Phantom pains phenomenon homework help

 

Phantom is a type of pain that feels as if it is coming from a body part that is no longer exists. After amputation, some patients experience pain in the part of the limb that is not there. Doctors used to think that this post-amputation phenomenon was a psychological problem but they later discovered that these sensations came from originated in the spinal cord and the brain.

Phantom pains phenomenon homework help

Phantom pains phenomenon homework help

This type of pain is also known as phantom limb pain. The phantom part refers to the location of the pain: the missing limb or part of the limb such as fingers or the toes. Phantom pain ranges from mild to severe and can last for hours, days, or longer although it can be managed.

Rehabilitation is a type of care that can help you get back, keep or improve abilities you need for life. These abilities may be mental, physical thinking, and learning. These abilities may have been lost because of a disease or an injury or as a side effect of medical treatment. Rehabilitation, therefore, can help you improve your functioning and daily life.

The difference between phantom limb, phantom sensation, and residual limb pain

 

  • Phantom pain is when a person feels pain where the missing part has been or should be. Patients often feel pressure, pinching, or even burning.
  • Phantom sensations- the missing limb or extremity still feels like it is still part of the body. There isn’t any pain though. A person experiencing phantom sensations may forget that part of a lower limb is missing and may try to walk on both legs.
  • Residual limb pain – this type of pain affects the remaining part of the limb known as the stump, where the amputation occurred. This pain has a medical reason such as nerve damage or pressure on the nerve.

Some people develop a neuroma at the amputation site and this occurs when a cut nerve ending forms a tiny ball on its end during healing or gets trapped in the suture when the surgeon closes the incision. It is pain originating from the stump. Poor-fitting prosthetics or limb bruising can cause residual limb pain.

What is stamp pain?  

This is the pain that arises in the residual body part as opposed to phantom pain which is the missing body part.

 causes residual limb pain

 

Phantom pain results from a mix-up of nervous system signals which originate from the spinal cord and the brain. When a body part is amputated the nerve connections from the periphery ton the brain remains in place. The problems that affect the remaining part of the stump cause residual limb pain and they include:

  • Poor blood flow or lack of blood flow to the limb
  • Nerve damage (neuropathic pain) or inflammation (neuroma)
  • Bone infection (osteomyelitis or bone spurs)
  • Skin or wound infections
  • Pressure injuries especially bed sores
  • Bruising
  • Surgical pain
  • Deep tissue infection especially infection of the bone
  • Excessive growth of nerve tissue

Other factors that can worsen the pain include:

  • Stress
  • Anxiety
  • Depression
  • Pain in the limb before amputation

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Theories about phantom pain

There are 3 theories about phantom limb pain which include:

  • Peripheral theory-it states that the remaining nerves in the stump grow to form neuromas, which then generate impulses. These impulses are then perceived as pain in the limb that has been removed. After changes in the severity of the phantom limb pain were noted in different temperatures another theory says that cooling of the nerve endings increases the rate of firing of the nerve impulses which are sometimes perceived by the patient as phantom limb pain.
  • Central theory- a person by the name Mel Zack proposed that the body is represented in the brain by a matrix of neurons and that sensory nerves experiences create a unique neuromatrix which is then imprinted on the brain. When the limb is removed, the neuromatrix tries to recognize but the neuro signature remains due to the chronic pain experienced before the amputation, hence causing pain after amputation.
  • Spinal theories- the cutting of peripheral nerves during amputation causes a loss of sensory input from the area below the level of amputation. Hence, this reduction in neurochemicals alters the pain pathway in the dorsal horn.

Signs of phantom pain

 

Some patients experience phantom pain soon after amputation while others experience pain after weeks or months later. The pain in the limb may be unpredictable or ongoing. This kind of pain is usually worse during the night when your thoughts turn inwards and there is less distraction. You may feel the pain that is:

  • Throbbing
  • Sharp
  • Feels like pins and needles
  • Burning
  • Feels similar to cramps

Other characteristics of phantom pain include:

  • Pain that comes and goes or it might be continuous
  • Sometimes may affect the part of the limb farthest from the body such as the foot of an amputated leg
  • The onset within the first week after amputation though it can be delayed by months or longer
  • Presence of pain that may be described as stabbing, throbbing, cramping, crushing, shooting, pins and needles, etc.

