Discuss about the Phantom Pain and its Treatment.
Phantom pain refers to a condition characterized with actual pain that an individual feels as a result of a missing body part (Weeks, Anderson-Barnes, & Tsao, 2010). Phantom pain is also known as phantom limb pain and causes frustrations to both patients and physicians. Phantom pain is difficult for physician to manage while it causes discomfort to patients (Ahmed, Mohamed, & Sayed, 2011). High levels of 60%-70% phantom cases are reported after one year of amputation (Kim, & Kim, 2012). Phantom pain was not recognized until it was defined by Silas Weir who was a surgeon in civil war (De Ridder, Elgoyhen, Romo, & Langguth, 2011). The following report is a research review on phantom limb pain and methods that can be used to treat the condition. This will involve examining various perspectives of phantom pain and critically reviewing literature on phantom pain and methods that can be used to treat the condition.
There are different perspectives that different scholars and physicians use to study phantom pain. The phantom pain is perceived to be caused by different actors that stimulate mild or severe pain to a patient. Weeks, Anderson-Barnes, & Tsao, (2010), defined phantom pain as conscious feeling as a result of a painful limb even after amputation. Kim, & Kim, (2012) on the other side, defined phantom pain as perceived pain from a region of a body that is no longer present in the body. The authors noted that nearly all amputees are likely to feel as if their missing limb still exist that lead to chronic phantom pain. Kumar, & Saha, (2011) also defined phantom pain as an ongoing painful sensations coming from a limb that is not there. Phantom pain is real despite the limb being absent and the pain length differs from one person to another. There are two distinct perspectives to phantom pain; top down and bottom up approach. These approaches have been hypothesized and put down to theories that enhance rational treatment. The top down perspective puts forward that phantom pain occurs when sensory inputs are suddenly lost and the patient brain had no change to adapt. This perspective shows that phantom pain is stimulated by the brain in the process of adapting to loss of an input. The brain causes pain in the process of adapting to new change that has happened to the body. The top down perspective therefore argues that phantom pain can be managed by tricking the brain (Hsu, & Cohen, 2013). On the other side, the bottom up approach is opposite of top down. The perspective show that phantom pain resides in nerves in the patient’s spinal cord. The neurons are the ones that carry pain signals from the body to the spinal code. The spinal cord then sends signals to the brain. The bottom up perspective shows that pain starts from the area affected with amputation where the signal is sent to the spinal cord then pain is indicated in the brain. This approach also argues that phantom pain is not imagined in the patient brain but felt. Therefore there is no single agreed perspective to phantom pain.
Several studies have been done to explore, explain, and illustrate phantom pain. Amputees have to face both the stump and phantom pain. The amputees have other several challenges that include; self concept and self image, financial changes, physical functioning impairment, loss of independence, adapting to prosthesis use and many psychosocial adjustments. These challenges stress amputees that cause depression which in some cases lead to contemplation of suicide. Despite phantom pain having large impact to amputees, it has proven difficult to standardize it clinical management and assure patients’ quality health care (Kumar, & Saha, 2011). Kumar, & Saha, (2011), in their study established that phantom pain is both caused by peripheral and central mechanism. The changes in peripheral and central mechanisms following an amputation were found to be involved in phantom pain. Phantom pain was found to be frequent where the amputees had long-term stump pain (Mulvey, Bagnall, Johnson, & Marchant, 2010). Mulvey et al., (2010) established that phantom pain was correlated to stump temperatures. Lower temperature in stump show reduced near-surface blood flow which is correlated to burning symptoms of phantom pain. De Ridder et al., (2011), found that pressure sensitive neuromas exacerbated phantom pain. In another research, Flor (2014), found that there was neuropathic stump pain to 61% of patients with phantom pain and only 39% without phantom limb pain. Central mechanisms play a role in sensitization of dorsal horn stimulates phantom pain. An increase in peripheral nociceptors activities lead to permanent change in synaptic structure. This change leads to reduced inhibitory processes and then lead to increase in excitability making neurons prone to fire effected causing persistent phantom pain. Flor, (2014) concluded that both central and peripheral aspects have a role in causing phantom pain. Phantom pain is therefore caused by peripheral and central mechanisms.
Phantom pain has high prevalence and is difficult to manage. Several studies have outlined several methods of treating phantom pain. There are several suggestions in surgical, medicinal, and conventional therapeutic approaches that reduce phantom pain. The phantom pain treatment examples that reduce pain include; stump manipulations, sympathectomy, nerve blocks, pharmacologic therapies, stump ultrasound, cordotomy, myoeletric prosthesis, and transcutaneous nerve stimulation (Subedi, & Grossberg, 2011). Subedi & Grossberg (2011) noted that these approaches were only slightly effective that meant their application was not satisfactory to treat phantom limb pain.
