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Chandni Patel12/11/12BEH.350

Phantom Limb Pain

INTRODUCTION

Post-surgery, about 93% of amputees feel a sensation where the limb used to be

(Ramachandran and Hirstein 1604). This feeling known as a phantom limb is a

sensation that an amputee may get after losing a limb. Amputations may be done for a

variety of reasons such as cancer, traumatic incidents, and congenital malformations to

name a few (Rusy, Troshynski, and Weisman). A main symptom of phantom limbs is

phantom limb pain which is defined as being the sensation of a limb after being

amputated in which the sensation is painful (Nikolajsen 237); Phantom limb pain occurs

in episodes and is not constant. However, many researchers feel that phantom limb pain

is hard to define within a specific context because the type of pain sensations, the

intensity of pain varies from individual to individual, and the number of episodes of

phantom limb pain.

Phantom limb pain can happen to a person right after the amputation or years after

the amputation (Nikolajsen 239). When an amputee experiences phantom limb pain,

there is no one way to describe the pain; it is not just a sharp throbbing which many

assume it to be. Some sufferers of phantom limb pain feel a tingling sensation like that

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of restless leg syndrome which is not as painful as the other sensations but is still

bothersome. Others feel an itching and scratching sensation that mimics the scratching

of the skin if it is dry. Also, people may feel a sensation of burning where the missing

limb was. Sharp shooting, cramping, or stabbing sensations sometimes are felt among

most amputees. The sensation that has researchers confused is the sensation of the limb

being in an unnatural position. Unlike any of the previous sensations, and unnatural

position of the limb not only gives sensation to the missing limb but it now has the

ability to contort itself and cause tremendous pain to the amputee. Researchers believe

that each specific phantom limb pain sensation triggered may be specific to the incident

that caused the amputation of the limb in the first place; traumatic incidents like motor

vehicle accidents are more likely to trigger phantom limb pain at a greater intensity

(Rusy, Troshynski, and Weisman 78).

There is no way to physically measure pain in the ways that we measures fluids or

money. Therefore, it is very difficult for patients to subjectively and objectively describe

their pain (Whyte and Niven 948). However, researchers have come up with different

ways to measure pain intensity. One such scale used is the phantom limb pain index

named the McGill Pain Questionnaire, a type of verbal rating scale, measures pain

intensity by having the patients circle different words that describe different pain

sensations in a specific way (Whyte and Niven 947). Another scale used was the

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numerical rating scale which measures the patient’s pain level on a scale of zero to ten;

zero being no pain while ten is the most excruciating pain experienced by the patient

(Whyte and Niven and Niven 950). Today the numerical rating scale is used in many

hospitals.

Unlike like other pain conditions in which pain may be constant, in phantom limb

pain is episodic. On average amputees report four to five phantom limb pain episodes

per day averaging a four on the numerical rating scale. The episode may last from two to

more than fourteen hours but the average is about eight to ten hours (Whyte and Niven

949). While the pain intensity may be low according to the numerical rating scale, a

small intensity of pain over a long period of time would greatly affect a person’s ability

to complete daily tasks.

Researchers have not yet been able to decide upon much regarding phantom limb

pain. The causes of phantom limb pain is an area in which there are many hypotheses

but despite extensive research the workings of phantom limb pain are still not known.

Within the category of causes, the physical and psychological categories can be split up

into a numerous amount of theories; but nothing has been proved yet. It may be

something solely physical or psychological or the combination of the two. Treatment is

another area in which researchers greatly disagree because “…there is only little

evidence from randomized trials to guide clinicians with treatments… and most studies

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have errors [where] samples are small, randomization and blinding are either absent,

controls are often lacking, and follow-up periods are short” (Nikolajsen 242). Both

problems of the causes and treatments of phantom limb pain combine to hinder proper

research results of phantom limb pain. One explanation that can be given is that amputee

phantom limb pain may be caused by certain triggers which could potentially determine

what types of coping mechanisms and treatments are used by amputees. These triggers

may also effect amputees according to their environment.

