Phantom Limb Pain: Causes, Symptoms & Treatment

Phantom limb pain, also known as phantom limb, is a pain primarily associated with missing or amputated limbs. Although the body parts are no longer present, the affected person feels pain in this case. Phantom limb pain is one of the amputation pains, along with stump pain.

What is phantom limb pain?

Infographic on pain regions, progression and development of pain, and intensity levels in pain sensation. Click image to enlarge. Even in the ancient civilizations of mankind, such as in ancient Egypt or among the South American Mayans, physicians amputated diseased or injured limbs. In earlier times gangrene was a common cause for the amputation of an arm or leg and often the only hope to save a human life. Even today, limbs sometimes need to be amputated, for example, due to irreparable damage from an accident or infectious disease. An estimated 50 to 80 percent of patients who have had a limb or even an organ removed subsequently complain of phantom pain or phantom sensations in the now missing body parts. Phantom limb pain usually occurs within a month after surgery and can vary in intensity. In rare cases, however, affected individuals may complain of phantom limb pain for the first time months or years after surgery.

Causes

Science has not yet been able to find specific causes for the occurrence of the phenomenon of phantom limb pain. A few years ago, it was believed that the reason for virtual pain was inflamed nerve stumps. Today, doctors believe that phantom pain is caused by some kind of brain confusion. Even after the amputation, the brain has not yet classified the limb or organ as missing and simply continues to assume the old, complete body scheme. This approach also explains why phantom sensations occur: For example, some patients think they can gesture with a missing hand. Another observation supports the thesis of the brain that cannot rethink: Phantom pain is based in its intensity on the real pain felt before the operation. At the same time, patients’ brains seem to remember the real pain they went through before surgery. Some people claim to feel phantom pain when the weather changes on former wounds or fractures, e.g. from high pressure to low pressure. However, this cause has not yet been scientifically verified and, accordingly, represents a subjective sensation.

Symptoms, complaints, and indications

Patients can usually specify exactly where they feel phantom limb pain. For example, a person whose right forearm was amputated might feel the phantom pain in the (now missing) ball of the hand or in the little finger and ring finger. Although the pain does not originate from an adequate stimulus in the amputated tissue, the nervous system responds as if an appropriate neural stimulus were present. The pain is not simulated and does not occur directly on the residual limb. In principle, phantom limb pain can develop in any part of the body that has been amputated. However, the discomfort is especially common when the surgical site is close to the trunk. Phantom limb pain often occurs in phases. Continuous pain is also possible, but is less common. Both the pain attacks and the continuous phantom pain represent a burden that often results in psychological discomfort. Both the intensity and the quality of the pain can vary. Phantom limb pain can feel sharp, cutting or burning. In addition, affected patients may feel as if they have a painful spasm in the amputated body part. Some patients suffer from phantom limb pain immediately after amputation. In other cases, the symptoms appear only after a longer period of time. Most sufferers develop the phantom limb pain within the first month after surgery. However, the symptoms may also first appear after several years.

Diagnosis and course

Phantom limb pain is diagnosed primarily on the basis of patient descriptions. However, before the physician commits to this diagnosis, he must first rule out organic causes of the pain. So-called stump pain is also common after amputation and is sometimes difficult for the patient to distinguish from phantom limb pain.Stump pain is often triggered by pressure points caused by ill-fitting prostheses, inflammation or circulatory disorders. Phantom limb pain usually occurs in the form of episodes or attacks. Rather rarely, they are described as being present all the time. The nature of the pain can vary widely: Patients reported sharp, burning, cramping, stabbing, or even cutting phantom limb pain. Phantom limb pain also varies in intensity and duration. Some people suffer from it so extremely that they want to take their own lives.

Complications

Phantom limb pain after amputation is common, with about 70 percent of all people suffering from it. Up to a certain level, it is normal and often occurs in conjunction with residual limb pain. Although phantom limb pain is harmless in most cases, a doctor should still be consulted to prevent the symptoms from worsening or becoming chronic. It is important that phantom limb pain is treated early, because otherwise the body develops a so-called pain memory. In this case, signals are sent from the brain to the amputated area of the body and there is no response. If this happens several times, the brain classifies the missing feedback as an injury and reacts to it with pain. Therefore, it is important to counteract this pain memory as early as possible. Phantom limb pain can be severe and require pain medication. However, long-term use of pain medication again carries the risk of becoming dependent on pain medication. In addition, phantom limb pain can cause increased irritability and sleep disturbances, and can limit both health and social life. Without treatment, depression or even mental illness may also occur and require treatment.

When should you see a doctor?

