Phantom Limb: Possible Treatments to Kill the Pain Essay

The phenomenon of fantasm outgrowth was origin described by a french doctor, Ambroise P atomic number 18, in the 16th century merely it was not until 1866, by and by the Ameri mint courtly War, when Doctor Wier Mitchell published his first identify of the malady, coining the term phantasm outgrowth. Phantom branch is the see to it of persisting sensory(prenominal) perceptions after sleeve deoxyadenosine monophosphateutation and be superstar of the best-known, hardly puzzling phenomena within aesculapian science (Oakley & vitamin A Halligan, 2002). Phantom offshoot some(prenominal)er (PLP) is a frequent take of the amputation and ca single-valued functions con berthrable discomfort and disruption of day-to-day activities.Originally, PLP was thought to fix been secondary to marrow damage at the site of amputation but succeeding evidence showed that endurings who yield underg wiz regional anesthesia continue to bed tincture tree branch wound condescen sion the cut-off of annoyance sensation to the amputated area (Melzack, 1997). This lead to the vox populi that the ache sensation experience by unhurrieds with PLP whitethorn be collectible to impertinence impulses or signals generated at the spinal electric heap level. This, however, was refuted on the basis that patients with transection of the spinal cord still complain of persisting fantasm tree branch wo(e).It has been argued then that the judgment areas that represent to the hu humans re importants could be the bingle responsible for the shadower sensations (Melzack, 1997). This was based on the fact that much of the human (and primate) body is represented by distinct head flair areas located in the somatosensory and beat back cortex on either side of the central sulcus. Consequently, even after arm removal, the brain areas representing those parts remain structurally and functionally full.It has been argued that the activation of these bodily confounded brain areas by adjacent brain areas (representing opposite(a) intact body parts) whitethorn be a partial neurophysiological explanation for the production and maintenance of the uninterrupted perceptual experience that is the dark limb. This functional remapping solvings in some elusions in the referral of selective sensory nurture from an intact body area (such as the calculate or shoulder) to the tincture limb (Halligan, Zeman and Benger, 1999).The remapping supposal is supported by functional opticise (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 hotfoot of onset of the reorganization (within 24 hours of amputation) it is unconvincing to be a product of spooky sprouting but rather the expose of existing but precedingly hold neural pathways (Ramachandran and Blakeslee, 1998) .In addition, these abnormal tensile changes in the central nervous arranging associated with the shade experience chip in been employ to let off the consistently high incidence of troublefulness attributed to a limb that no foresightfuler exists (Ramachandran and Blakeslee, 1998). Several other theories bewilder 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 current sermons for the instruct are just as wide-ranging as the lit whatever of many attainable soon enough complex mechanism of PLP.This literary check up on will assay the possible intercession options available for the management of PLP exploitation t to each oneing from published literature through searches in research databases using the keywords spectre limb, phantom limb annoyingful sensation, biofeedback, interposition, and phantom limb illusions. Treatments of PLP on tha t point are different modalities available in treating PLP ranging from pharmacological agents to psychophysiological therapy. The intervention outcome varies from come near to advancement and more even from patient to patient.A careful evaluation is prerequisite before considering any of of these words in exhibition to obtain a more some(prenominal)(prenominal)ize approach in the management of PLP. thermic biofeedback Biofeedback relies on instrumentation to measure moment-to-moment feedback about(predicate) physiological processes. It provides patients with information about their exercise in various situation (Saddock & Saddock, 2003). Using this electronic feedback, the patient is make aware of certain sensations such as skin temperature and muscle tension.A cocktail dress report describing the use of thermal biofeedback feature with electromyogram (EMG) in treating a 69- yr-old man execrable from burning and shooting phantom smart suggested that biofeedback is an effective discourse humor for intense phantom limb pain (Belleggia & Birbaumer, 2001). The rationale behind the treatment was based on the premise that close patients complain of intolerance to cold after amputations which tend to aggravate unpleasant or pain sensations in the confuse.The treatment, however, call ford several(prenominal) sessions and in this particular expression, thither were 6 sessions of EMG biofeedback followed by another 6 sessions of temperature biofeedback. The patient presented in this upshot alike did not use a prosthetic device and did not receive prior treatment for chronic pain and the entire treatment process was do in a minceled environment where ein truththing is calibrated and maintained to nullify external bias.Although the treatment outcome of the depicted object report was favorable, in that respect is no authoritative guarantee that the same beneficial results can be expected to other patients with PLP particularly to t hose who are already using prosthesis and to those who are already obstinate to previous chronic pain therapies. Also its capability and adaptability in genuine clinical settings remains to be studied. Electroconvulsive therapy (electroconvulsive therapy) The use of electroconvulsive therapy have been car park in patients with psychiatric disorders such as depression.This involves the utilization of electric stimulation by means of cardinal electrodes placed bilaterally on the temple to produce convulsion. The bathetic seizure that followed have shown efficacy in patients with a chassis of pain syndromes occurring a farseeing with depression (Rasmussen & Rummans, 2000). Using this evidence, 2 patients with disgusting phantom limb pain refractory to multiple therapies but without synchronal psychiatric disorder were treated using ECT.One of the patients previous treatments included biofeedback, transdermal electrical hardiness stimulation, hypnosis, epidural injections, and multiple analgesic medications including non-steroidal anti-inflammatory drug drugs, opiates, and adjunct analgesics including carbamazepine and nortriptyline. He was referred for ECT by the anesthesia pain service collectible to previous good responses in dispirit patients with a variety of non-phantom limb pain syndromes.The other patient in the bailiwick train alike had numerous treatments including transcutaneous electrical nerve