Explore
Phantom limb pain (PLP) is pain that arises in the missing limb after amputation and can be severe, intractable, and disabling. Various medications have been studied in the treatment of phantom pain. There is currently uncertainty in the optimal pharmacologic management of PLP. Objectives
What is phantom limb pain and how is it treated?
We review recent evidence for the efficacy of targeted muscle reinnervation, repetitive transcranial magnetic stimulation, imaginal phantom limb exercises, mirror therapy, virtual and augmented reality, and eye movement desensitization and reprocessing therapy.
What is the best treatment for phantom limb atrophy?
Katz J, Melzack R. Auricular transcutaneous electrical nerve stimulation (TENS) reduces phantom limb pain. J Pain Symptom Manage.
What is the role of electrical stimulation in the treatment of phantom limb?
Three case histories are presented in which amputees with acute or chronic phantom limb pain and phantom limb sensation were treated with Western medical acupuncture, needling the asymptomatic intact limb. Two out of the three cases reported complete relief of their phantom limb pain and phantom limb sensation.
Can acupuncture help amputees with phantom limb pain?
What is mirror therapy for phantom limb pain?
Mirror therapy is a type of therapy that uses vision to treat the pain that people with amputated limbs sometimes feel in their missing limbs. Mirror therapy does this by tricking the brain: it gives the illusion that the missing limb is moving, as the person looks at the real, remaining limb in a mirror.
What is the most effective treatment for phantom limb pain?
Medications used in the treatment of phantom pain include:Over-the-counter (OTC) pain relievers. Acetaminophen (Tylenol, others), ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve) might relieve phantom pain. ... Antidepressants. ... Anticonvulsants. ... Narcotics. ... N-methyl-d-aspartate (NMDA) receptor antagonists.
Can physical therapy treat phantom limb syndrome?
Physical therapists use a variety of treatment options to help people with phantom limb pain. Physical therapists are movement experts. They improve quality of life through hands-on care, patient education, and prescribed movement. You can contact a physical therapist directly for an evaluation.
How do you treat phantom limb pain?
Non-Medication Treatments for Phantom Limb PainAcupuncture.Massage of the residual limb.Use of a shrinker.Repositioning of the residual limb by propping on a pillow or cushion.Mirror box therapy.Biofeedback.TENS (transcutaneous electrical nerve stimulation)Virtual reality therapy.More items...
How does mirror therapy work?
Mirror therapy uses a mirror to create the illusion that the arm or leg affected by the stroke is moving. After a stroke, mirror therapy can improve movement in affected upper or lower limbs and activities of daily living, and appears useful as a supplement to other stroke rehabilitation activities.
What is a phantom limb?
Phantom limb syndrome is a condition in which patients experience sensations, whether painful or otherwise, in a limb that does not exist. It has been reported to occur in 80-100% of amputees, and typically has a chronic course, often resistant to treatment.
How does tens help phantom limb pain?
Another way in which TENS can relieve phantom limb pain is that the electrical impulses increase blood flow and reduce muscle spasms at the amputation site. One of the greatest advantages of TENS therapy is that the treatment is completely noninvasive, and there are no risky medications involved.
What are phantom exercises?
One of the less investigated strategies for the management of PLP is phantom motor execution (PME), also known as phantom exercises. PME involves the imaginary movement of phantom limb in the brain along with the performance of certain actual physical movements.
Does exercise help phantom pain?
CONCLUSION: Phantom exercises appear to be effective in reducing phantom pain, but further research is required to confirm this. The results of this study indicate that phantom exercises can be used safely to alleviate phantom limb pain in lower and upper limb amputees.
How do you deal with a leg amputation?
How to Cope With an AmputationAcknowledge Your Feelings. Acknowledging your feelings can help you heal and move through the grieving process. ... Express Negative Emotions. ... Connect With Others. ... Find a Purpose. ... Set Meaningful Goals. ... Create a Daily Routine. ... Embrace Optimism.
What type of pain is phantom limb pain?
Phantom limb pain is considered a neuropathic pain, and most treatment recommendations are based on recommendations for neuropathic pain syndromes.
What are some pain management strategies?