METHODOLOGY

The objectives will be proven by first finding evidence that is relevant to the subject

at hand and is from a reliable source. The reliable source was found using online

academic journals are narrowing the search to different articles regarding phantom limb

pain. Five sources were journals while the sixth source comes from a book that goes into

detail on different types of pain pertaining to different conditions. All of the sources put

together yielded sufficient information for starting research and key details of the

argument. Using the information garnered from all the sources, quotes and paraphrasing

were used to prove the argument to the fullest capacity and therefore allow the

assumptions made in the essay to be validated by the evidence found. Most of the

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research found referenced to leg and arm amputees as amputation of either or tend to

effect the amputee in many different aspects both physically and emotionally.

FINDINGS

Researchers have concluded many triggers which cause the onset of phantom limb

pain. One such trigger identified by a Katz and Melzack suggests phantom limb pain can

be explained using the concept of a neuromatrix which is defined as “…a network of

neurons that extends throughout widespread areas of the brain…including the

somatosensory cortex” (Hill, Niven, and Knussen 381). As long as the sense of touch is

associated with pain, prior to phantom limb pain sensory input will be stronger. This

comes into play when discussing the concept of the neuromatrix and somatosensory

memories. In a study, about “…74% of amputees reported pain in a similar location to

pre-amputation…” (Hill, Niven, and Knussen 381). If the amputee experienced pain

before the amputation they were more likely to develop pain in the exact same region

post-amputation. Also, if the patient is under severe emotional or physical stress, this is

considered a trigger for the phantom limb pain that resembles to pre-amputation pain to

occur (Hill, Niven, and Knussen 382). Since most of the pre-amputation pain that

amputees suffered was very intense and long, this somatosensory memory altered their

neuromatrix in such a way in which the thought the missing limb or the pain that it

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induced elicited phantom limb pain since the neuromatrix between the two had become

so strong. Therefore, phantom limb pain depicts the aspects of incorporating sensory

and emotional aspects of pre-amputation pain into the new phantom limb pain.

Since these amputees have experienced phantom limb pain in another form before,

they may attempt to treat phantom limb pain by using the treatments used pre-

amputation. Before the amputation many patients may have been given opioids such as

morphine in order to subside the pain (Nikolajsen 242). This would be done most likely

in the case of a traumatic incident which would not allow for a weak pain reliever. Also,

if the amputation was done in the case of a longer process such as osteosarcoma where

amputation is not immediate, phantom limb pain may be subsided if pre-amputation

pain is controlled prior to the operation. This can be done by giving “… [an] epidural

pain treatment 72 hours before the amputation” (Nikolajsen 244). Six months post-

surgery, phantom limb pain was greatly lower among patients who had received the

epidural blockade (Nikolajsen 244). Another treatment that would be used is called

transcutaneous electrical nerve stimulation where different nerves are stimulated (Rusy,

Troshynski, and Weisman 81). If different nerves are stimulated, then different neuron

connections would occur and the old somatosensory memories may become blocked.

However, this treatment has not had studies with consistent results. Also, physical

therapy may be used to massage and manipulate the point of the phantom limb pain

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(Nikolajsen 243). By doing this, new, positive somatosensory memories may form

blocking out the old ones. Another drug that could be used is called gabapentin (Rusy,

Troshynski, and Weisman 79). Many studies have shown that about after one year of

gabapentin use with other mild pain medication, patients do not experience phantom

limb pain even after stopping it (Rusy, Troshynski, and Weisman 80). In the next too

cases of triggers, the instead of combining physical and psychological aspects, both are

based on psychological theories.

