Phantom pain is pain caused by elimination or interruption of sensory nerve impulses by destroying or injuring the sensory nerve fibers after amputation or deafferentation
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
The International Association for the Study of Pain (IASP)1 defines trigeminal neuralgia (TN) as a sudden, usually unilateral, severe brief stabbing recurrent pain in one or more branches of the fifth cranial nerve
synonyms
Idiopathic trigeminal neuralgia / Tic Doulourex.
Trifacial Neuralgia.
Fothergell’s disease.
In 1677 John Locke, a American physician and philosopher, accurately identified the major clinical features of TN
In 1756 the French physician Nicolaus Andre coined the term “Tic douloureux” to the condition.
The English physician John Fothergill in 1773 published detailed description of TN, since then, it has been referred to as ‘Fothergill’s disease’.
Peripheral injections
Long acting LA
Alcohol
Glycerol
Peripheral neurectomy/ nerve avulsion
Cryotherapy
Gasserian ganglion procedures
Percutaneous stereotactic radiofrequency thermal lesioning of the trigeminal ganglion and/or root (rfl)
percutaneous glycerol gangliolysis of the trigeminal ganglion
percutaneous balloon microcompression of the trigeminal ganglion
Intracranial procedures
MVD
Partial sensory rhizotomy
Gamma knife radiation to the trigeminal root entry zone GKR
Different descriptions of Pain, Pain Pathways, Specific Types of pains and their management, Pharmacological treatment of pain and non-pharmacological maneuvers to relieve pain, WHO ladder of pain, Chronic Pain management Goals
Comprehensive description of pain pathways which covers related definitions, benefits, theories, classification and mechanism of pain with factors that affect pain and diagnosis of pain. Also covers assessment and management of pain along with brief description of ascending and descending pain pathways.
Codeine is used to relieve mild to moderate pain. It belongs to the group of medicines called narcotic analgesics (pain medicines). This medicine acts on the central nervous system (CNS) to relieve pain.
When codeine is used for a long time, it may become habit-forming, causing mental or physical dependence. However, people who have continuing pain should not let the fear of dependence keep them from using narcotics to relieve their pain. Mental dependence (addiction) is not likely to occur when narcotics are used for this purpose. Physical dependence may lead to withdrawal side effects if treatment is stopped suddenly. However, severe withdrawal side effects can usually be prevented by gradually reducing the dose over a period of time before treatment is stopped completely.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
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Cardiac conduction defects can occur due to various causes.
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Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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3. History
• first medical descriptions at the 16th
century
• Silas Weir Mitchell (1829-1914) is
credited with coining the term phantom
limb, and more than anyone else
4. History
• over the past several decades, wars
and land mine explosions in many parts
of the world have been responsible for
numerous cases of traumatic
amputation
• In Western countries, the main reasons
for amputation are diabetes and
peripheral vascular disease in elderly
people
5. History
• after the war between Iraq and Iran,
64% of 200 soldiers who had lost limbs
during this war suffered from phantom
pain, 32% from phantom movement
pain, while 24% suffered from stump
pain.
6. Definition
• Phantom pain is pain caused by
elimination or interruption of sensory
nerve impulses by destroying or injuring
the sensory nerve fibers after
amputation or deafferentation.
• Phantom phenomena may also occur
following the amputation of other body
parts, such as the breast and rectum
8. PREVALENCE
• most recent studies agree that 60% to
80%
• The prevalence is probably not
influenced by age in adults, gender,
side, or level and cause (civilian versus
traumatic) of the amputation
• Phantom pain is less frequent in very
young children and congenital
amputees
9. TIME COURSE
• usually within the first week after
amputation
• The appearance of phantom pain may,
however, be delayed for months or even
years
10. INTENSITY AND FREQUENCY
• phantom pain is present in 60% to 80%
• severe pain is substantially smaller and in the
range of 5% to 15%.
• the mean intensity of pain 6 months after
amputation was 22 (range, 3 to 82) on a visual
analog scale (VAS, 0 to 100).
