Phantom Limb: Possible Treatments to Kill the Pain Essay

The phenomenon of dark leg was first expound by a French doctor, Ambroise Pargon, in the sixteenth century however it was non until 1866, after(prenominal) the American Civil War, when Doctor Wier Mitchell published his first greenback of the malady, coining the stipulation Phantom tree branch. Phantom offset is the sustain of prevail sensory perceptions after sleeve amputation and tolerates one of the best-known, tho puzzling phenomena inside checkup science (Oakley & H eitherigan, 2002). Phantom limb agony (PLP) is a frequent consequence of the amputation and ca manipulations considerable vexation and disruption of daily activities.Originally, PLP was thought to aim been utility(prenominal) to nerve damage at the site of amputation solely succeeding evidence showed that patients who progress to undergone regional anaesthesia continue to run across dark limb put out despite the cut-off of hassle in the neck sensation to the amputated argona (Melzack, 1997). This conduce to the belief that the wo(e) sensation experienced by patients with PLP may be due to nerve impulses or signals generated at the spinal cord level. This, however, was refuted on the founding that patients with transection of the spinal cord still kvetch of persisting tail limb irritation.It has been argued then that the wiz areas that harmonize to the human trunk could be the one obligated for the shadow sensations (Melzack, 1997). This was based on the fact that much(prenominal) of the human (and primate) personify is represented by intelligible brain areas located in the somatosensory and drive cortex on either side of the primal sulcus. Consequently, charge after limb removal, the brain areas representing those part remain structurally and usablely intact.It has been argued that the activation of these incarnate disconnected brain areas by adjacent brain areas (representing separate(a) intact body parts) may be a partial neurophysiological exp lanation for the employment and maintenance of the continuous perceptual experience that is the apparition limb. This functional remapping af full termaths in some incidents in the referral of selective sensory information from an intact body area ( much(prenominal)(prenominal) as the face or shoulder) to the fantasm 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 (Ramac eliminateran, Stewart and Rogers-Ramachandran, 1992 Halligan, Marshall, Wade, Davies and Morrison, 1993). Given the magnitude and speeding of onset of the reorganization (within 24 hours of amputation) it is unlikely to be a product of neural sprouting but rather the unmasking of existing but antecedently inhibited neural path courses (Ramachandran and Blakeslee, 1998).In addition, these abnormal shaping changes in the central nervous system associated w ith the tail experience welcome been dod to explain the systematically high incidence of pain attributed to a limb that no retentiveer exists (Ramachandran and Blakeslee, 1998). Several another(prenominal) theories construct 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 up-to-date words for the specialize are just as varied as the litany of many possible barely complex utensil of PLP.This literary review willing assay the possible intercession options available for the watchfulness of PLP development information from published writings with searches in research databases exploitation the keywords spook limb, phantom limb pain, biofeedback, treatment, and phantom limb illusions. Treatments of PLP there are different modalities available in treating PLP ranging from pharmacological agents to psychophysiological therapy. The treatment outco me varies from approach to approach and more even from patient to patient.A careful evaluation is all-important(a) before considering any of of these treatments in order to take a more individualized approach in the circumspection of PLP. Thermal biofeedback Biofeedback relies on instrumentation to judge moment-to-moment feedback about physiological processes. It provides patients with information about their cognitive process in various situation (Saddock & Saddock, 2003). Using this electronic feedback, the patient is made aware of certain sensations such(prenominal) as skin temperature and go through stress.A show window report describing the use of thermal biofeedback combined with electromyogram (EMG) in treating a 69-year-old man suffering from keen and shooting phantom pain suggested that biofeedback is an effective treatment modality for dangerous phantom limb pain (Belleggia & Birbaumer, 2001). The rationale behind the treatment was based on the premise that most patients complain of intolerance to stone-cold after amputations which tend to aggravate unpleasant or pain sensations in the podium.The treatment, however, required several(prenominal) sessions and in this particular baptismal fontful, there were 6 sessions of EMG biofeedback followed by another 6 sessions of temperature biofeedback. The patient presented in this caseful excessively did not use a prosthetic device and did not receive earlier treatment for inveterate pain and the entire treatment process was through with(p) in a run acrossled environment where everything is calibrated and maintain to avoid external bias.Although the treatment outcome of the case report was favorable, there is no absolute indorsement that the same undecomposed results can be pass judgment to other patients with PLP especially to those who are already using prosthesis and to those who are already dogged to precedent chronic pain therapies. Also its efficacy and adaptability in true(a) clinical settings remains to be studied. Electroconvulsive therapy ( electroshock therapy) The use of electroconvulsive therapy have been common in patients 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 categorization of pain syndromes occurring along with depression (Rasmussen & Rummans, 2000). Using this evidence, 2 patients with severe phantom limb pain refractory to quaternate therapies but without concurrent psychiatric disorder were treated using ECT.One of the patients prior treatments included biofeedback, transcutaneous electrical nerve stimulation, hypnosis, epidural anaesthesia injections, and multiple analgesic medications including non-steroidal anti-inflammatory drugs, opiates, and adjunct analgesics including carbamazepine and nortriptyline. He was refe rred for ECT by the anesthesia pain dish due to previous good responses in demoralise patients with a variety of non-phantom limb pain syndromes.The other patient in the case hire in any case had numerous treatments including transcutaneous electrical nerve stimulation, intra-axillary alcoholic beverage injections. Epidural steroid blocks, stellate ganglion blocks, biofeedback, and medications including antidepressants, benzodiazepines, opiates and carbamazepine. After ECT, twain patients enjoyed substantial patronage of pain with one case in remission from PLP 3. 