A trigger for phantom limb pain may be a person’s own personality type. A person

who has a “rigid” personality most likely “…dislike and resist change and therefore

experience persistent phantom limb pain…” (Whyte and Niven 938). The patient who

does not like change and resists it will most likely get a feeling of helplessness since

they are not able to do things on their own their own anymore. The feeling of

helplessness was also a trigger for longer, more intense phantom limb pain episodes. If

anyone tried to help them they would refuse the help and attempt to complete the task at

hand on their own. Also, a feeling of helplessness could potentially leading to a loss of

libido causing greater levels of pain intensity (Whyte and Niven 944). The people with

“rigid” personalities will attempt to mask their feeling of helplessness by attempting to

do physical activities on own even though the surplus of physical exertion may tire them

out. The physical and mental fatigue from over exertion may strain their relationships

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causing stress and anger leading to an emotional disturbance which triggers phantom

limb pain (Whyte and Niven 939). In the end the person with the “rigid” personality

type with phantom limb pain may develop depression if he or she is not able to exert

themselves like before along with any of the above factors that may play a role.

However, they may try to hide their depression fearing that it is a sign of weakness. This

in turn will turn out to be a cycle of the defense mechanism of denial (Whyte and Niven

941) that does not end until the affected person with a “rigid” personality type gets

treatment or tries coping mechanisms.

Instead of altering neuron connections of the neuromatrix regarding somatosensory

memories, treating trigger personalities who have phantom limb pain would require very

different types of treatments. Since the person is in denial regarding the loss of the limb

therefore disregarding the phantom limb pain, they may try to forget about it by taking

large amounts of over the counter medication (Whyte and Niven 951). Some may also

go as far as to try to manipulate the stump because of the pain it is causing and its

interference in their lives (Whyte and Niven 950). They may do this to also be able to

continue to be self-reliant. To target the depression, the amputee may drink more

alcohol since higher levels of stress are correlated to higher levels of pain; the amputee

may try to drown their phantom limb pain and mental fatigue with alcohol. Becoming

alcohol dependent is at very extreme levels of phantom limb pain (Whyte and Niven

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950). However, studies show that tricyclic antidepressants help depression and subside

phantom limb pain by 75% (Nikolajsen 242). Another strategy used is the Mirror

Therapy developed by Vilayanur Ramachandran. This treatment allows the amputee to

put the amputated limb and the not amputated limb into a box with two mirrors in the

center facing outwards. The stump and the limb are put into their respective openings

into the box and the amputee looks into the side with the limb and makes a movement

with it in which he or she mimics with the stump. These actions done repeatedly, since

the amputee sees the reflection of the limb moving, it also appears as though the stump

is moving (Ramachandran and Hirstein 1611). The Mirror Box Therapy allows the

amputee the feeling of being back in control because the mind is tricked into believing

that there is no stump but a normal limb. This therapy is supposed to greatly help

alleviate phantom limb pain but currently there is no consensus (Rusy, Troshynski, and

Weisman 81). Again, Gabapentin can be used to greatly alleviate phantom limb pain

with other milder medications (Rusy, Troshynski, and Weisman 81). This can be paired

with other types of therapies to speed the process of recovering from phantom limb pain.

Also, another treatment involves the changing of the psychological mindset of the

amputee. Since they are self-reliant, an overall therapy to break their cycle of using

denial as a defense mechanism would be to use therapies involving other people.

Physical therapy would allow the amputee to have contact with a health professional

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who would help them along the way with the phantom limb pain and therefore pain

having the self-confidence they has lost while trying to retain their ability to be self-

reliant (Whyte and Niven 951). Another concept of social therapy would be to allow

themselves to use coping strategies and not think of them as something the weak utilize

(Whyte and Niven 951). By doing this, family and friends could potentially help their

phantom limb pain subside and possibly just become a phantom sensation that causes no

pain.

