Phantom Limb Pain: Theories and Therapy

Phantom limb pain (PLP) is reported in nearly 80% of patients with missing limbs, yet the causes are still not fully understood. Recent research on the topic has helped to increase our knowledge of PLP, but the varying nature of the condition makes it difficult to define and treat. Patients often experience different sensations described as tingling, throbbing, piercing, or pins and needles. Some patients have reported experiencing these sensations immediately following an amputation, while others do not experience any phantom pain until years after the surgery. In addition to varying times of onset, the periods of pain onset may differ from patient to patient, ranging from a few weeks to any number of years (Subedi et. al. 1-2).

Risk Factors for Phantom Limb Pain

Female Sex

Upper extremity amputation

Presence of pre-amputation pain

Residual pain in remaining limb

Time after amputation

While the mechanisms of PLP are still debated, increased focus on the condition has led to the revelation of some interesting trends. Phantom limb pain occurs more often and with greater intensity in females than in males; upper extremity amputations have a greater tendency for PLP than lower extremity amputations; and patients who experience pain in their limb prior to its amputation are more likely to experience PLP after amputation. In the past, PLP was characterized as a psychiatric illness, but the mentality among physicians and researchers is changing. Research is now aimed at discovering the physiological mechanisms of PLP instead of dismissing the condition as purely psychological (Subedi et. al. 2).

Theories

Numerous theories exist in regards to the causes of PLP, and most experts believe that a combination of the proposed mechanisms may actually be responsible for the pain that patients experience. The most cited cause of PLP in recent years is associated with changes that occur in the brain when there is a lack activity in a certain region, such as the portion of the brain that controls a missing limb. When a portion of the brain is not being used, neighboring sensory or motor areas can take over. This process is termed cortical reorganization, and can partly explain why patients may still feel sensations in a missing limb (Subedi et. al. 2).

Another theory, the peripheral mechanism, explains PLP as the result of spontaneous discharges from neuromas that form in peripheral nerves following an amputation. A neuroma is a proliferation of cells that develop after injury to a nerve. This ball of nerve cells acts abnormally, and could result in stump or phantom pain (Subedi et. al. 2).

One last interesting theory attributes painful sensations to the incongruence between motor intention and sensory feedback in the brain. While a patient may feel as if his or her phantom arm is extending to reach for a cup, vision and other sensory feedback tells the brain that the limb is not present. Some experts propose that the brain interprets this conflict by sensing pain in the phantom limb (Jerrell). In reality, PLP is likely due to a combination of the proposed mechanisms and differs among the various types of patients.

Treatments

When treating PLP, each case must be addressed using trial and error as no single treatment has proven to be the best for all types of patients (Jerrell). While numerous patients have found success using some of the available therapy options, it is up to the patient and his or her provider to find what works best on a case-by-case basis.

Many different types of pain medications and anti-depressants have been used in the past, but studies have shown mixed results. NSAIDs such as Motrin or Advil were found to be the most common medications used to treat PLP, likely because they are over-the-counter and have few side effects (Subedi et. al. 3).

Transcutaneous Electrical Nerve Stimulation (TENS) is another noninvasive treatment that is becoming more common, even though only a few studies have shown its effectiveness. TENS therapy uses electrodes placed on the skin to apply current to the affected nerves. Stimulation may reduce pain by blocking pain signals from reaching the brain, or by prompting the body to produce neurotransmitters that act as natural painkillers (Desantana et. al. 492-494).

Another treatment – mirror therapy – has shown significant benefit in some patients, particularly lower mirrorleg amputees. During mirror therapy, the patient watches the intact limb move in a mirror (placed between their legs or arms), such that it appears that the missing limb is present. By “seeing” and feeling the phantom limb moving, this therapy attempts to resolve conflicting visual and proprioceptive sensations in the brain (Jerrell).

In summary, phantom limb pain is still elusive and requires more research to develop better definitions and treatments for the condition. It is a disability suffered by a large percentage of amputees, yet there are still no definitive answers to some fundamental questions in regards to its causes and treatments. In recent years, our understanding of PLP has grown and evolved, leading to numerous theories attempting to provide an explanation for the phenomenon. At the moment, however, no treatment has proven effective for every type of patient. PLP must be dealt with using a trial and error approach to find the treatment that is best for each individual patient.

