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Phantom - Limb Pain: A Real Sensation
Kathleen Hogan
January 13, 2014
Do you believe in ghosts? Well, what if I told you that each year 147, 815 Americans become new
victims of a phantom,.Would you believe me? This is not the type of spirit you see in sci fi movies or
impersonated on Halloween night, but rather this is a real phantom who haunts and can destroy lives if
not managed properly. This ghost is otherwise known as Phantom Limb Pain (PLP). It is a condition in
which about 80% of amputee patients experience within a year after amputation(“In the Face of Pain”
1). PLP is typically a painful sensation or pressure that comes from an absent limb due to sensory input
data. These sensations originate in the spinal cord and brain and can affect a person’ quality of life. John
Smith is one of many victims of this pain. He is your typical young, social, hardworking American with a
good heart. One day he decided to assist others when he witnessed a car accident occur 15 feet from his
own vehicle. He put his car in park at a stop sign and ran over to see if everyone was okay. He
immediately called 911 and he was told an ambulance was on its way, little did he know that ambulance
would be transporting HIM to the nearest hospital where a helicopter would then transfer him to Shock
Trauma at the University of Maryland Medical Center (UMMC). After the call he ran back to his car and
opened his trunk in search of a jacket when suddenly a vehicle from behind smashed into him, crushing
both legs. He described it as the worst pain he had ever felt in his life. He was in and out of
consciousness his whole way to the hospital and shock trauma. Within a couple of weeks stay at UMMC
the doctors ordered the amputation of his left leg and total reconstruction of his right leg. Smith
reported that the post amputation process was very painful and that he began feeling phantom limb
pain a little while after the removal of the leg and he still feels the sensation today, about 15 months
later. He claims he has a foot spasm in his amputated leg once about every couple weeks and he feels a
throbbing, weird sensation in his foot and toes. He states he is able to move his toes and has working
muscle in his lower leg and foot, which are no longer there. Smith said for him the phantom sensation
isn\u2019t extremely painful, but he does take pain medication and has participated in various therapy
interventions to help address the pain he does experience as a result of the amputation (Smith). There
are many factors that contribute to the intensity and frequency an amputee patient may experience this
phantom including: physical memory of pain before amputation, stump pain, damaged nerve endings,
and/or poor-fitting prosthesis (Mayo Clinic Staff 3). Because this phantom is stubborn and hard to get rid
of, it is necessary that patients experiencing PLP are treated in order to manage and deal with the
relentless phantom. Noninvasive therapies including acupuncture and electric artificial limbs, minimally
invasive treatments like spinal cord stimulation and injection, psychological interventions such as mirror
box and harp therapy, surgery such as brain stimulation and stump revision, and medications including
antidepressants and narcotics are all options to help victims of the phantom (Mayo Clinic Staff 5). Many
people are hesitant to believe in ghosts, viewing them as products of the imagination. Similarly, many
people believe phantom pain to be “within the head” of the patient. I am here to disprove all the nonbelievers. The phantom is real! Phantom Limb Pain is not a psychological condition, but rather it is a real
sensation experienced by amputee patients because of central, peripheral, and psychological factors.
Pain is a product of three key factors: physical, emotional and spiritual aspects. Pain is something that
is very patient specific and individualized, meaning people with the same traumatic injury can have
varying levels and intensities of pain. According to Margo McCaffery, creator of the field of pain
management nursing, claims the definition of pain is, “whatever the experiencing person says it is,
existing whenever and wherever the person says it does.” Pain follows a specific pathway through the
body starting with the nerves at the site of injury, then traveling to different receptors, which pass the
sensory data to the brain where it triggers a pain response(D. Audia, pers. comm.). The pain pathway
then flows back from the brain through the receptors to the damaged nerve endings at the site and a
painful sensation is experienced. Phantom Limb Pain is a specialized category of pain, however, all these
basic principles of pain still apply. PLP can be as excruciating as severe shooting pain to as mild as feeling
the presence of an absent limb (McGrath). Phantom Limb Pain is often confused with ResidualLimb/Stump Pain, which is a condition in which the patient feels pain in the area adjacent to the
amputated body part. PLP is strictly a painful sensation coming from the missing extremity cause by a
variety of factors.
Central factors contributing to the phantom pain sensation include the spinal cord and brain: the main
components of the nervous system. “During imaging scans - such as magnetic resonance imaging (MRI)
or positron emission tomography (PET) - portions of the brain that have been neurologically connected
to the nerves of the amputated limb show activity when the person feels phantom pain (Mayo Clinic
Staff 2).” When a limb is amputated, areas of the spinal cord and brain receive mixed signals due to a
change and lack of sensory input stemming from the missing extremity and damaged nerve endings at
the site, which is interpreted as something is wrong and causes the patient to feel pain as a response.
The brain being the “powerhouse” of the body often responds to the loss of sensory input from a region
of the body by remapping the sensory circuitry to another part of the body that is still present and
intact. This process is called cortical reorganization. For example, if you lose a hand your brain may rewire that sensory circuit to a muscle in your face affecting your mouth, so whenever your mouth is
touched it will feel as if the missing hand is also being touched. “The larger the shift of the mouth
representation into the zone that formerly represented the amputated hand and arm, the greater the
phantom-limb pain” (Flor 184). However, this rewiring can often times result in pain due to tangled
sensory wires sending mixed signals to the brain and spinal cord.
There are specific interventions used on patients to address pain originating from these central factors.
