Phantom Limb: Possible Treatments to Kill the Pain Essay

The phenomenon of darkness sleeve was first described by a French doctor, Ambroise P be, in the 16th century however it was not until 1866, later the American obliging War, when Doctor Wier Mitchell published his first account of the malady, coining the term Phantom subdivision. Phantom offset is the fellowship of persisting sensory perceptions later limb amputation and remains one of the best-known, but puzzling phenomena within medical erudition (Oakley & Halligan, 2002). Phantom limb chafe (PLP) is a frequent consequence of the amputation and ca intents hanker discomfort and disruption of daily activities.Originally, PLP was thought to adjudge been secondary to philia damage at the site of amputation but succeeding evidence showed that patients who pretend undergone regional anesthesia continue to experience phantasma limb throe condescension the cut-off of wound sensation to the amputated area (Melzack, 1997). This lead to the belief that the pain sensation e xperienced by patients with PLP may be due to philia impulses or signals generated at the spinal cord level. This, however, was refuted on the basis that patients with transection of the spinal cord still opine of persisting ghost limb pain.It has been argued then(prenominal) that the mavin areas that correspond to the human soulfulnessate could be the one trus iirthy for the phantom sensations (Melzack, 1997). This was based on the fact that much of the human (and primate) body is represented by distinct brain areas located in the somatosensory and motor cortex on either side of the central sulcus. Consequently, heretofore later on limb removal, the brain areas representing those parts remain structurally and structurally intact.It has been argued that the activation of these bodily disconnected brain areas by adjacent brain areas (representing opposite intact body parts) may be a partial(p) neurophysiological explanation for the production and maintenance of the con tinuous perceptual experience that is the phantom limb. This functional remapping results in some human faces in the referral of discriminating sensory reading from an intact body area (such as the exhibit or shoulder) to the phantom limb (Halligan, Zeman and Benger, 1999).The remapping hypothesis is supported by functional imaging (Kew, Halligan, Marshall, Passingham, Rothwell, Ridding, Marsden and Brooks, 1997) and behavioural studies (Ramachandran, Stewart and Rogers-Ramachandran, 1992 Halligan, Marshall, Wade, Davies and Morrison, 1993). Given the magnitude and speed of onset of the reorganization (within 24 hours of amputation) it is unlikely to be a product of neural pullulate but rather the unmasking of existing but previously envision neural pathways (Ramachandran and Blakeslee, 1998).In addition, these abnormal plastic changes in the central vile system associated with the phantom experience direct been utilise to explain the systematically high incidence of pai n attributed to a limb that no weeklong exists (Ramachandran and Blakeslee, 1998). Several some some different theories comport been proposed to explain the pathophysiological processes behind the PLP phenomenon but despite all of these, the exact cause of PLP remains uncertain. As a consequence, the received preachings for the destine are just as varied as the litany of many practicable yet complex mechanism of PLP.This literary review pull up stakes assay the possible interposition options available for the management of PLP use information from published books through searches in research databases using the keywords phantom limb, phantom limb pain, biofeedback, intervention, and phantom limb illusions. Treatments of PLP There are diametric modalities available in treating PLP ranging from pharmacological agents to psychophysiological therapy. The interference outcome varies from memory access to move up and much even from patient to patient.A careful evaluatio n is intrinsic before considering any of of these treatments in order to obtain a more individualized approach in the management of PLP. Thermal biofeedback Biofeedback relies on orchestration to measure moment-to-moment feedback about physiological processes. It provides patients with information about their performance in various situation (Saddock & Saddock, 2003). using this electronic feedback, the patient is made informed of certain sensations such as skin temperature and muscle accent.A flake report describing the use of thermal biofeedback combined with electromyogram (EMG) in treating a 69-year-old man despicable from burning and shooting phantom pain suggested that biofeedback is an utile treatment modality for severe phantom limb pain (Belleggia & Birbaumer, 2001). The rule behind the treatment was based on the premise that most patients complain of intolerance to cold afterward amputations which tend to aggravate unpleasant or pain sensations in the dais.The tr eatment, however, required several(prenominal) sessions and in this particular suit of clothes, at that place were 6 sessions of EMG biofeedback followed by another 6 sessions of temperature biofeedback. The patient presented in this brass also did not use a prosthetic device and did not receive prior(prenominal) treatment for chronic pain and the entire treatment process was done in a controlled environment where everything is calibrated and maintain to avoid external bias.Although the treatment outcome of the look report was favorable, in that respect is no absolute guarantee that the same beneficial results can be expected to other patients with PLP especially to those who are already using prosthesis and to those who are already unflinching to previous chronic pain therapies. overly its ability and adaptability in certain clinical settings remains to be studied. Electroconvulsive therapy ( electroshock) The use of electroconvulsive therapy have