2. Definitions
Phantom sensation: non painful sensation of the
missing limb
Phantom pains:is a noxious sensation where the
limb existed
Stump pain:is the pain that is restrictedto the
amputated site
Phantom Pain coined by Silas Weir Michel in 1892
4. Incidence
50-80% of amputees feel pain in the missing
limb.
begins immediately after the arm or leg has been
removed and it may last for years.
In over half of the cases, the phantom limb
sensations decrease gradually.
not related to age, sex, location of the
amputation, or reason for the amputation (e.g.
trauma vs. disease).
5. Onset and Duration
Several studies have shown that 75% of patients
with PLP develop pain within the first few days
after amputation.
One study of 58 amputees found incidence of PLP
to be 72%, 65% and 59% after 1 week, 6 months
and 2 years. (Jensen, et al 1985)
Another study of 56 amputees showed that
although the incidence and intensity of pain
remained constant, the frequency and duration of
pain attacks decreased significantly. (Nikolajsen, et
al 1997)
6. Phanthom Phenomena
Phanthom Limb
Phanthom Pain
Stump Pain
Super added Phanthom
Referred Phanthom
Sensation
60% and 80% of amputees experience PLP
(Nikolajsen and Jensen., 2000)
7. Stump Pain
Somatic stump pain usually resolves as the wound
heals
Can trigger Phantom pain
Prolonged stump pain usually attributable to local
pathology – delayed wound healing, infection,
surgical complications, poor prosthetic fit,
neuromas, adherent scars
Late onset stump pain - neuromas, prosthetic fit,
claudication, bony overgrowth, osteoarthritis ,
tumour recurrence
8. Phantom Pain vs Sensation
Phantom limb Sensation – almost universal
doesn’t correlate with pain reports
Non-painful phantom sensations of 3 types:
Kinetic senstations (movement)
Kinesthetic (size,shape,position)
Exteroceptive (touch, pressure, temperature, itch,
vibration)
11. PLP Onset
Mostly onset immediately after amputation, some at
two weeks. Rarely months later
1/3 maximal immediately post-op and generally
resolved by 100 days
½ slowly peaked then improved within 100 days
¼ slower rise toward maximal pain
(Weinstein, 1996)
12. Prognosis
When PLP persists 6 months, prognosis for
spontaneous improvement is poor
Probably <10% have persistent severe pain
15. Mechanisms of Phantom Pain
Following a nerve cut, formation of
neuromas are seen, which show
spontaneous and abnormal evoked activity
following mechanical and chemical
stimulation. (Amir, et al 1993)
Percussion of stump/neuromas induces
stump and PLP; increased activity of
afferent C fibers (Nystrom, et al 1981)
16. Spinal Plasticity
After nerve injury, C-fibers and A delta-afferents
gain access to secondary pain signaling neurons .
This is manifested by mechanical hyperalgesia and
expansion of peripheral receptive fields. (Doubell,
et al 1999)
Increased activity of NMDA receptor; central
sensitization can be reduced by NMDA antagonists
such as ketamine. (Eichenberger, et al 2008)
17. Anatomical reorganization
Peripheral nerve damage can lead to
degeneration of C-fiber afferent terminals in
laminae II.
As a result, central terminals of Aβ-
mechanoreceptive afferents (which normally
terminate in laminae III and IV) sprout into
laminae I and II. (Woolf, et al 1992)
Ultimately, this results in increased general
excitability of spinal cord neurons.
18. Sympathetic nervous system role
Application of norepinephrine or activation of
post-ganglionic sympathetic fibers excites and
sensitizes damaged (not normal) nerve fibers.
(Devor, et al 1994)
Sympatholytic block can abolish neuropathic pain,
but pain can be rekindled by injection of
norepinephrine under the skin. (Torebjork et al
1995)
19. Cerebral reorganization
One study of adult monkeys revealed cortical
reorganization in which the mouth and chin invade
cortices corresponding to arm and digits.
(Dotrovsky, et al 1999)
In humans, similar reorganization has been
observed using magnetoencephalographic
techniques and there was a linear relationship
between pain and degree of reorganization (flor, et
al 1998)
25. TENS
Topographically relavant afferent signals from intact
limb through transcallosal fibres activates cortical
area which acts as afferent input from missing limb
(Orazio, 2010)
PARAMETERS:
Type: Conventional or Burst TENS
Pulse Frequency: 10-200 pps
Pulse duration: 100-250 ms
Area of application: Over stump, Contralateral limb, main nerve bundle,
dermatome, across spinal cord, auricles
(Mark Johnson,2009)
BEST POSITION: Contra lateral TENS application????
(Winnem, 1982)
26. Mirror Box therapy
Ramachandran created a method of using mirrors to
provide the brain with the missing visual
stimulation.
The reflection of the intact limb is optically
superimposed on the location of the amputated limb
(Phantom Limb), tricking the brain into thinking
that the Phantom Limb is real.
“MIRROR NEURONS”
27. Principle for MT
Visual feedback as a substitution for missing
proprioceptive feedback will reduce pain
To fool the brain and to achieve normal interaction
between motor intention to move the limb and the
sensory feedback through mirror
(Ramachandran, 2000)
28. How to use mirror box
A box with mirror on sides is
placed in front of the client.
The normal leg is placed on
the side of the box in such a
way to see it’s reflection on
the mirror.
Then client is asked to move
his/her normal limb
Daily use of the mirror for
30 min/day is beneficial
29. Exercise Protocol for MT
Brodie et al(2003) explained the procedures of the
exercises to be performed
Duration of exercising 20 minutes daily(Serin et al 2013)
30. Neuromas
Localized pain, sharp/shooting/paraesthesia
Reproduced by local palpation, relieved by LA
injection
Socket correction and local steroid/LA injection
Phenol alcohol injection into neuroma
Surgery – not much evidence, high recurrence rate
ULTRASOUND/TENS/SENSORY
REINTEGRATION TECHNIQUES
31. Managing Phanthom Pain
Daily 30 minutes of MBT
TENS over stump/normal extermity
Weight bearing on the stump using temporary
prosthesis
Massage
Sensory integration techniues
Relaxation techniques
Stump Strengthening exercises
Proper positioning of stump
Applying crepe bandage to the stump
Pre operative PT role is crucial..!