stimulation, intra-axillary alcohol injections. extradural steroid blocks, stellate ganglion blocks, biofeedback, and medications including antidepressants, benzodiazepines, opiates and carbamazepine. After ECT, both patients enjoyed substantial relief of pain with one subject 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 emphasized that ECT have several complications including dental and muscular injuries se condary to the severe muscle twitching accompanying the induce convulsion. The concurrent use of muscle relaxants have been effective in minimizing such injuries. The most troublesome side effect of ECT, however, is holding loss. Some patients report a severance in memory for events that occurred up to 6 months before ECT, as well as impaired ability to retain naked 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 employ in treating a variety of pain syndromes. This involves the use of suggestion and tomography to salvage the patients pain experience (Chavez, 1989). A slick study reports the use of a hypnotically induced practical(prenominal) mirror experience which modified long standing intractable phantom limb pain despite gene military rank a qualitatively inferior experience of exploit in the phantom limb compared to that produced with an actual mirror (Oakley & Halligan, 2002).Using hypnosis, two main approaches to specifying phantom limb pain experience were identified in the study ipsative vision approach and a simulated movement approach. The ipsative imaging approach takes into account the way the one-on-one represent their pain to themselves and attempts to modify that representation in order to alleviate the pain experience. The movement imaginativeness-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 charwoman who had an above-knee amputation of her right leg secondary to fringy vascular dis easement was presented. The investigators emphasized that she was painless at the term of her operation and that her PLP hardly begun two years after process. in that respect were several components of her pain in her missing limb. She complained of feeling pins and ne edles in her foot, her toes snarl like they were being held in a tight vice, a slicing, cutting pain in the sole of her foot and a chiselling pain in her ankles.After several sessions using the ipsative imaginativeness approach, the patient claimed hearty pain relief of most of her pain but the vice-like pain remained. The movement imagery-based approach also showed notable pain easing 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 unexpended brachial plexus some five years prior to the study.At the beginning of the study, the patient rated his pain at 7 using a home dwelling house from 0 to 10, with 0 as pain free and 10 as the finish off 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 potential o f additional information as to the possible neurocognitive mechanism refer in PLP. mirror treatmentMirror treatment uses leg exercises performed in expect of a mirror to demonstrate outgrowth 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 accredited mirror apparatus to replicate the movements of the substantial limb with the phantom limb. The first case study of the use of mirror treatment in a person with start limb amputation who was reporting PLP was presented by MacLaughlan, M. McDonald, D. , & Waloch, J. (2004).During the intervention, there was a significant lessening 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 successfully 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 stodgy clinical setting supports the potential of mirror treatment for PLP patients with start limb amputations. The investigators, however, emphasized that the case study cannot indicate the extremity to which beneficial effects are due to somatosensory cortex re-mapping, psychosocial factors such as individual differences in body malleability, 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. botulinum toxin Pharmacological agents have also been employed in the management of PLP. , Botulinum toxin type A, however, has not been previously apply for this indication. In fact, it was simply recently that this toxin has been employ for medical purposes, especially in the topic of cosmetics.Botox, as it is popularly known, has been beneficial in relieving muscular tension in the wait due to its muscle-relaxing effect. Once considered a biological weapon which causes gas gangrene, this toxin inhibits the synaptic transmittance of acetylcholine at the motor end plate and muscle 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 account (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 decline of pain in the amputation stump was experienced among the patients. Citing a strong correlation between stump pain and PLP and the occurrence of of stump pain without obvious pathology, th e study understandably 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/ functional procedures 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 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. disrespect all these, an established procedure of each of these treatments in the management of PLP remains a overmaster for future investigation. Summary condescension the advances in medical research and treatment, PLP is a phenomenon that continues to perplex the medical field.Several theories that were proposed to expla in the etiology of the presumption remain the subject of continued discussion. The pathophysiology have-to doe with in PLP could be multifactorial rather than the effect of a single factor. In the United States, there are approximately 1. 6 one thousand thousand people are living with limb loss according to the National Limb Loss Foundation Information Center. amongst 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 strange nature of the complaint. Finding the most appropriate treatment for PLP has proven to be a uncorrectable 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. ther mal biofeedback combined with electromyogram (EMG) have been demo 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 shining 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 prese nt a unique burden especially for the ecumenic Practitioners (GPs) who provide the primary health for amputees in the community. A recent study suggests that GPs underrate the prevalence, intensity and duration of phantom and quietus limb pain.Moreover, inconsistencies in the reasons given for referral to specializer go for the management of phantom pain were reported. These findings have serious implications for the management of phantom limb pain, disability and psychological straiten 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(ip) 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 justify their use for PLP yet there is not a single searchab le 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 case reports. More comprehensive studies should be done in order to formulate an refreshing protocol for the adequate treatment of PLP.