Ever heard people complain of pain in a body part that no longer exists? Doesn’t this sound weird? But, phantom pains are very real and a concept that’s so misunderstood.
Phantom pain is a common symptom after the amputation of a limb. Further, studies have shown that almost 50%- 80% of amputees have phantom pain symptoms. Mitchell in 1872 coined the term phantom limb.
Amputations are nothing but removal of a body part due to a variety of reasons. Some of the common reasons for amputation includes,
Peripheral Artery Disease (PAD) is a very common phenomenon in diabetes. This condition can cause the blood vessels of the extremities to narrow down and this reduces blood flow to the limbs. Further peripheral neuropathy can cause a person to lose sensations in a particular body part.
This leaves us devoid of any sensation. If any injury occurs in that particular body part we might not give the needed attention. Further, reduced blood flow to that body part might delay healing. This blows out a severe infection leading to removal or amputation of that part.
Most of the upper body part amputation often result as a sequela of trauma. This could be from wars, road traffic accidents, physical violence etc. Amputation is the last resort of treatment option (when the infection is severe and the damage is beyond repair).
In case of large inoperable tumours. Especially the ones that involve the major bones or muscles.
Apart from these major reasons there are certain other reasons too that can lead to an amputation.
MECHANISM OF PHANTOM PAINS AFTER AMPUTATION:
The cause of this pain is not very clear. Ambroise Paré in 1552 was the first person to describe this phenomenon. He stated that peripheral factors, as well as central pain memory, cause phantom limb pain. This pain usually occurs in a previous area of injury. The brain is tricked into thinking that the limb is still present. The signal is interpreted as pain regardless of the signal from the injured nerve.
Originally this was thought to be a problem of psychological origin. But, with later researches, this was proved wrong. Apart from a lot of theories that revolve around phantom pain mixed sensory outputs are also commonly cited reasons. Further, damaged nerve endings, scar tissue, and certain memories of the pre-amputated legs are also seen as reasons.
MRI’s and PET scans showed neural activity in certain parts of the brain that were connected with the amputated limb. This clearly shows us that the brain loses signals to the amputated body part and adjusts to this loss in ways we cannot understand. Hence, basic sensations like pain is used as a choice by the brain to express that something does not feel right.
Firstly, the person will feel a sensation of pain in the area where the limb was amputated. This pain can be related to a certain position or movement of the phantom. Further, a range of physical factors can elicit or exacerbate the pain.
Phantom pain is very common in the arms and legs. But, it can also be felt after the removal of other body parts like the breast.
NATURE OF THE PAIN:
Shooting pain (stabbing pain) is the most common symptom. In addition, tingling, cramping, heat and cold sensation are common (especially in the distal regions). However, these sensations gradually decrease or disappear with time.
Patients often report feeling of movement or itchiness.
Electric sensations and other types of paraesthesias are also common. Changes in weather and pressure in the residual limb can exacerbate pain. Further psychological factors like emotional stress, anxiety worsen the situation.
ONSET OF PAIN:
The pain often starts within a week post-amputation. However, this differs from person to person.
Further, if the symptoms persist for more than 6 months the prognosis is not good.
RESIDUAL LIMB PAIN OR STUMP PAIN:
Oftentimes, people tend to confuse residual limb pain and stump pain. This is due to the nature of the pain and the time of occurrence. Both residual limb pain and phantom pain occurs at the same time. The main difference between phantom pain and residual pain lies in the fact that residual limb pain occurs in the part of the limb that remains after amputation. Further, residual limb pain may be caused by
- Underlying infections
- Increased pressure in the skin
- Limited blood supply to the limb
- Moreover, issues with the fit of the artificial limb or body part prosthesis.
MEDICAL MANAGEMENT OF PHANTOM PAINS:
Drugs can effectively manage these pains. The trick lies in accurately diagnosing this condition. Differentiating between phantom pains and residual limb pains might be tricky. Clearly stating your symptoms and circumstances under which the trauma of the surgery happened can help the doctor accurately diagnose the underlying issue.
- Medications like painkillers (over the counter) might help manage the pain effectively. However, limit the intake of these drugs. It is better to take them in accordance with a doctor’s prescription. Overuse of these drugs can lead to serious addiction issues. This could lead to an array of problems.
- Prescribing narcotics (opioids) have helped in some cases. This includes drugs like morphine, codeine etc. Similarly, these drugs can also cause serious addiction issues. Certain side effects of narcotics include nausea, vomiting, sedation or constipation.
- NMDA’s (N-Methyl D Aspartate receptor antagonist) effectively manage phantom pains. These are a group of anaesthetics. They block certain receptors present in the brain’s nerve cells (neurons). These, in turn, block the production of glutamate. Glutamate is proteins that play a vital role in relaying nerve signals. This avoids pain. Side effect includes hallucination, mild sedation and loss of consciousness (LOC).
- Tricyclic antidepressants are a part of management. They try to ease the pain by altering certain chemicals in the body that sends pain signals.
- Anti-convulsants are drugs that treat seizures. These drugs manage phantom pains. Certain anticonvulsants help with nerve pain.
OTHER MODALITIES OF PHANTOM PAIN MANAGEMENT:
Apart from management with drugs, other commonly used modalities include,
MIRROR BOX THERAPY:
Mirror therapy uses a mirror between the intact limb and the absent limb. This tricks the brain into believing that the intact limb is the absent limb. This setup allows a professional to treat the intact limb as if it were the absent limb.
For instance, a patient had the fingers of his left hand amputated due to an infection. Seat the person comfortably. Rest both the intact and amputated hand on a table. Place a mirror between the two hands. The patient perceives that he folds or moves the fingers of the amputated hand. While perceiving he/ she should move the actual fingers of the intact hand.
The brain is tricked into believing the movement of the fingers of the amputated hands. Moreover, this gives a sense of relaxation to the brain and lessens the pain and discomfort. This is a very effective way of treating phantom pains. But, the drawback is it may not work for everyone. The patient must be mentally and physically ready to try out the treatments. They should be persistent and patient.
Nerve stimulation is mainly through transcutaneous electric nerve stimulation (TENS). These devices send weak electric signals through small patches that can be stuck on the skin. These electric signals can interupt pain signals before they reach the brain.
Acupuncture can also relieve pain effectively. It involves the insertion of small needles at specific parts of the skin. This can aid in the release of chemicals that are helpful in pain management.
SURGICAL AND MEDICAL MANAGEMENT:
SPINAL AND BRAIN STIMULATION:
Surgery is also an option of management. Done in cases that do not respond to meds or therapy. Spinal stimulation involves the use of certain electrodes along the spinal columns. These electrodes send small electric signals through the spine that help in managing the pain.
Similarly, brain stimulation uses these electrodes at parts of the brain. Both these modalities are under research.
A REVISION SURGERY:
A last resort of managent is a revision surgery. When the nerve root is the main problem, performing revison surgery is mandatory.
In this, the surgeon may perform a surgery on the stump region.
The term ‘CRYO’ means extreme cold and ‘ABLATION’ means destruction or removal. Cryosurgery is a surgical technique that use extreme cold temperature to freeze off or remove body parts.
Studies have that cryosurgery could be extremely helpful in treating phantom pains. This is an image-guided procedure. Select the point of limb loss. Insert a probe needle through the skin. Expose the local nerve endings at that sight to cryo blast for a period of 25 minutes. Further, this method was proven to show reduced levels of pain in patients with phantom pains.
To sum up, even though this is a mysterious phenomena, there are a lot of ways to handle the pain and distress this condition causes. The most important thing is observing the body and answering its needs in a timely manner. This simple thing could save us from a lots of distress.