The opposite of a “rigid” personality is also discussed by researchers as being more

prone to develop a greater intensity of phantom limb pain. People is this personality

group are categorized as “…“sensitive”, “intelligent”, and “neurotic” individuals”

(Whyte and Niven 939). People in these personality categories are all greatly affected by

the change they see physically and mentally. While physically only a limb has been

amputated, mentally their whole concept of their body image changes. As the body is no

longer symmetrical, they believe they are unattractive to the rest of the world. This

perfect body image they have thought for themselves is no longer possible so they try to

avoid instances where the topic may come up (Whyte Niven 943). This happens

multiple times thus stopping socializing with friends. By doing this they go into

seclusion in order not to be seen by others. There may be so much focus put on the

negative body image that they may forget important daily activities or will not perform

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such activities which will get them noticed. All of this combined may lead to a paranoia

that everyone in constantly negatively talking about their stump leading to low self-

esteem (Whyte and Niven 944). This may also lead to depression due to the greatly

lowered self-esteem. The phantom limb pain occurrence because of anxiety and

overwhelmed emotions may lead to more episode and a higher intensity of phantom

limb pain.

Like the “rigid” personality type, “sensitive”, “intelligent”, and “neurotic” amputees

have similar therapies but for very different reasons. Due to the negative body image,

the amputee may abuse alcohol because high levels of phantom limb pain are caused by

anxiety (Whyte and Niven 943) that would occur from the low self-esteem and trying

augment their perception of themselves. Again, Gabapentin can be used to greatly

alleviate phantom limb pain with other milder medications (Rusy, Troshynski, and

Weisman 81). Like before, the Mirror Box Therapy would hypothetically work well

here, because the whole idea is to trick the mind into thinking that the body image

displayed is normal versus being abnormal (Ramachandran and Hirstein 1622).

Accomplishing this would allow the amputee to gain self-esteem and a more positive

body image. Also, in order to combat the depression, tricyclic antidepressants could be

used since it works well to help phantom limb pain and depression (Nikolajsen 242).

Lastly, amputees may have secluded themselves before and not used any social coping

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mechanisms. However, these may be used to increase the self-esteem of the amputee by

attempting to incorporate friends and family that will ensure that body image topics are

not discussed nonchalantly (Whyte and Niven 951).

CONCLUSSION AND DISSCUSION

In order to prove the thesis journal articles and a textbook chapter were thoroughly

read and annotated so that the most valuable and reliable information was found, After

this, from the information found a thesis was formed that could be proved using the

information given in the text, In the essay, each section contained quotes or paraphrased

text which pertained to the thesis which entailed to prove that phantom limb pain was

caused by triggers which had certain effects which would determine the treatments or

therapies used,

Especially for phantom limb pain, the McGill Pain Questionnaire aspect of measuring

pain intensity is better because instead of using a numerical system which may not be

applicable to some patients, it incorporates different types of pain sensations and

intensities that may be felt by the patient. On the other hand, the numerical rating scale

is something that can be done in seconds but, it does not have a lot of room for creativity

of the different phantom limb pain sensations. While the McGill Pain Questionnaire and

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numerical pain scale each do its job in identifying the levels of pain intensity, they each

measure the pain intensity at a given time, not over a long period of time which has been

a problem for many researchers. It is hard to believe that long term (greater than two

years) studies has not been done on phantom limb pain because “...78.8% of amputees

experienced phantom limb pain after 6 months…” (Nikolajsen 239). The only

explanation that researchers have now for phantom limb pain 6 months later is trauma

(emotional or physical) to the stump which seems very valid. If so many people are

having phantom limb pain much later after the surgery there must be another trigger of

the phantom limb pain. Also, it may just be that there is not enough funding for such

long-term studies. Either way it seems as though such a study could conclude promising

theories if done in the future.