been common in patient s with psychiatric disorders such as depression.This involves the utilization of electric stimulation by means of two electrodes placed bilaterally on the temple to produce convulsion. The artificial seizure that followed have shown efficacy in patients with a variety of pain syndromes occurring along with depression (Rasmussen & Rummans, 2000). Using this evidence, 2 patients with severe phantom limb pain refractory to eight-fold therapies but without concurrent psychiatric disorder were treated using ECT. ane of the patients previous treatments included biofeedback, percutaneous electrical nerve stimulation, hypnosis, epidural injections, and three-fold analgesic medications including non-steroidal anti-inflammatory drugs, opiates, and adjunct analgesics including carbamazepine and nortripty parenthood. He was referred for ECT by the anesthesia pain service due to previous grievous responses in depressed patients with a variety of non-phantom limb pain syndromes.The other pat ient in the case turn over also had numerous treatments including transcutaneous electrical nerve stimulation, intra-axillary alcohol injections. Epidural steroid blocks, stellate ganglion blocks, biofeedback, and medications including antidepressants, benzodiazepines, opiates and carbamazepine. after(prenominal) ECT, both patients enjoyed substantial relief of pain with one case in remission from PLP 3. 5years after ECT. From this clinical note, it was concluded that patients with PLP who are refractory to multiple therapies may respond to ECT.It should be emphasised that ECT have several complications including dental and muscular injuries secondary to the severe muscle twitching sequential the induced convulsion. The concurrent use of muscle relaxants have been workive in minimizing such injuries. The most troublesome side effect of ECT, however, is memory deprivation. whatever patients report a gap in memory for events that occurred up to 6 months before ECT, as well as i mpaired ability to persist in new information for a month or two after the treatment (Smith, et al, 2003).You may equate this to the data loss in computers after an unexpected reboot. Hypnotic reflects and phantom pain Hypnotic procedures have long been used in treating a variety of pain syndromes. This involves the use of shadow and tomography to alleviate the patients pain experience (Chavez, 1989). A case translate reports the use of a hypnotically induced practical(prenominal) mirror experience which modified long standing intractable phantom limb pain despite gene rate a qualitatively inferior experience of feces in the phantom limb compared to that produced with an actual mirror (Oakley & Halligan, 2002).Using hypnosis, two main approaches to substituteing phantom limb pain experience were identified in the study ipsative imagination approach and a simulated exercise approach. The ipsative imagery approach takes into account the way the individual represent their pai n to themselves and attempts to modify that representation in order to alleviate the pain experience. The movement imagery-based approach encourages the PLP patient through hypnosis to move the phantom limb and to take control over it.In the study, a case of a 76-year-old woman who had an above-knee amputation of her proper(a) leg secondary to peripheral vascular disease was presented. The investigators emphasized that she was unpainful at the time of her operation and that her PLP only begun two years after surgery. There were several components of her pain in her missing limb. She complained of feeling pins and needles in her foot, her toes felt like they were being held in a rigorous vice, a slicing, cutting pain in the sole of her foot and a chiselling pain in her ankles.After several sessions using the ipsative imagery approach, the patient claimed meaning(a) pain relief of most of her pain but the vice-like pain remained. The movement imagery-based approach also showed not able pain alleviation in another case that was presented, this time of a 46-year-old man who had experienced PLP since suffering from an avulsion of his left brachial plexus some five years prior to the study.At the beginning of the study, the patient rated his pain at 7 using a scale from 0 to 10, with 0 as pain assuage and 10 as the worst pain imaginable. During treatment, the patient had 0 rating and immediately after treatment it was 2. 5. The result of the study showed that hypnotic movement imagery is worth investigating further, considering the comparative ease of use and the capability of additional information as to the possible neurocognitive mechanism involved in PLP. Mirror treatmentMirror treatment uses leg exercises performed in crusade of a mirror to demonstrate increased motor control over the phantom limb. In contrast to hypnotic imagery techniques which uses hypnotically induced virtual mirror experience, mirror treatment involves the use of a tangible mirror apparatus to replicate the movements of the real limb with the phantom limb. The first case study of the use of mirror treatment in a person with lower limb amputation who was reporting PLP was presented by MacLaughlan, M. McDonald, D. , & Waloch, J. (2004).During the intervention, there was a significant step-down in the patients PLP associated with an increase in sense impression of motor control over the phantom, and a change in purviews of the phantom limb that was experienced. Although this effect was successfully replicated by using hypnotic imagery alone, the significant difference between the two approaches was the qualitatively more mighty experience of movement in the phantom left hand with the real visual feedback.The case study which was conducted in a conventional clinical setting supports the potential of mirror treatment for PLP patients with lower limb amputations. The investigators, however, emphasized that the case study