(Image – US Defense Department photo, Donna Miles)

Guest blogger – A. Allen

 

 

 

 

Works Cited

Subedi, Bishnu, and George T. Grossberg. “Phantom Limb Pain: Mechanisms and Treatment Approaches.” Pain Research and Treatment (2011): 1-8. Web. 24 June 2015. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3198614/>.

Jerrell, Mary L. “Cause of Phantom Limb Pain Still Elusive.” Healio O&P News. O&P News, 1 Feb. 2012. Web. 24 June 2015. <http://www.healio.com/orthotics-prosthetics/prosthetics/news/print/o-and-p-news/{3bb02d3c-6b4a-4b5d-bfbc-f0027e7191c9}/cause-of-phantom-limb-pain-still-elusive?sc_trk=internalsearch>.

Desantana, Josimari M., Deirdre M. Walsh, Carol Vance, Barbara A. Rakel, and Kathleen A. Sluka. “Effectiveness of Transcutaneous Electrical Nerve Stimulation for Treatment of Hyperalgesia and Pain.” Curr Rheumatol Rep Current Rheumatology Reports 10.6 (2008): 492-99. Web. 24 June 2015. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2746624/>.

Posted in: Research and News

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Is 3D Printing Changing the World of Prosthetics and Orthotics?

3D printing is one of the fastest growing industries at the moment. It seems that almost every day people are finding new applications for this technology, especially within the medical field. 3D printing boasts the ability to create complex designs quickly and for prices much lower than ever before. With prosthetists and orthotists requiring custom plastic molds every day, this could revolutionize the business. By scanning residual limbs and using a 3D printer to create a socket, prosthetists would be able to offer patients potentially better-fitting devices the same day of the scan, without going through a middleman. While it has its advantages, there are reasons that technology has not already put prosthetics/orthotics manufacturers out of business.

Current 3D-printed prosthetics may spend more time under repair than being used day-to-day. That’s because the materials used for printing are not durable enough for legitimate use. Most jobs are printed using polylactic acid, an extremely light material that makes it possible to attach 3D-printed hands to the body using nothing more than Velcro straps. While lightweight is good, it also means that they are not strong enough to support any significant weight [1].  Even when using more expensive, durable materials than polylactic acid, 3D-printers work by laying down thin layers of hot plastic. So, when a force is applied parallel to the direction that the layers were laid down, the printed object is strong, but when a force is applied perpendicular to the layers, the device is weaker and subject to cracking [2]. While there are certain materials that are strong enough to overcome this issue, they are so expensive that the process is no longer cheaper than the old-fashioned method.

All of this being said, the technology is exciting, and could have a greater impact in the future. Right now, the technology is useful for generating model prostheses that are not meant to stand up to everyday wear and tear. In some cases, 3D-printed products can be useful for kids who quickly outgrow their devices and cannot afford to invest in something more expensive that won’t fit a month later. Some successful applications have also been seen in scoliosis braces offering more appealing aesthetics and increased comfort [3].

The bottom line though is that we must be realistic about the uses of 3D-printing in the field of prosthetics and orthotics. 3D-printed materials are not at the point that they can replace current devices to be used every day, but hopefully they can in the future, saving patients money, time, and discomfort.

Guest Blogger – A. Allen

 

 

  1. (http://gizmodo.com/can-open-source-3d-printing-make-custom-prostheses-affo-1707392769)
  2. (http://www.thedailybeast.com/articles/2015/03/11/the-reality-of-3d-printed-robo-hands.html
  3. (http://www.cnet.com/news/3d-printing-makes-scoliosis-braces-more-sleek-comfortable/)

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One-of-a-kind: An Intern’s Perspective

We are thrilled this summer to invest part of our time into a student intern from UNC-Chapel Hill, Andrew Allen. Andrew has been a huge asset in the Raleigh office, offering his help in whatever capacity needed, and as internships are often a mutually beneficial two-way street, he has also gained great insight into the field of Prosthetics and Orthotics and into varying perspectives regarding patient care. Below is a glimpse into one of the things Andrew has learned about our highest value at EastPoint — excellence in patient care.

