Phantom limb

Phantom limb refers to brain's perception of pain in a limb that has been surgically amputated and is one of the most common sequelae of limb loss, with prevalence estimates ranging from 50% to 80% of all individuals who undergo amputation. Phantom limb can also present itself in two ways: phantom limb pain (PLP) or phantom limb sensations. Phantom limb pain is a painful or unpleasant sensation experienced where the amputated limb was. Phantom sensations are any other, nonpainful sensations perceived in the amputated or missing limb area.

Signs and symptoms Majority (50%-80%) of amputees experience a phantom limb, with some of them having non-painful sensations. The amputee may feel very strongly that the phantom limb is still part of the body. People will sometimes feel as if they are gesturing, feel itches, twitch, or even try to pick things up with their non-existing limbs. 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. Exposure to extreme weather conditions, especially below freezing temperatures, can cause increased sensitivity to the sensation. Phantom limb pain is usually intermittent, but can be continuous in some cases. 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.

Phantom limb syndrome The term "phantom limb" was coined in 1872 by a physician named Silas Weir Mitchell, who, almost poetically, reported that '...nearly every man who loses limb carries about with him constant or inconstant phantom of the missing member, sensory ghost of that much of himself, and sometimes most inconvenient presence, faintly felt at times, but ready to be called up to his perception by blow, touch, or change of wind'. Nevertheless, there have been earlier reports of the phenomenon. One of the first known medical descriptions of the phantom limb phenomenon was written by a French military surgeon, Ambroise Pare, in the sixteenth century. Pare noticed that some of his patients continued reporting pain in the removed limb after he performed the amputation. 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, V. 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. Ramachandran have also performed the world's first phantom limb amputation surgeries by asking patients to visualize the missing limb, which relieved pain, and in the long term completely removed the sensation of a phantom limb – the method is now known as the mirror therapy. 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.

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