Aggressive pre- and post-operative pain management strategies that encompass a combination of different therapies have been effective in treating the pain, he noted. Besides medication, non-pharmacological strategies include acupuncture, meditation, physical modalities such as heat, ice, and electrical stimulation (TENS), and getting back to function using a prosthesis.
What is PLP in amputation?
Unfortunately, many of these individuals (as well as people who’ve lost a limb in accidents or for other reasons) suffer from a condition called phantom limb pain (PLP), whereby the patient feels pain in the lost limb. “ Phantom limb pain continues to be a common problem for most individuals with acquired limb amputation, ...
How does mirror therapy work?
In mirror therapy, patients view the reflection of their good limb in a mirror and move it. When the brain observes the intact limb moving, the reflection gives the brain visual feedback it wasn't receiving previously and relieves the pain.
How does the brain feel when a patient's hand is clenched?
Put another way, say a patient has pain from a perceived cramp in a tightly-clenched fist that no longer exists. By watching the action of the still intact hand clenching and unclenching in the mirror, the brain receives the visual feedback it needs to "unclench" the non-existent/phantom hand. It's a little like scratching an itch that couldn't be accessed.The image stops the pain.
Does mirror therapy reduce pain?
Shepetofsky theorizes that in terms of pain reduction with mirror therapy, it may be that when patients visualize the lost limb while “moving” it might result in a slight decrease in the way the patient perceives the pain. “I am not convinced but I do think there are great psychological benefits from the patient having the experience of mirror therapy,” he explained.
Is phantom limb pain a problem?
Despite mirror therapy and other forms of treatment, phantom limb pain continues to be a problem for some patients. “Therefore we are actively pursuing additional research to better understand the central and peripheral nerve changes associated with acquired limb loss,” Dr. Pasquina explained. “We hope that by better understanding the underlying mechanisms behind the pain, we might be better able to target future treatments.”
How does PLP work after limb amputation?
After limb amputation, an individual’s cortical and peripheral body representations remain intact , but no longer correspond, and this mismatch is enhanced by a lack of visual feedback from the missing limb, thus genera ting excessive pain, in spite of the lack of a sensory stimulus (20). A study investigating the relationship between body representation within a dream and the experience of PLP found a positive correlation between increased PLP after lower limb amputation and the ability to recall intact body representations (21). These findings suggest that aversive somatosensory experiences mediate the skewed interactions between mental and physical body representations, which then facilitate PLP (21).
What is the sensation of an amputated limb?
Amputations cause changes in both the PNS and CNS, including the emergence of phantom limb sensations (PLS), characterized by the feeling that the amputated limb is still present. Most amputees experience PLS and can even control phantom movements, such as wiggling toes or opening and closing the hand, immediately after surgery (1, 2). The majority of amputees also experience intense episodes of pain throughout the missing limb that are termed phantom limb pain (PLP), characterized by throbbing, stabbing, electric shock sensations, and even cramped and painfully immobile limb sensations (3).
What are the structures that are affected by amputation?
Somatosensory and motor cortices may not be the only areas affected by amputation. Subcortical structures, including the thalamus, may also be reorganized (15, 19, 37). Changes at the subcortical level may originate in the cortex and cause reorganization through strong efferent connections to the thalamus and lower structures (37). It is also possible that reorganizational processes begin at the thalamic level and changes are relayed up to the cortex (19). In an effort to map the thalamus in amputees, researchers using microstimulation and microelectrode recordings found that the representation of the residual limb in the thalamus was enlarged compared with that of corresponding areas of individuals with intact limbs and that thalamic stimulation could evoke PLS and even PLP in amputees (38).
What is PLP pain?
Considered a neuropathic pain or “complex pain state of the somatosensory nervous system” (13), PLP is thought to be driven by CNS abnormalities. However, research investigating the contribution of the PNS and its function also needs to be considered (14). While the mechanisms underlying PLP remain unclear, it is known that sensitized and reorganized nerve endings and cell bodies within the peripheral limb affect the CNS, causing changes in somatosensory processing pathways (15). PLP presents a considerable impairment to amputees’ quality of life, and a better understanding of its pathophysiology and etiology could lead to new modalities to alleviate the suffering it causes. This Review aims to provide up-to-date knowledge regarding the current state of PLP theories, research, and therapies.