Phantom pain has six main treatment methods; neurosurgery, electrical stimulation, biofeedback treatment, pharmacological treatment, psychological management and dorsal column stimulation. The nervous system is highly associated with phantom pain. The surgeons apply neurosurgery method to treat phantom pain by destroying nervous system that connect the peripheral and cerebral hemisphere with an objective of reducing phantom pain. Wolff et al., (2011) found that neurosurgery as method of phantom pain treatment is a temporary means to relief pain and the method has an inherent risk of patient permanent neurological incapacity. Secondly, electrical stimulation method of phantom pain treatment stimulates peripheral nerves that lack sensory stimuli following amputation. The methodology increase stimuli that increase inhibitory effects in the brain decreasing hyperactive neural mechanisms that cause pain. Hsu & Cohen, (2013) found that electrical stimulation method has 50% success rate. In another research, Flor, (2014), assessed twenty patients and 7 were found to have gotten excellent relief and 3 obtained partial relief. Only 2 patients did not obtain any pain relief. He concluded that electrical stimulation was an effective method of treating phantom pain because of it high percentage of success. Thirdly, the dorsal column stimulation method of treating phantom pain is designed similar to electrical stimulation except that it used for stimulating the dorsal columns of spinal cord rather than peripheral nerves. Ahmed, Mohamed, & Sayed, (2011) in their research on 5 phantom pain patients found that the treatment was successful and results sustained for more than two years. The fourth method of treating phantom pain is pharmacological treatment. Patients are treated with Lysergic Acid Diethylamide (LSD-25) drug that increase neurotransmitter serotonin. The serotonins are central to pain modulation and their deficiency can lead to increased pain sensitivity stimuli. The methodology therefore administers LSD-25 that increases levels of serotonin. This helps reduce phantom pain. Flor, (2014), found that LSD-25 improved patients’ condition by reducing pain. However, Flor, (2014), concluded that LSD-25 drug is a non hallucinogenic dose and therefore has psychic reaction, addictive and distorts perceptions that make it ineffective method of treating phantom pain. The other method of treating phantom pain is biofeedback treatment. This method is based on peripheral and psychologic theories and it approach is based on anxiety-muscle tension-pain cycle. The biofeedback system contracts patient’s muscles to make them audible using electrodes. The patient then learns how to relax musculature and the pain in peripheral nerves is relieved. Lastly, phantom pain is treated using psychological management method that is based on three-phased strategy. The first phase is prevention, second phase is intervention and the last phase is behavioural and psychotherapy therapies. Woolf, (2011) argue that pain personalities pose are difficult to treat and require behavioural and psychotherapy therapies to remove the pain. Therefore, there is no one agreed method of phantom pain treatment.
Conclusion
From the research review, phantom pain is a common condition among amputees. The phantom pain is ongoing and cause discomfort to the patients and is difficult for physicians to manage. Despite several studies on phantom pain, there is no agreed mechanism to the cause and treatment of the condition. The two common perspectives are top down and bottom up approaches of phantom pain. The top down perspective show that phantom pain starts from the brain as a result of amputation. On the other side, bottom up approach show that phantom pain start from the amputated areas to the spinal cord that is then connected to the brain. Phantom pain can be treated using several methods that include electrical stimulation, dorsal column stimulation, neurosurgery, pharmacological treatment, biofeedback treatment, and psychological management. Therefore, it can be concluded that there is no definitive treatment that can cure phantom pain because it cause mechanism is still unknown.
References
Ahmed, M. A., Mohamed, S. A., & Sayed, D. (2011). Long-term antalgic effects of repetitive transcranial magnetic stimulation of motor cortex and serum beta-endorphin in patients with phantom pain. Neurological research, 33(9), 953-958.
De Ridder, D., Elgoyhen, A. B., Romo, R., & Langguth, B. (2011). Phantom percepts: tinnitus and pain as persisting aversive memory networks. Proceedings of the National Academy of Sciences, 108(20), 8075-8080.
Flor, H. (2014). Psychological pain interventions and neurophysiology: Implications for a mechanism-based approach. American Psychologist, 69(2), 188.
Hsu, E., & Cohen, S. P. (2013). Postamputation pain: epidemiology, mechanisms, and treatment. Journal of pain research, 6, 121.
Kumar, S. P., & Saha, S. (2011). Mechanism-based classification of pain for physical therapy management in palliative care: A clinical commentary. Indian journal of palliative care, 17(1), 80.
Kim, S. Y., & Kim, Y. Y. (2012). Mirror therapy for phantom limb pain. The Korean journal of pain, 25(4), 272-274.
Mulvey, M. R., Bagnall, A. M., Johnson, M. I., & Marchant, P. R. (2010). Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults. Cochrane Database Syst Rev, 5.
Subedi, B., & Grossberg, G. T. (2011). Phantom limb pain: mechanisms and treatment approaches. Pain research and treatment, 2011.
Weeks, S. R., Anderson-Barnes, V. C., & Tsao, J. W. (2010). Phantom limb pain: theories and therapies. The neurologist, 16(5), 277-286.
Woolf, C. J. (2011). Central sensitization: implications for the diagnosis and treatment of pain. Pain, 152(3), S2-S15.
Wolff, A., Vanduynhoven, E., van Kleef, M., Huygen, F., Pope, J. E., & Mekhail, N. (2011). 21. Phantom pain. Pain Practice, 11(4), 403-413.
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