“As an intern at EastPoint Prosthetics and Orthotics, I can truly say that this company is one-of-a-kind. It is the only facility in North Carolina that offers mobile services. This sets EastPoint apart from its competitors, as patients are relieved of transportation challenges to and from an office. Mobile services require a lot of time and effort for EastPoint clinicians who sometimes drive nearly 45 minutes away, which is one of the reasons most competitor companies do not offer this option, yet EastPoint gladly takes the time to serve their patients in this way because they know, in the end, it’s all about building lasting relationships and ensuring their patients’ needs are met.

The unique benefit of mobile services really hit home for me the day I accompanied Brent Wright on one of his home visits, 30 miles away, in Zebulon. We pulled up to a small trailer home out in what felt like the middle of nowhere. There were a couple of red pick-up trucks parked out front and some catnip bags lying around in the back yard. Brent and I walked up the back steps and entered through a screen door to find the patient sitting in his wheel chair watching “The Price is Right.” The trailer was decorated with NASCAR paraphernalia, most of it labeled with Dale Earnhardt Jr.’s number 88. He is an older patient, and he lives in his trailer alone. He was unable to wear his prosthesis that day because it was causing him pain in the back of his leg. Brent carefully took his time adjusting the prosthesis to be certain the problem was resolved while enjoying conversation and jokes along the way. It was clear to me that at EastPoint taking care of patients isn’t just about fixing problems with their prosthetic and orthotic devices; it’s about making each patient feel valued and appreciated — like a true friend. Had we not made the 30-minute drive out to this patient’s mobile home, I can only imagine how difficult it would have been for him to put on a painful prosthesis and drive himself into Raleigh to come to the office.  

EastPoint recognizes that transportation is a real barrier for many, if not most, of their patients and they are not only willing, but they are excited to alleviate this challenge. Relationship building is clearly important to EastPoint, and I am thankful to enjoy an internship with a company that puts patient care over the bottom dollar. ” — Andrew Allen, Intern

Posted in: Company News, Inspirational Stories

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Coping After An Amputation

While your body heals physically after an amputation, there is an emotional healing that takes place as well. Neither of the two healing processes are quick, but taking steps to move forward in a healthy way can help promote a positive outcome in the end.

The Power of Positive Thinking

Did you know that scientific study has actually proven that optimism promotes physical health and may improve the well-being of an individual [1]? While a period of grief, frustration and possibly anger is expected and okay, it is important to then move forward with hope and with positive thoughts. Remind yourself that simply going through this process has shown you that you are stronger than you ever thought you were.  Recognize the unique perspective you now have on what is important in life. Identify the creative ways you have learned do tasks that you previously took for granted before your amputation. Be thankful for the strength your body has to adapt to this new change.

Boundaries and Expectations

Learning to navigate the world after an amputation takes time. Identify your new challenges and consider how you can address them. It is important to communicate with your family about what things you need help with and what things you can do for yourself. Don’t be too quick to assume that you can’t do something. You may be surprised how your new resilience can provide just the push you need to figure out good options.

Emotional and Spiritual Well-Being

Keeping a journal is one of the best ways to express your feelings and frustrations without letting them bring you down. It’s also a great way to track your progress; it can encourage you down the road as you look back at how far you’ve come as you record milestones and accomplishments. Never underestimate the power of prayer either. Taking time daily to sit quietly, reflect, pray and journal can provide balance to what otherwise can be an emotional roller coaster.

Physical Health

Despite the changes in your mobility, finding new ways to exercise is still important. While combatting disease, exercise is also proven to improve your mood, your energy and your quality of life [2,3]. Core exercises surrounding your lower back, hips and gluteal muscles can also make a major difference in your ability to comfortably wear a prosthesis [4]. Physical exercise and a healthy diet also combat weight gain, which results in a better fitting prosthesis.  Talk with your physical therapist and prosthetist about exercise ideas that are best for you.