What is the mechanism of PLP?
Another possible mechanism underlying PLP is proprioceptive memory. Proprioception is the brain’s awareness of the position of the body’s limbs in 3D space. Amputees continue to have proprioception of missing limbs, including both voluntary and involuntary movements. A voluntary movement sensation includes an amputee’s attempt to move the phantom limb, while an involuntary movement sensation is the feeling of the limb being frozen or sporadically moving on its own (32). One theory posits that the proprioception needed to perform specific tasks may be incorporated into a “proprioceptive memory” that aids us in accomplishing the tasks more quickly and efficiently in the future (41). When an amputation occurs, memory engrams of the limb are retained even though visual feedback confirms limb absence (Figure 1B). Supporting this theory is a study of limb repositioning after regional anesthesia, with patients reporting that their limbs remained in the last position they remembered before anesthesia (42). It is also possible that proprioceptive memories provide a protective feature, serving as a reminder of painful situations and how to remedy them, such as moving a joint out of hyperextension without having to confirm with visual feedback (41). Thus, certain positional movements with the phantom limb may trigger these painful proprioceptive memories. Amputees have reported feeling their phantom limbs stuck in the last positions they remembered prior to amputation, supporting a stored proprioceptive memory as the final feedback from the limb (43).
How does the brain work with amputation?
For instance, vision primarily guides hand movements toward a target. While the hand is moving, the brain receives proprioceptive feedback regarding the location of the limb relative to the body. The brain coordinates each piece of information to complete the directed movement. With an amputation, visual feedback of the now-removed limb is no longer available. However, proprioception regarding the location of the once-intact limb still remains, either through proprioceptive memories or activation from the residual limb nerve endings. Perhaps the inability to visualize the amputated limb is insufficient to override the proprioceptive information from the residual limb. An alternative possibility is that the brain’s interpretation of conflicting signals from the two systems resurrects a phantom limb. The fact that visualization therapies have been relatively successful at reducing PLP implies that the accuracy provided by both visualization and proprioception may be critical in reducing PLP (44).
How does axotomy affect the DRG?
The nature and time course of morphological changes in the DRG cell body following axotomy have been documented by a number of investigators (reviewed in ref. 52). Histological and biochemical evidence show that the cellular metabolic machinery is modified dramatically, which is described as a “phenotypic change” in the neuron (53). Although some changes are related to the growth response at the end of the residual limb, other changes occur at the axonal extensions into the spinal cord dorsal root. Modifications of the central terminals of transected axons could induce further “phenotypic changes” in the postsynaptic neurons, and the surrounding supporting elements and hundreds or even thousands of gene and protein changes occur in the transected neurons (52). Changes in the DH begin within minutes after the pattern of sensory input changes; central sensitization also begins within minutes (54), and the amplitude of the spinal reflex changes (55). It is likely that similar alterations in neuronal responsiveness occur centrally within minutes of nerve transection.
What databases use phantom limb?
MEDLINE, EMBASE, CINAHL, British Nursing Index, Cochrane and psycINFO database s were searched using “Phantom limb” initially as a MeSH term to identify treatments that had been tried. Then, a secondary search combining phantom limb with each treatment was performed to find papers specific to each therapy. Each paper was assessed for its research strength using the GRADE system.
How many treatments were used to treat PLP?
In 1980, Sherman identified that 43 treatments had been used to control PLP13and since that time, multiple drugs, surgery and complementary therapies have been added to the list. According to a recent Cochrane review of pharmacologic interventions for PLP, there is inconclusive evidence for any single therapy.14
How many therapies were identified for mirror therapy?
Thirty-eight therapies were identified. Overall, the quality of evidence was low. There was one high-quality study which used repetitive transcutaneous magnetic stimulation and found a statistical reduction in pain at day 15 but no difference at day 30. Significant results from single studies of moderate level quality were available for gabapentin, ketamine and morphine; however, there was a risk of bias in these papers. Mirror therapy and associated techniques were assessed through two systematic reviews, which conclude that there is insufficient evidence to support their use.