• The pain is usually intermittent and only a few
patients are in constant pain
• Episodes of pain attacks are most often reported
to occur daily or at daily or weekly intervals
11. LOCALIZATION AND CHARACTER
• Phantom pain is primarily
localized to the distal parts
of the missing limb
• In upper limb amputees,
pain is normally felt in the
fingers and palm of the
hand
• in lower limb amputees, it is
generally experienced in
the toes, foot, or ankle
12. Common descriptions of phantom pain
• Phantom pain is often
described as shooting,
pricking, and burning, pins
and needles, tingling,
throbbing, cramping,
crushing
– a hammer is slammed at my
calf
– Ants are crawling around
inside my foot
13. PHANTOM SENSATIONS
• more frequent than phantom pain
• experienced by nearly all amputees
• do not usually pose a major clinical problem
• 30% of amputees may find these sensations
moderately to severely
• appear within the first days after amputation
• Immediately after amputation, the phantom limb
often resembles the preamputation limb in
shape, length, and volume
• Over time, the phantom fades, with sensation of
the distal parts of the limb disappearing.
14. Telescoping
• shrinkage of the
phantom is reported
to occur in about a
third of patients.
• The phantom
gradually
approaches the
amputation stump
and eventually
becomes attached to
it
15. STUMP PAIN
• Stump pain is common in the early postamputation
period.
• all patients experienced some stump pain in the first
week after amputation, with a median intensity of 15.5
• prevalence of chronic stump pain varies in the
literature,
• severe pain is probably seen in only 5% to 10%
• Stump pain may be described as pressing, throbbing,
burning, squeezing, or stabbing
• hypoesthesia, hyperalgesia, or allodynia
• Stump pain and phantom limb pain are strongly
correlated.
16. MECHANISMS OF PHANTOM PAIN
• Not completely understood
• it is now clear that nerve injury is followed
by a number of morphologic, physiologic ,
and chemical changes in both the
peripheral and central nervous system and
that all these changes
• Divided to : peripheral, spinal, and
supraspinal mechanisms
17. PERIPHERAL MECHANISMS
• The ectopic and increased spontaneous and
evoked activity from the periphery is
assumed to be the result of an increased and
also de novo expression of sodium channels
• increased activity in afferent C fibers
• Stump neuromas induces stump and
phantom pain.
• It has been claimed that surgical removal of a
neuroma abolishes phantom pain
18. PERIPHERAL MECHANISMS
• DRG cells exhibit dramatic changes in the
expression of different sodium channels
following axonal transection.
• The sympathetic nervous system may also
play an important role
• Sympatholytic blocks can abolish or reduce
phantom pain,
• pain can be rekindled by injection of
noradrenaline into the skin
19. SPINAL MECHANISMS
• Phantom limb pain may appear or disappear
following spinal cord neoplasia.
• After nerve injury there is an increase in the
general excitability of spinal cord neurons,
where C fibers and Aδ afferents gain access
to secondary pain-signaling neurons.
• Sensitization of dorsal horn neurons is
mediated by release of glutamate and
neurokinins
• reduced flexion reflex thresholds in response
to noxious mechanical
20. SPINAL MECHANISMS
• increased persistent neuronal discharges with
prolonged pain after stimulation (wind-up
phenomena)
• expansion of peripheral receptive fields
• increased activity in N-methyl-d-aspartate
(NMDA) receptor–operated systems
22. SUPRASPINAL MECHANISMS
• alter neuronal activity in cortical and subcortical
structures
• complex perceptual qualities and its modification by
various internal stimuli (e.g., attention, distraction, or
stress) shows the phantom image to be a product of
the brain.