Peer Support

Plug in to an amputee support group, organization or sports team. The camaraderie with others who understand your unique challenges renews your confidence in yourself and your abilities. See our previous post on local amputee support groups.

And always remember:

quote

 

 

[1] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2894461/

[2] http://www.mayoclinic.org/healthy-lifestyle/fitness/in-depth/exercise/art-20048389

[3] http://www.heart.org/HEARTORG/GettingHealthy/PhysicalActivity/FitnessBasics/Physical-activity-improves-quality-of-life_UCM_307977_Article.jsp

[4] http://www.amputee-coalition.org/wp-content/uploads/2014/11/common-exercise-issues.pdf

 

 

Posted in: Tips and Self-Help

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Proper Limb Care: Taking Care of Your Skin

Ouch! Between your skin and your prosthesis there is no room for air circulation.  This traps sweat and dirt that can lead to bacterial and/or fungal infections.  Without proper skin care practices, even a well-fitting prosthesis can wreck havoc on your residual limb.  Anything from red irritation, to infection or even ulcers can lead to the inability to enjoy your limb or worse.  Keep these tips in mind to keep minor irritations from turning into significant complications.  

IMG_1596        Tip #1: Wash your limb daily 

It’s best to wash your limb with mild soap and water and pat it dry, taking special care to insure you do not leave wet areas that can lead to fungal growth.  

Do not shave your limb as a tight-fitting socket can lead to in-grown hairs.

Do not use powders or creams unless recommended by your prosthetist or doctor. The only cream we recommend is called Healthy Limb.  It is comprised of organic ingredients and botanical extracts. You can find out more information and order through www.healthylimb.com

We suggest new amputees shower at night as the hot water can lead to swelling. Discuss with your prosthetist if and how long you should consider wearing a shrinker during the night. 

While sleeping, never use a pillow between your knees or rest your limb on a pillow.  This will likely result in contractures (the inability to straighten your muscles). 

IMG_1601

Tip #2: Regularly Check for Redness/Pressure Marks

It is a good idea to examine your limb a few times throughout the day.  Take a careful look at your limb in the morning to get a baseline of how the natural coloring should appear.  Then once throughout the day and again at night before bed, remove your prosthesis and check your limb again. You are looking for redness that does not go away after about 4-5 minutes of removing your prosthesis.  

If you notice any issues, do not try to pad the area or make adjustments on your own. This will lead to unintended additional pressure points in other areas.  Simply contact your prosthetist for an adjustment.  

If you notice an area of skin breakdown – you must take steps to allow that area to heal properly before wearing your prosthesis again. If you try to bandage the area and continue wearing your prosthesis you could end up with an ulcer or infection.  

Tip #3: Wash Everything!

If it touches your skin, it needs to be washed regularly with soap and water. This includes liners, socks, even the inside of the socket.  Be sure everything DRIES COMPLETELY before reusing any of these items.  

IMG_1603Tip #4: Be Prepared for Anything

It’s a good idea to assemble a take-along emergency kit. Items to include would be additional socks to account for any changes in your fit throughout the day, bandages, antibiotic ointment and SUNCREEN! Remember, your residual limb is almost always covered from the elements, so if you find yourself in a situation where it becomes exposed for any length of time, that skin will likely burn easily.  

Tip #5: Remember, We’re Here For You

At EastPoint Prosthetics and Orthotics, we genuinely want your prosthesis to fit well and for you to enjoy your mobility.  If you feel that your socket needs alignment or something needs to be adjusted, just give us a call.  We’re here for you!

Posted in: Tips and Self-Help

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Limb Loss Awareness Month

April is Limb Loss Awareness month.  The Amputee Coalition is raising awareness specifically on April 25th with Show Your Mettle Day. This is a day that all amputees are encouraged to proudly wear and show their prosthetic devices or wheelchairs (metal) as we recognize the resilience and strength they posses in the face of difficulties and daily challenges (mettle).  For more information click below:

http://www.amputee-coalition.org/events-programs/limb-loss-awareness-month/ 

Posted in: Community News, Upcoming Events

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