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phantom limb pain handout assessment

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phantom limb pain handout assessment

  1. 1. 04250065 Psychology of Pain Mathew Aspey Psychology of Pain. Pharmacological Treatments as a Stand - Alone Treatment of Phantom Limb Pain. Word Count = 993 words. Pharmacological Treatments as a Stand - Alone Treatment of Phantom Limb Pain.
  2. 2. 04250065 Psychology of Pain What is Phantom Limp Pain? Phantom limb pain (PLP) is a phenomenon referring to the pain experienced from limb that has previously been amputated or severed. PLP has a surprisingly high level of prevalence, as it effects up to 72% of all amputees (Jensen et al, 1984 (1) ). They also found that pain persisted until 7 years after amputation; Sherman et al (1980) (2) found that no more than 15% find total pain relief. Pain can be either episodic or continuous and is often described as a ‘cramping, crushing or stabbing pain’ in the missing limb (Clement and Taunton, 2001 (3) ). Livingston (1943) (4) suggested that a common feature is that the reported pain is felt in definite parts of the phantom limb (e.g. the phantom hand is clenched so it feels tired and painful). What Causes Phantom Limb Pain? A vast body of research has been conducted to determine the causes of this phenomenon. It is widely accepted that it is a result of damage to the nerve endings in the residual limb (A) sending pain signals to the brain making it think that the limb is still there (5). Sussman (1995) (6) suggested that it starts in the homunculus (B) , an area of the sensory cortex (C) . When a part of the actual body is lost, the corresponding part of the homunculus remains, but is unable to handle the loss of information from the missing area. To remedy this, the brain rewires its circuits so that the neighbouring neurons in the cortex invade the vacant territory in order to compensate this loss of sensations; this is known as cortical reorganisation. Pharmacological Treatments of Phantom Limb Pain. It is currently unsure whether there exists a stand-alone treatment for PLP. Although there are many treatments that successfully help with aspects of PLP, there does not appear to be a single treatment to eliminate phantom pain altogether. It appears as though the best way to treat PLP is to employ a combination of pharmacological treatments with psychological treatments. Initially, measures are taken in an attempt to try and prevent the onset of PLP. Calcitonin (D) is a hormone produced by the thyroid gland (E) to slow the rate at which the body breaks down bone and is often used to prevent bone deterioration in the treatment of postmenopausal osteoporosis (F) . This is often administered intravenously (G) during the week following amputation (7) . Flor et al (2000) (8) suggested that pharmacological treatments resulting in vasodilation (H) of the residual limb, ease burning PLP but not other features. Cramping phantom pain is caused by muscle tension in the residual limb; clonazepam may relieve cramping PLP as it depresses activity in the central nervous system and is used as a treatment of muscle tension. Baclofen is also a muscle relaxant, often used to treat muscle spasms and neuropathic (I) pain syndromes, of which PLP is one. Although these treatments have proven successful, they do not always eliminate phantom pain for all patients.
  3. 3. 04250065 Psychology of Pain In cases where pain is severe, an opioid (J) , such as morphine (K) may be administered in order to ease the pain. Sawynok (2003) (9) suggests that Opioids are generally safe treatments when closely monitored by health professionals. Although proven to be highly successful in the treatment of severe pain, morphine is not without its dangers. If patients are over – dosed, side effects such as sweating (in extreme cases causing hypothermia), salivation and certain lung secretions which may depress lung function to the point of respiratory arrest (L) . Morphine is also known for causing both constipation and vomiting. Research in this area suggests that although pharmacological treatments specialise in easing certain types of PLP, they are not broad enough to cover all types of pain that are experienced here. In order to account for this it is often useful to implement the use of psychological treatments, to be used in conjunction with pharmacological treatments. Psychological Treatments of Phantom Limb Pain. Stress has been identified as a common factor in phantom limb pain. Arena et al (1990) (10) tested for relationships between situational stress and PLP in 27 male, 71 year old amputees and found that 74% demonstrated significant stress - pain relationships. This finding brings light to the possibility that psychological treatments may also be useful in the alleviation of phantom pain. There has been research into the effects of hypnosis as a treatment of PLP; Wain (1986) (11) suggested that hypnosis allows effective strategies to be implemented in order to allow patients to gain control over their experienced pain. Although hypnosis has a good reputation for having no pharmacological side effects, there is a debate about whether or not all people are susceptible to hypnosis, Horn and Munafo (1997) (12) suggests that people react to hypnosis in many different ways, dependent upon their ‘hypnotisability’ which can either facilitate or inhibit their openness to hypnotic suggestions. This may significantly decrease its effectiveness. However, hypnosis is also regarded as a recognised relaxation technique; this provides a basis for the assumption that relaxation may be a feasible treatment for PLP. Conclusion. In conclusion, although there is much research to provide support for the use of pharmacological treatments to eradicate PLP, most research points to specific drugs as an appropriate treatment for certain aspects of the pain experienced in a phantom limb. At present research has produced inconclusive findings for a stand – alone pharmacological treatment for phantom limb pain. From, this it may be important to suggest a systematic collaboration of pharmacological treatments such as a strictly monitored course of opioid treatments to ease pain, with muscle relaxants to ease muscles cramping and a psychological treatment such as hypnosis to promote relaxation. This collaboration of treatments may need extensive research before being implemented as most pharmacological treatments have unique side effects relating to each one, care must be made to ensure that these side effects do not outweigh the initial pain.
