What is phantom limb. Ambrose Pare, a sixteenth century French Military surgeon first explained the idea of phantom limb. Phantom limb is the feeling of the amputated area of the limb still attached to the body and moving appropriately with other areas of the body. People who were amputated typically will either feel a phantom discomfort or phantom pain. Phantom discomfort differs from pain where in fact the person will experience a tingly, cramping, or itching feeling where the removed limb used to be. It is said that is clearly a normal part of healing after the surgery treatment and it often goes away completely as time passes. Phantom pain is a discomfort of using, crushing, or stabbing experience where it can be a short-term or can last for a long period. 3 Phantom limb sometimes also happened when a part of organ is removed such as breasts, teeth, or the attention.
1. 2 Pain theory
As a person limbs been removed, how would the individual experienced the pain? To understand this, the basic concept of pain needs to be explored. Pain is referred to as an unpleasant sensation that may be associated with actual or potential tissue damage and may have physical and mental components. Ron Melzack and Patrick Wall membrane suggest in 1962 that physical pain is not really a direct consequence of activation of pain receptor neurons, but instead its perception is modulated by interaction between different neurons. 5 By understanding the basic idea of pain, the relationship of phantom limb and pain will be further mentioned in the other section.
1. 3 Incidence
There were an estimation of just one 1. 6 million people with limb damage in 2005 and it is likely to increase to 3. 6 million by the year 2050 in a study done in USA. 1 The amount of traumatic amputation also increased due to the war in Iraq and Afghanistan. 1 For the individual that received amputation, the occurrence of PLP reported to maintain the range of 42. 2% to 78. 8%. 1 Another studies in 62 claim that this phantom occurrence is less observed in early childhood because of the fact that in early childhood there isn't plenty of time for your body image to 'consolidate'.
2. 0 The Mechanism of phantom limb (patophysiology)
2. 1 Introduction
To understand the factors that creating the pain in phantom limb the underlying basic of anatomy and physiology must be well known first. The phantom limb pain initially was taught just to be a consequence of psychiatric condition. However research after research was done to justify the idea behind the mechanism that causes the phantom limb. Multiple mechanism theory were suggested which entail peripheral mechanism, central system and also psychogenic device.
2. 2 Peripheral mechanism
In this article "Exactly what is a Phantom Limb" from the news headlines medical, the peripheral mechanism theory that was creating the pain was taught to be scheduled to neuromas which is soreness in the severed nerved finishing. The irritability was a result of many nerve endings are terminated at staying stump whenever a limp is amputated. The inflamed nerves then will send impulses to the brain that the mind identified it as a pain. Based on this theory, treatments are done but the results were failing. Some cosmetic surgeon would perform a second amputation so the swollen nerved endings can be removed and could bring temporary alleviation but the consequence was that the phantom pain increased than they had previously. Some medical expert also attempts to remove the sensory nerved leading to spinal cord and in a more acute cases, a medical expert would removed the part of thalamus that received the sensory signals from your body. 2 In neuromas, there's a hyper-excitability and spontaneous discharge of sodium programs and drugs are used to prevent this sodium programs really helps to reduce just a little pain that resulted in this theory being supported. 1 However this will not explain about the phantom limb pain in the individual with congenital lack of limb. 1
2. 3 Central Mechanism
The National Health Institute (NHI) in 1990 found out that the brain would reorganize itself if the sensory source were being take off. This then provides idea that the phantom limb pain was credited to mix wiring in the somatosensory cortex. 2 Somatosensory cortex is located at the post-central gyrus and it will get source from the limbs as well your body. V. S. Ramachandran, a neuroscientist explained that when a person right palm is amputated, the input from the side left somatosensory cortex would be ceased. 2 However this person would experience a phantom limb feeling because of the somatosensory cortex near the hands which is the arm and face will need over the right hand cortical region or known as remapping. 2 This cortical reorganization at the amount of brain partly clarifies the afferent nociceptive activation of neurons within the surrounding area produces the sensation in the lacking limb. 1 Another theory propose is the fact that in the level of spinal cord there can be an increase of N-methyl-D-aspartate (NMDA) receptor activity which leads to a neuronal firing of nociceptive neurons hence this exacerbate the phantom limb pain.
