Sandhya Raghavan
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Written By: Sandhya Raghavan | Updated : October 6, 2017 1:51 PM IST
Often in the dead of the night, 53-year-old Mr Shah feels a piercing pain radiating from his left foot. And in his sleep, he tries to stroke it with his right foot only to find a void where the pain was. He wakes up startled and pulls the blanket away from his legs; suddenly it dawns on him that he lost his left foot to diabetes three months ago. But if the foot was amputated, where did the pain come from in the first place?
Mr Shah, like many other amputees, was experiencing Phantom limb pain or palpable sensations where the amputated limb once was. It is different from stump pain where the amputee feels pain in the residual part of the limb. The phenomenon is experienced either as pains or as painless sensation in the severed, non-existent limb. Lord Nelson, a famous British officer in the Royal Navy also experienced this puzzling phenomenon. After losing his right arm, he felt terrible pain in where his hand once was. He also experienced weird sensations similar to fingers digging into his non-existent right palm. He thought that this was the proof that the soul existed.
Almost all amputees (60-80 percent) experience the phantom limb sensation or phantom limb pain.1 French military surgeon Silas Weir Mitchell, a famous war surgeon in the 19th century was the first to christen it as phantom pain. Although a very common phenomenon, there is little understanding about this mysterious ailment, even in the age of such medical advancements.
Amputations were prolific back in the day when medical science was in its infancy and the only way of staving off infection in problematic limb was to cut it off. One may have seen woodcut illustrations of medical procedures being carried out with crude equipment like the saw. But amputations are also quite Problems like vascular conditions, trauma, gangrene, cancer, infections and congenital limb deficiency are some of the reasons amputations are carried out.
The exact mechanism of the phantom limb is complex and is still shrouded in mystery. One hypothesis is that the pain stemmed from irritation in the severed nerve endings called nueronomas. On being cut, these nerve endings become inflamed and send abnormal and functionally nonsensical signals to brain. The brain then interprets this phenomenon as pain. But when the surgeon further amputated the supposed inflamed part of the limb, the pain still persisted or increased. Scientists also argued that phantom pains could be a result of changes in the cortex of the human brain or the spinal cord. But still, more studies are required to come to a more definite conclusion.2
What parts of the body get affected by phantom sensations?
Phantom sensations are commonly felt in the hands legs. But there have been instances where other amputated body parts such as the face, breasts, uterus, stomach and the penis have also felt phantom sensations. Phantom erections and ejaculations have been experienced by people who have had their penis removed. Women who had their uterus removed sometimes feel menstrual cramps. Even after appendicitis, some people report feeling stabbing pain in the area where the organ once was. Bowel movements were felt in people who had their sigmoid colon and rectum removed.3
Who are more susceptible to phantom sensations or pain?
Medically speaking, both men and women are equally susceptible. But since men are more vulnerable vascular problems and trauma, they are subjected to more amputations than women. And for this reason, phantom limb sensations and pain are more recorded in men.
Age wise, people between the age groups 30 and 60 are more susceptible to phantom limb. However, the youngest person who felt the sensation was just 11 years old and the oldest was 80 years old.3
What are the usual symptoms?
The commonest symptom is a sensation or pain in the amputated part of the limb or in the place where the limb once was.
How is phantom pain treated?
Usually, a multidisciplinary approach is taken to manage the pain caused by phantom sensations.
Pharmacological treatment: Doctors try to treat the pain like an actual physical pain with the use of drugs. Pre-emptive painkillers and anaesthetics are used during the time before the operation. This is done to prevent amplification of pain impulses from the amputation site. NSAIDs or non steroidal anti-inflammatory drugs are also quite common, since inflammation of the nerve endings is one of the hypothesised causes of phantom limb pain. Opioids, antidepressants, anticonvulsants, calcitonin, NMDA receptor antagonist and beta blockers are also used to treat the pain.
Non-pharmacological treatment: A treatment that involves the stimulation of the nerves through electrical impulses has been shown to be effective. The technique is called Transcutaneous electrical nerve stimulation. Mirror therapy is also used as a treatment method where the patient sits with one leg in front of the mirror and the amputated leg behind it. When the patient moves his good leg which is casting its reflection in the mirror, it seems like both his legs are moving. This is a technique invented by Dr Vilayanur S Ramachandran which has shown to treat phantom limb pain.
Cognitive behaviour therapy, guided imagery, hypnosis and other relaxation techniques are also being used to treat this debilitating pain in amputees. Sometimes, surgical interventions and electro convulsive treatments are also used.
Phantom limb pain is a relatively common phenomenon which causes the sufferers a lot of pain and discomfort. It also makes it very difficult for them to explain their ordeal to their loved ones who think they may be having a psychotic episode. Despite there being no unifying theory as to why it happens, newer and more effective treatments for phantom limb is investigated.
References:
1.Knotkova, H., Cruciani, R. A., Tronnier, V. M., & Rasche, D. (2012). Current and future options for the management of phantom-limb pain. Journal of Pain Research, 5, 39 49. https://doi.org/10.2147/JPR.S16733
2.Ramachandran, V. S., & Hirstein, W. (1998). The perception of phantom limbs. The DO Hebb lecture. Brain: a journal of neurology, 121(9), 1603-1630.
3.Bailey, A. A., & Moersch, F. P. (1941). Phantom limb. Canadian Medical Association Journal, 45(1), 37.
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