|A cat attempting to use its left foreleg to scoop litter several months after it has been amputated|
A phantom limb is the sensation that an amputated or missing limb is still attached. Approximately 80 to 100% of individuals with an amputation experience phantom sensations in their amputated limb. However, only a small percentage will experience painful phantom limb sensation. These sensations are relatively common in amputees and usually resolve within two to three years without treatment. Research continues to explore the underlying mechanisms of phantom limb pain (PLP) and effective treatment options.
Signs and Symptoms
People will sometimes feel as if they are gesturing, feel itches, twitch, or even try to pick things up. The missing limb often feels shorter and may feel as if it is in a distorted and painful position. Occasionally, the pain can be made worse by stress, anxiety and weather changes. Phantom limb pain is usually intermittent. The frequency and intensity of attacks usually declines with time.
Repressed memories in phantom limbs could potentially explain the reason for existing sensations after amputation. Specifically, there have been several reports from patients of painful clenching spasms in the phantom hand with the feeling of their nails digging into their palms. The motor output is amplified due to the missing limb; therefore, the patient may experience the overflow of information as pain. The patient contains repressed memories from previous motor commands of clenching the hand and sensory information from digging their nails into their palm. These memories remain due to previous neural connections in the brain.
Neural Mechanisms Contributing to Phantom Limb Syndrome
Pain, temperature, touch, and vibration are carried in the central nervous system via the anterolateral and spinothalamic tracts, carrying incoming sensory information and sending motor information. Incoming sensory information travels along the anterolateral pathway and arrives at the primary sensory cortex, located in the postcentral gyrus in the parietal lobe; also the location of the sensory homunculus.
In phantom limb syndrome, there is sensory input indicating pain from a part of the body that is no longer existent- this phenomenon is still not fully understood, but it is hypothesized that it is caused by activation of the somatosensory cortex.
Phantom Limb Syndrome
The term "phantom limb" was coined by physician Silas Weir Mitchell in 1871. For many years, the dominant hypothesis for the cause of phantom limbs was irritation in the peripheral nervous system at the amputation site (neuroma.) By the late 1980s, Ronald Melzack had recognized that the peripheral neuroma account could not be correct, because many people born without limbs also experienced phantom limbs. According to Melzack the experience of the body is created by a wide network of interconnecting neural structures, which he called the "neuromatrix."
Pons and colleagues (1991) at the National Institutes of Health (NIH) showed that the primary somatosensory cortex in macaque monkeys undergoes substantial reorganization after the loss of sensory input.
Hearing about these results, Vilayanur S. Ramachandran hypothesized that phantom limb sensations in humans could be due to reorganization in the human brain's somatosensory cortex. Ramachandran and colleagues illustrated this hypothesis by showing that stroking different parts of the face led to perceptions of being touched on different parts of the missing limb. Later brain scans of amputees showed the same kind of cortical reorganization that Pons had observed in monkeys.
Maladaptive changes in the cortex may account for some but not all phantom limb pain. Pain researchers such as Tamar Makin (Oxford) and Marshall Devor (Hebrew University, Jerusalem) argue that phantom limb pain is primarily the result of "junk" inputs from the peripheral nervous system.
Despite a great deal of research on the underlying neural mechanisms of phantom limb pain there is still no clear consensus as to its cause. Both the brain and the peripheral nervous system may be involved.
Research continues into more precise mechanisms and explanations.
Most approaches to treatment over the past two decades have not shown consistent symptom improvement. Treatment approaches have included medication such as antidepressants, spinal cord stimulation, vibration therapy, acupuncture, hypnosis, and biofeedback. Reliable evidence is lacking on whether any treatment is more effective than the others.
Most treatments are not very effective. Ketamine or morphine may be useful around the time of surgery. Morphine may be helpful for longer periods of time. Evidence for gabapentin is mixed. Perineural catheters that provide local anesthetic agents have poor evidence of success when placed after surgery in an effort to prevent phantom limb pain.
One approach that has received public interest is the use of a mirror box. The mirror box provides a reflection of the intact hand or limb that allows the patient to "move" the phantom limb, and to unclench it from potentially painful positions.
Although mirror therapy was introduced by VS Ramachandran in the early 1990s, little research was done on it before 2009, and much of the subsequent research has been of poor quality, according to a 2016 review. A 2018 review, which also criticized the scientific quality of many reports on mirror therapy (MT), found 15 good-quality studies conducted between 2012 and 2017 (out of a pool of 115 publications), and concluded that "MT seems to be effective in relieving PLP, reducing the intensity and duration of daily pain episodes. It is a valid, simple, and inexpensive treatment for PLP."
Other Phantom Sensations
Phantom sensations may also occur after the removal of body parts other than the limbs, e.g. after amputation of the breast, extraction of a tooth (phantom tooth pain) or removal of an eye (phantom eye syndrome).