Phantom limb pain is experienced by people who have lost body parts. Other people are not in the risk group of this unpleasant pain experience. If the affected person perceives discomfort in areas of the limbs that were severed in an accident or amputation, he or she should see a doctor. What is needed in these cases is therapeutic work with various exercises and training so that the necessary reprogramming in the brain can take place. Otherwise, the symptoms will persist or increase in intensity. A visit to the doctor should be made so that a therapy plan can be created. In the case of sleep disturbances, a persistent experience of stress, inner restlessness as well as an impairment of the joy of life, a doctor should be consulted. If there are vegetative dysfunctions, changes in personality, a general dissatisfaction or a restriction of the way of life, a doctor is needed. Depressive moods, apathy or behavioral problems should also be discussed with a physician. Disturbances in concentration, attention deficits and a decreasing ability to cope with stress are signs of a health impairment. A doctor should be consulted so that relief can be initiated. Often the intensity of the complaints varies. There may also be a period of freedom from symptoms. During these periods, a doctor is not normally needed. However, if the pain recurs after a period of time, consultation with a physician is advised.

Treatment and therapy

There is no single treatment option for phantom limb pain. Possible therapies must be individualized to each patient and are designed to help the brain reorganize itself. In general, phantom limb pain is treated with medication, physical or psychosomatic therapy, or a combination of some or more of the above. Severe cases of phantom limb pain are initially treated with narcotic opiates, such as morphine, to relieve the patient’s distress. Treatment with antidepressants and / or electrostimulation is common. Here, an electrode placed under the skin irritates the spinal cord with electrical impulses designed to distract the brain from the phantom pain. Newer methods such as mirror therapy as well as therapy using virtual reality seem to achieve very good results. Both therapies simulate the amputated limb and ask the patient to move it, freeing it from its painful position. Also a targeted distraction and other occupation of the patient sometimes makes the phantom pain disappear.On the other hand, therapies such as acupuncture, hypnosis, physiotherapy or biofeedback have proven to be of little help. Treatment methods such as shortening the residual limb, severing the sensory nerves in the spinal cord, and removing the thalamus are no longer common. They generally showed little or no success.

Outlook and prognosis

What the prognosis is for phantom limb pain depends on certain factors. It is especially important to start medical treatment for the pain as early as possible. If pain treatment is positive, a favorable course of symptoms occurs in approximately 70 to 90 percent of all affected individuals. However, if pain therapy is started at a later stage, the prospects are less favorable. Thus, only one third of patients show a positive course of healing. It is impossible to say how long phantom limb pain will last. It is possible that the pain will disappear spontaneously. However, a sudden return of the painful symptoms is also possible. The prognosis is particularly unfavorable if the patient suffers from the amputation pain for more than six months. The type of amputation pain plays an important role in the further course of the complaints. For example, abrupt stump pain sets in suddenly immediately after the surgical procedure, and in some cases it can take on chronic proportions. However, they are often acute and severe. In the case of phantom pain, a prolonged period of discomfort is generally to be expected. In addition, the pain can reappear at any time. Sometimes phantom limb pain develops as a result of inflammation or infection. However, the prognosis can usually be improved by the administration of antibiotics.

Prevention

Phantom limb pain is difficult to prevent. However, in many cases, administration of neuroleptics or analgesics before planned surgery has been helpful. Phantom limb pain did not occur as severely afterwards or, in some cases, did not occur at all.

Follow-up

Phantom limb pain resolves with appropriate therapy in the first few weeks after an amputation. Many patients do not require follow-up care because they are symptom-free. Subsequent acute discomfort is not uncommon but can usually be resolved without consulting a physician. However, if there are recurring attacks of pain or a continuous sensation of pain, follow-up care becomes indispensable. The extent of follow-up depends on the intensity of the symptoms. Long-term treatment with medication is not uncommon. Alternative healing methods are sometimes promising. Depending on the severity of the symptoms, psychotherapy may be indicated. The teaching of relaxation exercises often helps as well. Some sufferers are so distressed by their condition that they attempt suicide. The checks and treatments serve to identify and address life-destroying tendencies at an early stage. Follow-up care primarily reflects the patient’s feelings. Physical examinations serve to exclude other diseases. The treating physician documents the effect of therapies that have been carried out. What promises success is continued, what does not contribute to an improvement is discarded. Doctors cannot prevent phantom pain because of its unpredictable onset. Thus, follow-up cannot have a preventive character, as is usual in tumor diseases.

What you can do yourself

People who suffer from phantom limb pain can use cognitive approaches to improve their symptoms. Since pain is stored in the brain based on experiences as well as experiences and is not based on a real impact, training can bring about relief from the pain. It is helpful to have the help and support of a therapist. Together with the therapist, exercises can be worked out that the person affected can perform on his or her own as needed in everyday life. The mirror therapy approach is helpful and very promising. They are an enormous relief for the patient and improve the well-being considerably. In consultation with the therapist, the training sessions can be carried out independently between or after the treatments. With dexterity exercises in front of a mirror, sensory impressions are evoked that help with pain management.In addition, awareness processes are helpful in dealing with the changed situation. Since it is an imagined pain, some patients manage to specifically change it by dealing with their stored memories. Cognitive techniques offer possibilities and methods that can also be applied autonomously by the patient in everyday life. Phantom pain should not be ignored, as this can lead to an intensification of the symptoms and significant impairments in everyday life.