cannot indicate the extent to which bene ficial effects are due to somatosensory cortex re-mapping, psychosocial factors such as individual differences in body plasticity, somatic preoccupation or creative imagination, or to other factors.Since it is the first case study of the use of mirror treatment in a person with lower limb amputation, similar case studies are needed to ascertain the treatments applicability to other patients with lower limb amputations. Botulinum toxin Pharmacological agents have also been use in the management of PLP. , Botulinum toxin type A, however, has not been previously used for this indication. In fact, it was only recently that this toxin has been used for medical purposes, especially in the field of cosmetics.Botox, as it is popularly known, has been beneficial in relieving muscular tension in the face due to its muscle-relaxing effect. Once considered a biological limb which causes gas gangrene, this toxin inhibits the synaptic transmission of acetylcholine at the motor end scale and mu scle spindles of the skeletal musculature and influences nociceptive transmitters. A pilot study on the influence of the agent on phantom pain after amputations was recently reported (Kern, Martin, Scheicher, et al, 2003). Four cases of patients with knee amputations who were suffering from severe stump pain following surgery were presented.After botulinum toxin injection, significant reduction of pain in the amputation stump was experienced among the patients. Citing a strong correlational statistics between stump pain and PLP and the occurrence of of stump pain without evident pathology, the study clearly emphasized the need for further investigation into the use of botulinum toxin in the treatment of post amputation pain. Other treatments of PLP Multiple other modalities, adjunct medications and anesthetic/ surgical procedures have been used in the treatment of PLP with varying long term success.Although at least 60 methods of treating PLP have been identified, successful treat ment of persistent type is not commonly reported. tricyclic antidepressants, anticonvulsants, calcitonin and mexilitine have been used with varying success (Delisa, Gans, Bochenek, et al, 1998). Other surgical procedures and drug regimens have also been proposed. Despite all these, an established mapping of each of these treatments in the management of PLP remains a checkmate for incoming investigation. Summary Despite the advances in medical research and treatment, PLP is a phenomenon that continues to bother the medical field.Several theories that were proposed to explain the etiology of the condition remain the subject of continued discussion. The pathophysiology involved in PLP could be multifactorial rather than the effect of a single factor. In the United States, there are around 1. 6 million people are living with limb loss according to the National Limb Loss Foundation Information Center. amid 1988 & 1999, an average of 133,735 hospital discharges per year was due to amputation. It is estimated that 50%-80% of patients with amputations complain of PLP (Delisa, Gans, Bochenek, et al, 1998).The actual incidence of this problem is, however, unclear because the condition tends to be underreported because of the complexity and peculiar nature of the complaint. Finding the most appropriate treatment for PLP has proven to be a difficult challenge for medical practitioners. The current treatment options for the condition are just as varied as the litany of many possible yet complex mechanism of PLP. Thermal biofeedback combined with electromyogram (EMG) have been demonstrated to completely eliminate PLP after treatment.In a case study, the use of ECT have shown pain relief in patients with PLP refractory to multiple therapies. The use of hypnosis and visual imagery in several case reports has indicated significant success in modifying the pain experience of PLP patients. Interestingly, the success of this technique in treating PLP has given a deeper in sight on the psychological aspect of the condition. Botulinum toxin, a drug considered as a very sedate toxin that causes gas gangrene, has also shown promising results in alleviating stump pain.Multiple other modalities, adjunct medications and anesthetic/surgical procedures have been used in the treatment of PLP with varying long term success. Establishing an accepted role of each of these treatments in the management of PLP, however, would require further investigation. The highly varied approaches involved in the treatment of PLP present a unique burden especially for the commonplace Practitioners (GPs) who provide the primary health for amputees in the community. A recent study suggests that GPs underestimate the prevalence, intensity and duration of phantom and residual limb pain.Moreover, inconsistencies in the reasons given for referral to specialist services for the management of phantom pain were reported. These findings have serious implications for the management of p hantom limb pain, disability and psychological affliction in amputees in that GPs not only provide first line treatment, but are also the gatekeepers for referral to other services (Kern, Martin, Scheicher, et al 2003). The prevalence of case studies presented in this review clearly shows the lack of major clinical trials targeted into identifying the best approach in the management of PLP.Most of these treatments are already being used for other diseases and there is ample literature to rationalize their use for PLP yet there is not a single searchable literature involving a bigger study population investigating any of the above methods. It is obvious that the efficacy and cost-effectiveness of these individual treatment methods cannot be ascertained by only a handful of case reports. More comprehensive studies should be done in order to formulate an acceptable protocol for the sufficient treatment of PLP.