Some people who have undergone gender reassignment surgery have reported the sensation of phantom genitals. The reports were less common among post-operative transgender women, but did occur in transgender men. Similarly, subjects who had undergone mastectomy reported experiencing phantom breasts; these reports were substantially less common among post-operative transgender men.
- Phantom eye syndrome
- Neuropathic pain
- Supernumerary phantom limb, where sensations are felt in a limb that never existed
- Visual release hallucinations
- Manchikanti, Laxmaiah; Singh, Vijay; Boswell, Mark V. (2007-01-01), Waldman, Steven D.; Bloch, Joseph I. (eds.), "chapter 28 - Phantom Pain Syndromes", Pain Management, W.B. Saunders, pp. 304–315, doi:10.1016/b978-0-7216-0334-6.50032-7, ISBN 978-0-7216-0334-6, retrieved 2019-12-09
- Chahine, Lama; Kanazi, Ghassan (2007). "Phantom limb syndrome: A review" (PDF). MEJ Anesth. 19 (2): 345–55. Retrieved July 20, 2019.
- Melzack, R. (1992). "Phantom limbs". Scientific American. 266 (4): 120–126. Bibcode:1992SciAm.266d.120M. doi:10.1038/scientificamerican0492-120. PMID 1566028.
- Nikolajsen, L.; Jensen, T. S. (2006). McMahon S, Koltzenburg M (eds.). Wall & Melzack's Textbook of Pain (5th ed.). Elsevier. pp. 961–971.CS1 maint: uses editors parameter (link)
- Ramachandran, V. S. (1998-11-29). "Consciousness and body image: lessons from phantom limbs, Capgras syndrome and pain asymbolia". Philosophical Transactions of the Royal Society of London. Series B: Biological Sciences. 353 (1377): 1851–1859. doi:10.1098/rstb.1998.0337. ISSN 0962-8436.
- Kaur, Amreet; Guan, Yuxi (December 2018). "Phantom limb pain: A literature review". Chinese Journal of Traumatology. 21 (6): 366–368. doi:10.1016/j.cjtee.2018.04.006. ISSN 1008-1275.
- Woodhouse, Annie (2005). "Phantom limb sensation". Clinical and Experimental Pharmacology and Physiology. 32 (1–2): 132–134. doi:10.1111/j.1440-1681.2005.04142.x. ISSN 0305-1870. PMID 15730449.
- Canadian Psychology, 1989, 30:1
- Pons TP, Garraghty PE, Ommaya AK, Kaas JH, Taub E, Mishkin M (1991). "Massive cortical reorganization after sensory deafferentation in adult macaques". Science. 252 (5014): 1857–1860. Bibcode:1991Sci...252.1857P. doi:10.1126/science.1843843. PMID 1843843.
- Ramchandran, VS; Hirstein, William (1998). "The perception of phantom limbs" (PDF). Brain. 121 (9): 1603–1630. doi:10.1093/brain/121.9.1603. PMID 9762952.
- Epoch Times website, July 16,2014
- Peripheral nervous system origin of phantom limb pain, Pain, Vol. 155, Issue 7, pages 1384-1391 
- Collins, Kassondra L; Russell, Hannah G. (2018). "A review of current theories and treatments for phantom limb pain". J Clin Invest. 128 (6): 2168–2176. doi:10.1172/JCI94003. PMC 5983333. PMID 29856366.
Currently, the most commonly posited CNS theory is the cortical remapping theory (CRT), in which the brain is believed to respond to limb loss by reorganizing somatosensory maps (16)... While an amputation directly affects the PNS, the CNS is also affected due to changes in sensory and movement signaling. Debate still remains over the cause and maintaining factors of both phantom limbs and the associated pain.
- Kaur, Amreet; Guan, Yuxi (2018). "Phantom limb pain: A literature review". Chin J Traumatol. 21 (6): 366–368. doi:10.1016/j.cjtee.2018.04.006. PMC 6354174. PMID 30583983.
It is unsurprising that with an amputation that such an intricate highway of information transport to and from the periphery may have the potential for problematic neurologic developments...Although phantom limb sensation has already been described and proposed by French military surgeon Ambroise Pare 500 years ago, there is still no detailed explanation of its mechanisms.
- Foell, Jens; Bekrater-Bodmann, Robin; Flor, Herta; Cole, Jonathan (December 2011). "Phantom Limb Pain After Lower Limb Trauma: Origins and Treatments". The International Journal of Lower Extremity Wounds. 10 (4): 224–235. doi:10.1177/1534734611428730. PMID 22184752.
- Alviar, Maria Jenelyn M.; Hale, Tom; Dungca, Monalisa (2016-10-14). "Pharmacologic interventions for treating phantom limb pain". The Cochrane Database of Systematic Reviews. 10: CD006380. doi:10.1002/14651858.CD006380.pub3. ISSN 1469-493X. PMC 6472447. PMID 27737513.
