisation - massage/bandagingGet patient moving, distraction helpsEarly prosthetic training
Treatment Options
TENS/Ultrasound/MassageVibration TherapyAcupunctureRelaxation techiniquesBiofeedbackProsthesis trainingSensory discrimination trainingElectroconvulsive TherapyMirror TreatmentCognitive Behavioural Therapy
(Conine 1993)
TENS
Topographically relavant afferent signals from intact limb through transcallosal fibres activates cortical
area which acts as afferent input from missing limb (Orazio, 2010)
PARAMETERS:
Type: Conventional or Burst TENS
Pulse Frequency: 10-200 pps
Pulse duration: 100-250 ms
Area of application: Over stump, Contralateral limb, main nerve bundle, dermatome, across spinal cord, auricles
(Mark Johnson,2009)
BEST POSITION: Contra lateral TENS application????
(Winnem, 1982)
Mirror Box therapy
Ramachandran created a method of using mirrors to provide the brain with the missing visual stimulation.
The reflection of the intact limb is optically superimposed on the location of the amputated limb (Phantom Limb), tricking the brain into thinking that the Phantom Limb is real.
“MIRROR NEURONS”
Principle for MT
Visual feedback as a substitution for missing proprioceptive feedback will reduce pain
To fool the brain and to achieve normal interaction between motor intention to move the limb and the sensory feedback through mirror
(Ramachandran, 2000)
How to use mirror box
A box with mirror on sides is placed in front of the client.
The normal leg is placed on the side of the box in such a way to see it’s reflection on the mirror.
Then client is asked to move his/her normal limb
Daily use of the mirror for 30 min/day is beneficial
Exercise Protocol for MT
Brodie et al(2003) explained the procedures of the exercises to be performed
Duration of exercising 20 minutes daily(Serin et al 2013)
Neuromas
Localized pain, sharp/shooting/paraesthesiaReproduced by local palpation, relieved by LA
injectionSocket correction and local steroid/LA injectionPhenol alcohol injection into neuromaSurgery – not much evidence, high recurrence rateULTRASOUND/TENS/SENSORY
REINTEGRATION TECHNIQUES
Managing Phanthom Pain
Daily 30 minutes of MBT TENS over stump/normal extermityWeight bearing on the stump using temporary
prosthesisMassageSensory integration techniuesRelaxation techniquesStump Strengthening exercisesProper positioning of stumpApplying crepe bandage to the stump
Pre operative PT role is crucial..!
THANK YOU