The somatosensory memories connecting to the neuromatrix is very similar to

thinking of someone who used to be in your life but is no longer. In both cases,

something was once there and now is not but elicits the same emotional and physical

response. The limbic system and prefrontal cortex are both greatly responsible for how

emotions work (Hill, Niven, and Knussen 381). In both cases above, each would be

attacked to the neuromatrix. Since the pre-amputation has made somatosensory

memories with the specific body part, may be it would be possible to permanently sever

those neuron ties and make new, positive somatosensory memories that would take the

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place of the old ones relinquishing the amputee from the burden of having to worry if

the phantom limb pain will come back or not. This may not be possible because the old

somatosensory memories may be so strong between the phantom limb and phantom

limb pain that it cannot be broken entirely. A somatosensory memory may be built

around it, but it could be broken since it has not had time to develop.

Before amputation, those who are to “rigid” personality types may have to convince

their loved one that it is okay to ask for and receive help; it is not a sign of weakness. In

many cases, people do believe that asking for help is a sign for weakness like when men

won’t stop to ask for directions because they do not want to hurt their ego. The same

case may be for when women use their looks to get what they want; they use their looks

as a sign of weakness to get what they want. In this way, self-reliant amputees must be

taught that asking for help is not a weakness. Sometimes weakness may even be a good

thing because it is something that helps build character. This plan of action must be

done before any problems arise post-amputation that could greatly affect the amputee

negatively. It seems as though this trigger in correlation to phantom limb pain may not

be increasing in numbers because it today’s society it is widely accepted by all to ask for

assistance when needed; it is not something looked down upon.

On a side note, in many other journals referenced, it was found that gabapentin was

used to treat those with phantom limb pain. However, it was not discussed in a majority

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of the journals used within the essay and more emphasis was given to lesser known

therapies. Even though in all of the clinical trials it has worked so well to alleviate

phantom limb pain, it goes to show how something still not proven and in the stages of

development will not be a large aspect even though it seems as though it is the best

treatment available to those with phantom limb pain.

The most intriguing aspect of phantom limb pain triggers was how the concept of

body image can affect people with phantom limb pain so greatly. Today when people

think of the concept of a perfect body image, people relate it to things seen on

television, magazines, and the Internet. From all these media channels the public has

formed its body image or more so it has been imposed on the public. Since the media

has such great influence on the public, this is of great concern to amputees who suffer

from phantom limb pain and have been bombarded by such images for long periods of

time. This media bombardment convey that people need to conform to the specific look

or be out casted by others. An amputation may hinder a person’s body image of

themselves. This is something that would not be surprising if it continued to be a trend

with phantom limb pain.

In general, the goals put forth by the thesis were accomplished in the essay. The

introduction introduced the main ideas of the topic well and flowed into the concept of

the argument. From there, for evidence was used to prove the thesis and its different

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objectives. For each case, the trigger was well stated with its effects and was followed

by numerous treatments and therapies that applied back to the trigger. Although for

some of the triggers the therapies and treatments may have been the same, there was a

different reason behind each why it correlated to the given trigger. Overall, the thesis

was proved with evidence and good insight.

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Works Cited

Hill, A., Niven, C.A., & Knussen, C. (1996). Pain Memories in Phantom Limbs: a Case Study. International Association for the Study of Pain, (66), 381-384.

Nikolajsen, L. (2010). Chapter 19: Phantom Limb Pain. In J. Ballantyne, E. Kalso, & C. Stannard (Eds.), Evidence-based Chronic Pain Management (pp. 237-245). Oxford, UK: Wiley-Blackwell Publications.

Niven, C., & Whyte, A. (2001). Psychological Distress in Amputees with Phantom Limb Pain. Journal of Pain and Symptom Management, 22(5), 938-946.

Niven, C., & White, A. (2001). Variation in Phantom Limb Pain: Results of a Diary Study. Journal of Pain and Symptom Management, 22(5), 947-953.

Ramachandran, V.S., & Hirstein, W. (1998). The Perception of Phantom Limbs. Oxford Journal, (121), 1603-1630.

Rusy, L. M., Troshynski, T. J., & Weisman, S. J. (2001). Gabapentin in Phantom Limb Pain Management in Children and Young Adults: Reports of Seven Cases. Journal of Pain and Symptom Management, 21(1), 78-82.