• cortical reorganization after amputation
• Changes have also been observed at subcortical
levels
• was shown that thalamic neurons, which do not
normally respond to stimulation, begin to respond
and show enlarged somatotopic maps in amputees
23. PREVENTION
1. phantom pain is in some cases a replicate of the pain
experienced before the amputation
2. pain before the amputation increases the risk for
postamputation phantom pain
24. EPIDURAL INTERVENTIONS
1. phantom pain was lower in patients who had
received the preoperative epidural blockade
2. The intensity of stump and phantom pain and
consumption of opioids were also similar in the two
groups at all four postoperative interviews
• no difference was found in the incidence of
phantom pain 24 months after the amputation in
those who had received epidural, spinal, or general
anesthesia for the amputation
25. PERIPHERAL REGIONAL ANESTHESIA
• Studies have found negative and positive effects,
• One study : a catheter into the transected nerve
sheath at the time of amputation and infused
bupivacaine for 72 hours. Phantom pain did not
develop in any patients during a 12-month follow-up
• incidence of phantom pain was similar in the two
groups after 3 days and 6 and 12 months
26. SYSTEMIC INTERVENTIONS
• intravenous ketamine infused intraoperatively
and for 72 hours: no effect of a treatment
• oral memantine: reduced phantom pain after 4
weeks and 6 months, but not after 12 months
• oral gabapentin: 300 mg - 2400 mg/day : early
and prolonged treatment with gabapentin did not
seem to reduce the incidence of phantom pain
27. conclusion
• In conclusion, perioperative interventions, such as
epidurals, other nerve blocks, and systemic treatments,
are effective in the treatment of immediate postoperative
stump pain
• further evaluate the potential for different perioperative
treatment regimens to reduce chronic phantom pain
• multimodal approach seems to generate better outcome
consist of: sychological counseling and treatment;
cognitive behavioral therapy and pharmacological
treatment
28. TREATMENT
• The authors’ conclusion was that data from the studies
included were not sufficient to support any particular
medication for established phantom limb pain.
29. MEDICAL TREATMENT
• Amitriptyline: dose of 125 mg/day: no effect of on
pain intensity or secondary outcome measures such
as satisfaction with life
• Both tramadol and amitriptyline had almost abolished
stump and phantom pain at the end of the treatment
period
• gabapentin : titrated in increments 300 to the
maximum dosage of 2400 mg/day:
– Gabapentin did not decrease the intensity of pain
significantly, but was better than placebo
30. MEDICAL TREATMENT
• oral morphine: a significant reduction in phantom pain
• Calcitonin alone had no effect on pain
• Memantine at doses of 20 or 30 mg/day failed to have
any effect on spontaneous pain, allodynia, and
hyperalgesia.
• A large number of other treatments, such as
dextromethorphan, topical application of capsaicin,
intrathecal opioids, various anesthetic blocks, injections
of botulinum toxin, and topiramate, have been claimed to
be effective in relieving phantom pain, but none of them
have proved to be effective in well-controlled trials with a
sufficient number of patients.
31. MEDICAL TREATMENT
• Sympathetic blocks may also reduce phantom pain, but
only for a limited time after the injection
• The inflammatory cytokine tumor necrosis factor alpha
(TNF - α ) plays an important role in neuropathic pain
conditions: perineural injections of etanercept, a TNF - α
antagonist, describes a significant improvement
32. NONMEDICAL TREATMENT
• Physical therapy involving
massage, manipulation, and
passive movements may
prevent trophic changes and
vascular congestion in the
stump.
• Transcutaneous electrical
nerve stimulation (TENS),
acupuncture, biofeedback, and
hypnosis, may in some cases
have a beneficial effect on
stump and phantom pain.
33.
34. Mirror therapy
• It has been suggested that mirror
therapy can reduce phantom but
failed to find any significant effect of
mirror treatment (benzon 2014)
• sham controlled crossover trial
showed that mirror therapy is better
than mental visualization or
covered mirror therapy.
• The principle of this treatment is
based on the idea that the central
representation of the missing hand
of the phantom could be recovered.
This could relieve or eliminate the
phantom pain.
35. Interventional m anagement
• pulsed radiofrequency of the proximal and distal ends of
a sciatic neuroma with treatment at 42 ° C for 120
seconds under ultrasound guidance with VAS reduction
of 90%, 90%,
• PRF adjacent to the L4 – L5 ganglion spinale (dorsal
root ganglion, DRG)
• Spinal cord stimulation to be effective and may be used
for the treatment of phantom limb pain.
• deep brain stimulation
• stump injections
36. SURGICAL AND OTHER INVASIVE
TREATMENTS
• Today, stump revision is performed only in cases of
obvious stump pathology
• Surgery may produce short-term pain relief, but the
pain often reappears