Phantom limb pain is experienced by 50-80% of amputees as pain in the missing limb. It is caused by neuromas forming at the amputation site that generate abnormal activity. Central and peripheral sensitization in the spinal cord and brain reorganize sensory processing after limb loss. A multidisciplinary approach is needed including desensitization, mirror therapy, TENS, massage and prosthesis training to manage phantom limb pain. Regular use of mirror box therapy tricking the brain into seeing movement of the missing limb has shown effectiveness in reducing phantom limb pain.

1. PHANTHOM LIMB
PAIN

2. Definitions
 Phantom sensation: non painful sensation of the
missing limb
 Phantom pains:is a noxious sensation where the
limb existed
 Stump pain:is the pain that is restrictedto the
amputated site
Phantom Pain coined by Silas Weir Michel in 1892

3. Common descriptions of phantom pain

4. Incidence
50-80% of amputees feel pain in the missing
limb.
begins immediately after the arm or leg has been
removed and it may last for years.
In over half of the cases, the phantom limb
sensations decrease gradually.
not related to age, sex, location of the
amputation, or reason for the amputation (e.g.
trauma vs. disease).

5. Onset and Duration
Several studies have shown that 75% of patients
with PLP develop pain within the first few days
after amputation.
One study of 58 amputees found incidence of PLP
to be 72%, 65% and 59% after 1 week, 6 months
and 2 years. (Jensen, et al 1985)
Another study of 56 amputees showed that
although the incidence and intensity of pain
remained constant, the frequency and duration of
pain attacks decreased significantly. (Nikolajsen, et
al 1997)

6. Phanthom Phenomena
 Phanthom Limb
 Phanthom Pain
 Stump Pain
 Super added Phanthom
 Referred Phanthom
Sensation
60% and 80% of amputees experience PLP
(Nikolajsen and Jensen., 2000)

7. Stump Pain
Somatic stump pain usually resolves as the wound
heals
Can trigger Phantom pain
Prolonged stump pain usually attributable to local
pathology – delayed wound healing, infection,
surgical complications, poor prosthetic fit,
neuromas, adherent scars
Late onset stump pain - neuromas, prosthetic fit,
claudication, bony overgrowth, osteoarthritis ,
tumour recurrence

8. Phantom Pain vs Sensation
Phantom limb Sensation – almost universal
doesn’t correlate with pain reports
Non-painful phantom sensations of 3 types:
Kinetic senstations (movement)
Kinesthetic (size,shape,position)
Exteroceptive (touch, pressure, temperature, itch,
vibration)

9. Refferred Phantom Sensation

10. Telescoping of the Phantom Limb

11. PLP Onset
Mostly onset immediately after amputation, some at
two weeks. Rarely months later
1/3 maximal immediately post-op and generally
resolved by 100 days
½ slowly peaked then improved within 100 days
¼ slower rise toward maximal pain
(Weinstein, 1996)

12. Prognosis
When PLP persists 6 months, prognosis for
spontaneous improvement is poor
Probably <10% have persistent severe pain

13. Sensations felt by an amputee

14. A Little Man on the top

15. Mechanisms of Phantom Pain
Following a nerve cut, formation of
neuromas are seen, which show
spontaneous and abnormal evoked activity
following mechanical and chemical
stimulation. (Amir, et al 1993)
Percussion of stump/neuromas induces
stump and PLP; increased activity of
afferent C fibers (Nystrom, et al 1981)

16. Spinal Plasticity
After nerve injury, C-fibers and A delta-afferents
gain access to secondary pain signaling neurons .
This is manifested by mechanical hyperalgesia and
expansion of peripheral receptive fields. (Doubell,
et al 1999)
Increased activity of NMDA receptor; central
sensitization can be reduced by NMDA antagonists
such as ketamine. (Eichenberger, et al 2008)

17. Anatomical reorganization
Peripheral nerve damage can lead to
degeneration of C-fiber afferent terminals in
laminae II.
As a result, central terminals of Aβ-
mechanoreceptive afferents (which normally
terminate in laminae III and IV) sprout into
laminae I and II. (Woolf, et al 1992)
Ultimately, this results in increased general
excitability of spinal cord neurons.