- Flor, H; Nikolajsen, L; Jensn, T (November 2006). "Phantom limb pain: a case of maladaptive CNS plasticity?" (PDF). Nature Reviews Neuroscience. 7 (11): 873–881. doi:10.1038/nrn1991. PMID 17053811.
- McCormick, Z; Chang-Chien, G; Marshall, B; Huang, M; Harden, RN (February 2014). "Phantom limb pain: a systematic neuroanatomical-based review of pharmacologic treatment". Pain Medicine. 15 (2): 292–305. doi:10.1111/pme.12283. PMID 24224475.
- Bosanquet, DC.; Glasbey, JC.; Stimpson, A.; Williams, IM.; Twine, CP. (Jun 2015). "Systematic Review and Meta-analysis of the Efficacy of Perineural Local Anaesthetic Catheters after Major Lower Limb Amputation". Eur J Vasc Endovasc Surg. 50 (2): 241–9. doi:10.1016/j.ejvs.2015.04.030. PMID 26067167.
- Ramachandran, V. S., Rogers-Ramachandran, D. C., Cobb, S. (1995). "Touching the phantom". Nature. 377 (6549): 489–490. doi:10.1038/377489a0. PMID 7566144.CS1 maint: multiple names: authors list (link)
- Ramachandran, V. S., Rogers-Ramachandran, D. C. (1996). "Synaesthesia in phantom limbs induced with mirrors" (PDF). Proceedings of the Royal Society of London B. 263 (1369): 377–386. Bibcode:1996RSPSB.263..377R. doi:10.1098/rspb.1996.0058. PMID 8637922.CS1 maint: multiple names: authors list (link)
- "The effects of mirror therapy on pain and motor control of phantom limb in amputees: A systematic review". Annals of Physical and Rehabilitation Medicine. 59:4: 270–275. September 2016.
"The level of evidence is insufficient to recommend MT as a first intention treatment for PLP"
- Campo-Prieto, P; Rodríguez-Fuentes, G (November 14, 2018). "Effectiveness of mirror therapy in phantom limb pain: A literature review". Neurologia. doi:10.1016/j.nrl.2018.08.003. PMID 30447854.
It is a valid, simple, and inexpensive treatment for PLP. The methodological quality of most publications in this field is very limited, highlighting the need for additional, high-quality studies to develop clinical protocols that could maximise the benefits of MT for patients with PLP.
- Ahmed, A.; Bhatnagar, S.; Rana, S. P.; Ahmad, S. M.; Joshi, S.; Mishra, S. (2014). "Prevalence of phantom breast pain and sensation among postmastectomy patients suffering from breast cancer: a prospective study". Pain Pract. 14 (2): E17–28. doi:10.1111/papr.12089. PMID 23789788.
- Marbach, J. J.; Raphael, K. G. (2000). "Phantom tooth pain: a new look at an old dilemma". Pain Med. 1 (1): 68–77. doi:10.1046/j.1526-4637.2000.00012.x. PMID 15101965.
- Sörös, P.; Vo, O.; Husstedt, I.-W.; Evers, S.; Gerding, H. (2003). "Phantom eye syndrome: Its prevalence, phenomenology, and putative mechanisms". Neurology. 60 (9): 1542–1543. doi:10.1212/01.wnl.0000059547.68899.f5. PMID 12743251.
- Andreotti, A. M.; Goiato, M. C.; Pellizzer, E. P.; Pesqueira, A. A.; Guiotti, A. M.; Gennari-Filho, H.; dos Santos, D. M. (2014). "Phantom eye syndrome: A review of the literature". ScientificWorldJournal. 2014: 686493. doi:10.1155/2014/686493. PMC 4273592. PMID 25548790.
- Phantom Penises In Transsexuals, by V.S. Ramachandran; in Journal of Consciousness Studies Volume 15, Number 1, 2008, pp. 5-16(12); retrieved July 30, 2016
- Halligan, P.W.; Zeman, A.; Berger, A. (1999), "Phantoms in the Brain", British Medical Journal, 319 (7210): 587–588, doi:10.1136/bmj.319.7210.587, PMC 1116476, PMID 10473458
- Halligan, P.W. (2002), "Phantom limbs: The body in mind", Cognitive Neuropsychiatry, 7 (3): 251–268, doi:10.1080/13546800244000111, PMID 16571541
- Murray, C. (2009), "Developing an Interdisciplinary Perspective on Amputation, Prosthesis Use, and Phantom Limb Pain: An Introduction", Amputation, Prosthesis Use, and Phantom Limb Pain, Springer, pp. 1–5, doi:10.1007/978-0-387-87462-3_1, ISBN 978-0-387-87461-6
- Vilayanur S. Ramachandran, Brang David (2009). "Phantom touch". Scholarpedia. 4 (10): 8244. Bibcode:2009SchpJ...4.8244R. doi:10.4249/scholarpedia.8244.
- Phantom limb syndrome: A review M.E.J. ANESTH 19 (2), 2007