  4. 4. 04250065 Psychology of Pain Additional Resources. Above is a diagram showing the Homunculus, which is a map of the body, within the sensory cortex in the brain. Here the areas of the body that detect more sensory information are represented much larger than areas which detect less sensory information.
  5. 5. 04250065 Psychology of Pain Glossary of Terms (13) . A. Residual Limb: - part of the amputated limb that is left behind (stump). B. Homunculus (little man): - The nerve map of the human body that exists on the parietal lobe of the human brain whereby each of its body parts is linked with its corresponding area of the actual body. C. Sensory Cortex: - located posterior to the central sulcus in the parietal lobe receives sensory input from receptors in the body. D. Calcitonin: - a hormone produced by the thyroid gland (E) to slow the rate at which the body breaks down bone. E. Thyroid Gland: - located around the trachea, the thyroid gland is a gland that makes and stores hormones which regulate heart rate, blood pressure and body temperature. F. Osteoporosis: - a chronic, progressive condition associated with deterioration of bone tissue resulting in low bone mass. G. Intravenous: - administration of medication directly into the vein. H. Vasodilation: - Widening of the interior of the blood vessels as a result of the relaxation of the muscular wall of the vessels. I. Neuropathic: - pain which comes from injury to the nerves themselves and not from injured body parts J. Opioid: - A synthetic narcotic, resembling the naturally occurring opiates. K. Morphine: - kills pain at low doses and makes you feel tranquil, increasing your tolerance to pain. With morphine, the perception of pain is still there, but the appreciation of the pain decreases L. Respiratory arrest: - spontaneous respiration dude to damage caused to the respiratory centre. References. • (1) Jensen TS, Krebs B, Nielsen J, Rasmussen P. Non-painful phantom limb phenomena in amputees: incidence, clinical characteristics and temporal course. Acta Neurol Scand 1984; 70: 407–14
  6. 6. 04250065 Psychology of Pain • (2) Sherman RA, Sherman CJ, Gall NG (1980) A survey of current phantom limb pain treatment in the United States. Pain 8:85-99 • (3) Clement, D.B. and Taunton J.E. ()Alleviation of pain with the use of Farabloc, an electromagnetic shield: A review BC MedicalJournal Volume 43, Number 10, December 2001, pages 573-577 • (4) Livingston, W.K. (1943) Pain Mechanisms. MacMillan, New York. • (5) Cleveland Clinic Foundation. Retrieved on 16th November 2006 from www.clevelandclinic.org/health/health-info/docs/3600/3692.asp?index=12092&src=news • (6) Sussman, V. (October 1995). The route of phantom pain. U.S. News & World Report, 76-78. • (7) Mayo Foundation for Medical Education and research. Retrieved on 16th November 2006 from http://www.mayoclinic.com/health/phantom- pain/DS00444/DSECTION=6 • (8) Flor H, Mühlnickel W, Karl A, Denke C, Grusser S, Kurth R, et al. A neural substrate for nonpainful phantom limb phenomena. Neuroreport 2000; 11: 1407–11 • (9) Sawynok, J. (2003). Topical and peripherally acting analgesics. Pharmacological Reviews, 55(1), 1-20. • (10) Arena, J., Sherman, R., Bruno, G. & Smith J. (1990). The relationship between situation stress and phantom limb pain: Cross-lagged correlation data from six month pain logs. Journal of Psychosomatic Research, 34(1), 71-77. • (11) Wain, H. (1986). Pain control with hypnosis in consultation and liaison psychiatry. Psychiatric Annuals, 16(2), 106-109. • Horn, S. & Munafo, M. Pain Theory, Research and Intervention. Open University Press: Buckingham. 1997 • Medical Terms. Retrieved on 16th November 2006 from http://www.medterms.com/script/main/art.asp?articlekey=5965
  7. 7. 04250065 Psychology of Pain • (2) Sherman RA, Sherman CJ, Gall NG (1980) A survey of current phantom limb pain treatment in the United States. Pain 8:85-99 • (3) Clement, D.B. and Taunton J.E. ()Alleviation of pain with the use of Farabloc, an electromagnetic shield: A review BC MedicalJournal Volume 43, Number 10, December 2001, pages 573-577 • (4) Livingston, W.K. (1943) Pain Mechanisms. MacMillan, New York. • (5) Cleveland Clinic Foundation. Retrieved on 16th November 2006 from www.clevelandclinic.org/health/health-info/docs/3600/3692.asp?index=12092&src=news • (6) Sussman, V. (October 1995). The route of phantom pain. U.S. News & World Report, 76-78. • (7) Mayo Foundation for Medical Education and research. Retrieved on 16th November 2006 from http://www.mayoclinic.com/health/phantom- pain/DS00444/DSECTION=6 • (8) Flor H, Mühlnickel W, Karl A, Denke C, Grusser S, Kurth R, et al. A neural substrate for nonpainful phantom limb phenomena. Neuroreport 2000; 11: 1407–11 • (9) Sawynok, J. (2003). Topical and peripherally acting analgesics. Pharmacological Reviews, 55(1), 1-20. • (10) Arena, J., Sherman, R., Bruno, G. & Smith J. (1990). The relationship between situation stress and phantom limb pain: Cross-lagged correlation data from six month pain logs. Journal of Psychosomatic Research, 34(1), 71-77. • (11) Wain, H. (1986). Pain control with hypnosis in consultation and liaison psychiatry. Psychiatric Annuals, 16(2), 106-109. • Horn, S. & Munafo, M. Pain Theory, Research and Intervention. Open University Press: Buckingham. 1997 • Medical Terms. Retrieved on 16th November 2006 from http://www.medterms.com/script/main/art.asp?articlekey=5965

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