5years after ECT. From this clinical note, it was cogitate that patients with PLP who are refractory to multiple therapies may do to ECT.It should be emphasized that ECT have several complications including dental and muscular injuries secondary to the severe go across twitching accompanying the bring forth convulsion. The concurrent use of muscle relaxants have been effective in minimizing such injuries. The mos t troublesome side effect of ECT, however, is depot loss. Some patients report a gap in memory for events that occurred up to 6 months before ECT, as well as impaired ability to wait new information for a month or two after the treatment (Smith, et al, 2003).You may get even this to the data loss in computers after an unexpected reboot. Hypnotic reverberates and phantom pain Hypnotic procedures have long been utilize in treating a variety of pain syndromes. This involves the use of suggestion and imagery to unbosom the patients pain experience (Chavez, 1989). A case take in reports the use of a hypnotically induced virtual mirror experience which modified long standing intractable phantom limb pain despite generating a qualitatively inferior experience of causal agency in the phantom limb compared to that produced with an actual mirror (Oakley & Halligan, 2002).Using hypnosis, two main approaches to modifying phantom limb pain experience were identified in the study ipsativ e imagery approach and a reproduce achievement approach. The ipsative imagery approach takes into account the way the individual represent their pain to themselves and attempts to modify that mold 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 run across over it.In the study, a case of a 76-year-old woman who had an above-knee amputation of her dependable leg secondary to peripheral vascular distemper was presented. The investigators emphasized that she was pain-free at the time of her achievement and that her PLP hardly begun two years after surgery. There were several components of her pain in her missing limb. She complained of persuasion pins and necessityles in her foot, her toes felt like they were creation held in a tight vice, a slicing, in the altogether 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 significant pain relief of most of her pain but the vice-like pain remained. The movement imagery-based approach also showed notable pain reliever 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 free 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 cost investigating further, considering the comparative ease of use and the potency of additional information as to the possible neurocognitive mechanism snarly in PLP. mirror treatmentMirror treatment uses leg exercises performed in front of a mirror to demonstrate increased motor control over the phantom li mb. In contrast to hypnotic imagery techniques which uses hypnotically induced virtual mirror experience, mirror treatment involves the use of a real 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 subvert limb amputation who was reporting PLP was presented by MacLaughlan, M. McDonald, D. , & Waloch, J. (2004).During the intervention, there was a significant reduction in the patients PLP associated with an increase in sense of motor control over the phantom, and a change in aspects of the phantom limb that was experienced. Although this effect was fortunately replicated by using hypnotic imagery alone, the significant difference amongst the two approaches was the qualitatively more powerful 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 authority of mirror treatmen t for PLP patients with lower limb amputations. The investigators, however, emphasized that the case study cannot indicate the extent to which beneficial effects are due to somatosensory cortex re-mapping, psychosocial factors such as individual differences in body plasticity, somatic preoccupation or seminal 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. botulinus toxin Pharmacological agents have also been employed in the management of PLP. , Botulinum toxin type A, however, has not been antecedently utilize for this indication. In fact, it was only recently that this toxin has been utilise 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 ef fect. Once considered a biological weapon which causes gas gangrene, this toxin inhibits the synaptic contagious disease of acetylcholine at the motor end plate and muscle spindles of the skeletal musculature and influences nociceptive transmitters. A pilot program study on the influence of the agent on phantom pain after amputations was recently inform (Kern, Martin, Scheicher, et al, 2003). Four cases of patients with knee amputations who were suffering from severe pulpit 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 correlation amidst stump pain and PLP and the occurrence of of stump pain without obvious 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 p rocedures have been used in the treatment of PLP with vary long term success.Although at least 60 methods of treating PLP have been identified, successful treatment of persistent type is not normally 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 theatrical role of each of these treatments in the management of PLP remains a subject for future investigation. Summary Despite the advances in medical research and treatment, PLP is a phenomenon that continues to perplex 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 angiotensin-converting enzyme factor. In the United States, there are more or less 1. 6 million people are backup with limb loss according to the National Limb Loss Foundation Information Center. Between 1988 & 1999, an amount 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 strange nature of the complaint. purpose 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 besides 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 insight on the psychological aspect of the condition. Botulinum toxin, a drug considered as a very dangerous 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 unmatched burden especially for the General Practitioners (GPs) who provide the ancient health for amputees in the community. A recent study suggests that GPs underestimate the preponderance, intensity and duration of phantom and counterpoise limb pain.Moreover, inconsistencies in the reasons given for referral to specialist run for the management of phantom pain were reported. These findings have sincere implications for the management of phantom limb pain, disability and psychological distress 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 deficiency of major clinical trials targeted into identifying the best approach in the management of PLP.Most of these treatments are already macrocosm used for other diseases and there is ample literature to justify their use for PLP yet there is not a single searchable literature involving a large 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 cas e reports. More comprehensive studies should be through with(p) in order to formulate an acceptable protocol for the adequate treatment of PLP.