2. 4 Psychogenic mechanism
Another theory that was suggested in this article "Phantom Limb Pain: Mechanisms and treatment" from the pain research and treatment journal is through psychogenic device. However this in not reinforced in a few research although it was assumed that stress, exhaustion, anxiety and melancholy would exacerbate phantom limb pain. In a single cross sectional analysis, the results discovered that amputation in people who have personality traits characterized by unaggressive coping style and catastrophic habit was found to be associated with the development of phantom limb pain impartial of panic and major depression. 1
3. 0 Pain Management
3. 1 Introduction
As for the management of phantom limb pain, there are no definite treatments that can cure the pain completely. There are lots of treatments either through drugs or by way of a non-drugs intervention. Like other drugs, some may bring gain and brings side-effect to the individual. Thus, it depends upon the doctors to make the decision based on the patient condition to gives what's the best treatment for their patient. For this pain management of phantom limb pain, all were from the same source, which is an article "Phantom Limb Pain: Anaesthesia Article Of the week 229".
3. 2 Drug intervention
3. 2. 1 Antidepressant
An example of an antidepressant is trycyclic antidepressants that the medicine functions by inhibiting the re-uptake of noradrenalin and serotonin and will potentiate the action of two important central anti-nociceptive pathways. There exists however no studies specifically that examine the utilization of trycyclic antidepressant in phantom limb pain but they are commonly used and it is thought to hold the modest efficiency.
3. 2. 1 Sodium route blockers and anticonvulsants
Gabapentin and Pregabalin are usually effective in variety of neuropathic pain problems. They take action by binding to voltage gated calcium mineral channels. However the side ramifications of this drug is somnolence and dizziness, that can be reduced by using continuous dose titration. Intravenous Lidocaine also has been reported it bring great results in neuropathic pain. Mixiletine, an dental analogue of intravenous Lidocaine has been shown in a tiny study that is leads to treatment in phantom limb pain
3. 2. 3 Tramadol
A synthetically produced drug that has a monoaminergic and opiod activity and has less undesireable effects compared to strong opiods. It really is ideal for neuropathic pain that require multiple receptor process. It has shown in a number of studies that it helps reduce neuropathic pain including post-amputation pain.
3. 3 Non-drug Intervention
3. 3. 1 Reflection Box
Mirror field is a non-medical treatments where a device filled with a vertical mirror and is put so a reflection of the individual intact limb is superimposed onto the perceived position of the phantom limb. It really is shown that the mirrored movements stimulate the contra lateral sensory electric motor cortex and result in a decrease in pain.
3. 3. 2 Mental imagery
This is an activity of imagining motor unit sequences which is considered to work similar way as the reflection box. Studies show that it results in a significant decrease in pain.
3. 3. 3 Psychology
Psychology remedy such as hypnosis and cognitive behavioral remedy may also gain patient in reduced amount of the phantom limb pain.
3. 3. 4 Electrical stimulation
Electrical arousal of spinal cord, deep brain constructions and electric motor cortex really helps to relieve pain but its success decreases as time passes.
3. 4 Prevention
In order to avoid the risk of developing phantom limb pain, doctors suggest the utilization of local anesthesia through vertebral or epidural few time or days leading to the amputation. By doing this procedure it might helps to decrease the pain before the surgery hence minimizing the chance of enduring phantom limb pain.
4. 0 Conclusion
Phantom limb pain is an issue that started out in the past and has been discussed until nowadays. Large amount of researched are done in order to find the right system and the most effective treatment to lessen the pain in a person with amputated limb. Together with the advanced technology nowadays, a whole lot of more scientist and research should come out with a fresh discovery in this studies of phantom limb pain. As for the anesthetic view of phantom limb pain, there are few research done that proves to help the pain management in phantom limb. A right decision by an anesthesia can helps and implies an improved treatment to be been through by an individual with an amputated limb.