Risk factors for phantom limb pain include:

 

Some patients who have had an amputation can develop phantom pain. In some patients, the pain is worse when they are not wearing a prosthetic device. factors that may trigger limb pain include:

  • Changes in temperature or barometric pressure
  • Angina- a type of chest pain that occurs due to low oxygen supply to the heart
  • Constipation
  • Smoking
  • Stress and anxiety
  • Shingles or herpes zoster

 

Triggers for phantom pain

 

Engaging in certain activities or conditions triggers phantom limb pain. The following are some of the triggers:

  • Defection or urination
  • Touch
  • Sexual intercourse
  • Herpes zoster
  • Cigarette smoking
  • Exposure to cold

Types of phantom sensations

 

Most people who have an amputation have some degree of phantom sensation. A phantom sensation is when you feel your missing part of the limb and you may feel an itch or a tickle. It may also feel as if the missing part of your limb is asleep. This kind of pain is mostly mild and no pain at all.

The various types of sensations that may be felt include:

  • Sensations of movement like the phantom leg is moving
  • Sensations of touch, sensations of temperature itchiness, and also other patient’s pain
  • In cases that are less severe where small numbers are amputated, the sensation can be described as a tingling feeling as opposed to a painful sensation.
  • Sensations that are normally related to the phantom limb’s length, posture, and volume eg. Feeling that the phantom limb is behaving like a normal limb like sitting with the knee bent or feeling that the phantom limb is as heavy as the real limb. Sometimes the experience is called telescoping with the feeling that the phantom limb is slowly shortening over time.

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Phantom pain mechanisms

 

Phantom pain mechanisms include:

  • Peripheral mechanisms

Injured nerve endings form neuromas at the stump site and can fire abnormal action potentials though they were historically thought to be the main cause of phantom limb pain. Neuromas can increase C Fiber activity hence increasing phantom but the pain persists once the neuromas have stopped firing action potentials. The peripheral nervous system is thought to have a modulation effect on phantom limb pain.

  • Spinal mechanisms

Spinal mechanisms are thought to have an influencing role in phantom pains. Because patients with complete spinal cord injury have experienced phantom pains, there must be an underlying central mechanism responsible for the generation of phantom pains.

Central mechanisms

 

The generally determined circuitry in the brain remains largely stable throughout life. MRI studies in amputees show that almost all patients have experienced motor cortical remapping. The majority of motor reorganization has occurred as a downward shift of the hand area of the cortex into the area of face representation, especially the lips.

Treatment for phantom pain

 

Finding a suitable treatment to relieve your phantom pain can sometimes be difficult. Doctors usually begin treatment with medications and may gradually add non-invasive therapies such as acupuncture. These non-invasive options include implanted devices or injections while surgery is done as the last resort.

  • Medications

No specific medicine that specifically treats phantom pain. However, some drugs designed to treat other conditions have been used in relieving nerve pain. No single drug works best for everyone and not all phantom pain patients benefit from medications.

Medicines used to treat phantom pain include:

  • Over the counter pain relievers, they include: ibuprofen, Tylenol, Advil, and naproxen sodium which might relieve pain.
  • Antidepressants like tricyclic may relieve pain caused by damaged nerves.
  • Anticonvulsants- these are epilepsy drugs such as Neurontin, and Grails with side effects of dizziness, mood changes, and sedation.
  • Narcotics- opioids such as morphine, codeine, etc may be an option for some patients. When taken in appropriate doses, being guided by the doctors, they may help control phantom pain. Patients with a history of substance abuse may not benefit from opioids and end up causing nausea, constipation, or sedation.
  • N-methyl-d-aspartate receptor antagonist-they work by binding to the NMDA receptors on the brain’s nerve cells blocking the activity of glutamate a protein that plays a big role in relaying nerve signals. NMDA receptor antagonists ketamine dextromethorphan can help to relieve phantom pain. Ketamine has side effects which include mild sedation, loss of consciousness, and hallucinations. So far, no side effects have been reported from the use of dextromethorphan.