Non-pharmacological, noninvasive, and psychological therapies are used to alter the mindset of the
brain which is responsible for triggering the pain response. Mirror box therapy is very commonly used
on amputee patients and tricks the brain into thinking it has two normal, working limbs with the help of
a mirror reflection of their intact limb. Even though the brain is receiving sensory data that would
usually trigger a painful response, the visual of the mirror’ reflection over powers this abnormal input
and puts the mind at ease. Tackling the site where pain is triggered can often help limit and manage PLP
(D. Audia, pers. comm.).
Peripheral factors also play a large role in causing the sensation of PLP. Peripheral factors are the
nerves that are connected to the body part that is lost. The nerve endings are cut at the site of
amputation. “Lesion to the peripheral nerves supplying a limb leads to structural and functional changes
within the peripheral nerve and is often associated with the development of neuromas” (“Current
Opinion in Anaesthesiology” ), tumors of nervous tissue which are typically painful. At the site of
amputation the nerves are cut and this causes abnormal sensory input to be received by the spinal cord
and brain, the central factors, and interpreted as something seriously wrong causing the patient to feel a
painful sensation in their absent limb known as phantom-limb pain. Similarly to the central factors,
there are treatments that address the pain associated with the peripheral factors to help the patient
manage the PLP sensation.
Another method of addressing phantom pain is to focus on the peripheral factors, especially the nerve
receptors. Pain medications such as Calcitonin and Ketamine are prescribed to patients with PLP to
minimize their pain by shutting off pain receptors in the pain pathway through the spinal cord up to the
brain (Mayo Clinic Staff 8). By shutting down these receptors the abnormal sensory input is unable to be
passed along to the brain where pain is triggered. Overall, both central and peripheral factors are
contributors to phantom pain and can be addressed individually through different interventions to
provide pain relief to patients suffering from Phantom Limb Pain.
The last factor that causes phantom pain are psychological factors. As mentioned above both central
and peripheral factors cause neuropathic pain or PLP making it a real sensation that requires different
interventions and medications. The psychological factors are responsible for triggering this pain
randomly and periodically. The pain is not “in the head” of the patient, but attributing factors causing it
can be. Patients suffering from phantom limb pain, “tend to have normal psychological profiles” ( Flor
185), for the painful sensation is only triggered and exacerbated by psychological factors including
stress, muscle tension, a lack of coping strategies, great fear, and the level of support the amputee
patient receives before the amputation takes place. Any pain memories established before the
amputation are also powerful elicitors of phantom-limb pain (Flor 186). Observing others in pain can
also trigger a PLP sensation. “Synaesthetic pain occurs when the observation or imagination of pain in
another induces a similar somatosensory experience in the pain synaesthete. In amputee pain
synaesthetes, this manifests in phantom pain being triggered by observing others in pain” (“Current
Opinion in Anaesthesiology” ). The brain is the most powerful, most complex thing in the universe, so it
only makes sense that factors affecting the brain directly can trigger a pain response in the body.
As mentioned before, treatments are required to manage and minimize phantom limb pain in amputee
patients in order to help them get back to living a normal, comfortable life after the accident. Just like
mirror box therapy is used often for PLP patients to address central factors, and pain medications like
Calcitonin and Ketamine to address peripheral factors, there are also specific treatments to address the
psychological factors. At the University of Maryland Medical Center I was able to shadow the hospital’
Integrative Medicine Team for a day to observe treatments for patients suffering from extreme pain.
One of the interventions I observed was harp therapy. The live music helped to relax and put
patients\u2019 minds at ease. Harp therapy is one of many psychological treatments offered to patients
at the hospital to help relax patients and put their minds in a place other than the hospital. Another
commonly used psychological treatment is visual therapy or imagery. The goal of this intervention is to
create a place where the patient feels him/herself and often a place where they experience a “Zen-like”
feeling, such as underwater or on top of a mountain. This imagery is very specific to the patient and
their interests and hobbies. Through both therapeutic music and visual therapy patients are able to relax
and send their mind elsewhere to help forget the suffering and pain they are currently experiencing.
This can be seen as manipulating the brain to focus on something else rather than continuing to trigger
pain responses.
Central factors, peripheral factors, psychological factors, pre-amputation pain, pain pathways, and
various pain interventions all collaborate to create a phantom called PLP. This phantom haunts innocent
people each and every day and is always seeking new victims to torture. 80% of amputee patients in the
nation are reported to suffer from this lingering pain the phantom causes with the assistance of central,
peripheral, and psychological factors. The only way to ease the pain and scare the phantom away is
through therapeutic interventions that focus on manipulating the brain, spinal cord, nerve receptors,
and psyche. Phantom-Limb-Pain is the most successful phantom when it comes to altering the lifestyle
of its victims, for it takes a whole lot of therapy and medications to rid the phantom from the life of
amputee patients so that they are able to live a normal, comfortable life. It has been 15 months after
the accident and John Smith has learned to walk again, but with a limp which will most likely affect him
for the rest of his life. He can no longer run or jump as a result of the loss of his left leg and severe injury
to his right one. He was fitter with a prosthetic leg about 6 months ago to help him with mobility and
insecurity in appearance. This car accident has had a tremendous impact on his life; however, he
continues to have a positive outlook and works to get through the pain he still suffers from. He is
currently part of UMMC’ Trauma Survivors Network and attends monthly support group meetings with
other trauma survivors to help assist others in recovery as well as his own healing process (Smith). Smith
is only one of MANY Americans who suffer from this phantom after experiencing the amputation of a
limb. I ask that you help me help these innocent people like John Smith. Spread the news of the
phantom to others so collectively we can be educated and sympathetic to a large group of Americans
and many war veterans who have lost limbs for our freedom. The least we can do is acknowledge the
phantom they are fighting instead of deeming them mentally ill. The phantom is a reality. So, I ask that
you help me to make a nation of believers!