18. Sympathetic nervous system role
Application of norepinephrine or activation of
post-ganglionic sympathetic fibers excites and
sensitizes damaged (not normal) nerve fibers.
(Devor, et al 1994)
Sympatholytic block can abolish neuropathic pain,
but pain can be rekindled by injection of
norepinephrine under the skin. (Torebjork et al
1995)

19. Cerebral reorganization
One study of adult monkeys revealed cortical
reorganization in which the mouth and chin invade
cortices corresponding to arm and digits.
(Dotrovsky, et al 1999)
In humans, similar reorganization has been
observed using magnetoencephalographic
techniques and there was a linear relationship
between pain and degree of reorganization (flor, et
al 1998)

20. Sussman (1995)

21. Assessment Tools
Visual Analoque Scale
Universal Pain Score
Macgill Pain Questionaire
Functional Independence Measure

22. Treatment: A
Multidisciplinary Approach

23. Treatment Approach
Non-Medical and Medical/Surgical
Prevent contractures
Limit oedema
Adequate Post-op Analgesia
Desensitisation - massage/bandaging
Get patient moving, distraction helps
Early prosthetic training

24. Treatment Options
TENS/Ultrasound/Massage
Vibration Therapy
Acupuncture
Relaxation techiniques
Biofeedback
Prosthesis training
Sensory discrimination training
Electroconvulsive Therapy
Mirror Treatment
Cognitive Behavioural Therapy

25. TENS
Topographically relavant afferent signals from intact
limb through transcallosal fibres activates cortical
area which acts as afferent input from missing limb
(Orazio, 2010)
PARAMETERS:
Type: Conventional or Burst TENS
Pulse Frequency: 10-200 pps
Pulse duration: 100-250 ms
Area of application: Over stump, Contralateral limb, main nerve bundle,
dermatome, across spinal cord, auricles
(Mark Johnson,2009)
BEST POSITION: Contra lateral TENS application????
(Winnem, 1982)

26. Mirror Box therapy
Ramachandran created a method of using mirrors to
provide the brain with the missing visual
stimulation.
The reflection of the intact limb is optically
superimposed on the location of the amputated limb
(Phantom Limb), tricking the brain into thinking
that the Phantom Limb is real.
“MIRROR NEURONS”

27. Principle for MT
Visual feedback as a substitution for missing
proprioceptive feedback will reduce pain
To fool the brain and to achieve normal interaction
between motor intention to move the limb and the
sensory feedback through mirror
(Ramachandran, 2000)

28. How to use mirror box
A box with mirror on sides is
placed in front of the client.
The normal leg is placed on
the side of the box in such a
way to see it’s reflection on
the mirror.
Then client is asked to move
his/her normal limb
Daily use of the mirror for
30 min/day is beneficial

29. Exercise Protocol for MT
Brodie et al(2003) explained the procedures of the
exercises to be performed
Duration of exercising 20 minutes daily(Serin et al 2013)

30. Neuromas
 Localized pain, sharp/shooting/paraesthesia
Reproduced by local palpation, relieved by LA
injection
Socket correction and local steroid/LA injection
Phenol alcohol injection into neuroma
Surgery – not much evidence, high recurrence rate
ULTRASOUND/TENS/SENSORY
REINTEGRATION TECHNIQUES

31. Managing Phanthom Pain
Daily 30 minutes of MBT
TENS over stump/normal extermity
Weight bearing on the stump using temporary
prosthesis
Massage
Sensory integration techniues
Relaxation techniques
Stump Strengthening exercises
Proper positioning of stump
Applying crepe bandage to the stump
Pre operative PT role is crucial..!

32. THANK YOU