Medical therapies for phantom pain:

Using medications to treat phantom pain with non-invasive therapies is a matter of trial and observation. The following techniques can be used to relieve phantom pain in patients:

  • A mirror box- this device contains mirrors that help to make it look like an amputated limb exists. The mirror box usually contains two openings, one for the intact limb and the other one for the residual limb. The person using it performs symmetrical exercises while watching the intact limb and imagining that he or she is observing the missing limb moving. Some studies have found that mirror box exercise can help to relieve phantom pain.
  • Acupuncture- studies have found that acupuncture may help to ease some types of chronic pain. The physician inserts extremely fine, sterilized stainless steel needles into the skin at various specific points on the body, and this technique is generally considered safe when performed correctly.
  • Repetitive transcranial magnetic stimulation – it is a therapy that uses an electromagnetic coil that is usually placed on the forehead. Short pulses are sent through the coil that causes small electrical currents in the nerves located in a specifically targeted area of the brain. Studies have suggested that this therapy can be helpful for phantom pain, though it isn’t yet specially and specifically approved for this therapy. rTMS is similar to the one used in MRI scans. The side effects may include mild headaches and dizziness.
  • Spinal cord stimulation- the physician inserts tiny electrodes along the spinal cord while releasing a small electrical current delivered continuously to the spinal cord to relieve pain.

Surgery

Surgery can be an option in cases where other ways of relieving pain fail. The surgical options available include:

  • Brain stimulation- motor cortex stimulation together with deep brain stimulation is similar to spinal cord stimulation except that the current is delivered within the brain. A surgeon normally uses a magnetic resonance imaging MRI scan to position the electrodes correctly. Even if the data is still limited and these treatments are not specifically approved for phantom pain, brain stimulation appears to be a better option in selected individuals.

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Non-medication treatment for phantom limb pain

 

Alternative theories to ease phantom pain can be helpful. They include:

  • Massage of the residual limb
  • Use of a shrinker
  • Biofeedback
  • Repositioning of the residual limb by propping on a pillow or a cushion
  • TENS (transcutaneous electrical nerve stimulation)
  • Emergency
  • Virtual reality therapy
  • Imagery

 

Techniques for managing post-amputation pain

 

The success of treatment for post-amputation pain depends on the level of pain and the various mechanisms that play a role in causing the pain. The following techniques can help you go beyond the basics:

  • Local injection therapy- in this technique, the physician injects a local-blocking agent at the amputation site. This helps in calming the painful symptoms sent by the nerve endings to the brain.
  • Mirror box therapy- this technique enables the patient to watch in a mirror while receiving physical therapy to re-map the brain’s neural pathways to register that the limb is no longer there. The patient feels the imaginary movement of the removed limb which behaves as the normal movement through the mirror. This type of therapy has proven efficacy for patients with post-amputation pain.
  • Non-analgesics- they are prescription pain medicines that slow or limit how the painful nerves send signals to the brain.
  • Deep brain stimulation- this is a technique whereby the surgeon places tiny electrodes directly on the surface of the brain to help attenuate pain with electrical impulses.
    Neurostimulation- in this technique, an electrical device is usually placed near the nerves traveling to the amputated extremity. Instead of blocking the nerve signals, it sends a pleasant signal through the nerve. Patients can control the neurostimulation unit through a small wireless remote control.

Self-care:

 

Phantom pain patients need to relax in ways that work best for them either by deep breathing or trying to relax the missing arm or leg. They can also engage in activities like reading, listening to music, or doing something that takes their mind from the pain may be helpful. They may also try taking a warm bath if the surgical wound is completely healed. They should also ask their healthcare provider if they can take acetaminophen, ibuprofen or aspirin, or any other medicines that can help with the pain. The following self-care habits can also help with phantom pain:

  • Tying to move or exercise the remaining part of the arm or leg
  • Keeping the remaining part of the arm or leg warm
  • Wearing a shrinker sock or compression stocking
  • If you are not wearing your prosthesis, put it on, and if you are wearing your prosthesis take it off.
  • In case you have to swell on the remaining part of your leg or arm, try wearing an elastic bandage.
  • You can try to tap or rub your stump

Conclusion

It is increasingly becoming important to understand and properly manage phantom limb pain. The management and treatment of neuropathic pain and phantom limb pain can be complex because efficacy is very subjective. There is no single treatment that is a universally effective medication for treating phantom limb pain. Healthcare professionals must strive to establish an effective medication regimen that can involve a combination of therapies that can target the multiple disease elements. Although there’re are no established treatment guidelines, pharmacists can play a very important role in maximizing medication therapy for phantom pain management. Therefore, pharmacologic treatment should be tailored to patients while considering all concomitant disease states and medications. The pharmacists can therefore recommend agents that will result in the best health outcome for the patients while trying to minimize adverse drug reactions and the potential mishaps associated with polypharmacy.

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