Phantom Phenomena Research Articles

Phantom phenomena in mastectomized patients and their relation to chronic and acute pre-mastectomy pain

Chronic and acute pre-mastectomy pain as well as prevalence and characteristics of phantom phenomena following mastectomy were investigated by interview in a sample of 39 women who had undergone unilateral breast amputation. Twenty of 39 participants reported phantom sensations in the breast. Nine of the participants with phantom sensations experienced phantom pain and 11 non-painful phantom sensations. Although some features of phantom breast phenomena appear to be similar to characteristics of phantom phenomena in limb amputees, phantom breast phenomena seem to differ in a variety of ways such as time of onset or localization. This difference may be explained by the absence of kinesthesis and the small representation of the human breast. Seven of the 39 participants experienced chronic and six acute breast pain prior to the amputation. The amount of chronic pre-mastectomy breast pain weighted by the amount of involved tissue was significantly higher among participants with non-painful phantom sensations, compared to women with painful phantoms and those without phantom phenomena.

A focus group study of health professionals’ views on phantom sensation, phantom pain and the need for patient information

Focus groups with 32 health professionals from pre- and post-amputation care in central Scotland were used to explore perceptions of phantom sensation and pain, and current practice and potential improvements to patient information. Findings were compared to our parallel study of patients’ experiences of phantom phenomena and information needs. Professionals’ perceptions of phantom phenomena did not always match patient experiences: few professionals were fully aware of the nature, or the problems associated with phantom pain. There was uncertainty about who provided information and reported information was inconsistent and only weakly grounded in theory and mechanism-based management. Whilst there was awareness of the benefits of information, content, mode of delivery and co-ordination were all identified as areas for improvement. Our findings suggest that the information given to patients on phantom phenomena is inconsistent and insufficient. Possible solutions are the development of minimum standards of information and specifically targeted interprofessional education.

Dracula's Teeth Syndrome

To describe a patient with facial pain, ipsilateral facial dystonia, and phantom supernumerary teeth, beginning after resection of hypertrophic gums. She had familial sensorineural deafness. Atypical cranial dystonia subsequent to dental procedures is associated with facial pain, dysesthesias, or phantom phenomena, but not with phantom supernumerary teeth. Patients with migraine are susceptible to experience cephalic phantom phenomena after dental procedures. Wynne syndrome is a hereditary autosomal dominant disorder characterized by congenital sensorineural deafness and supernumerary teeth. Clinical examination, computerized tomography of paranasal sinuses and facial bones, magnetic resonance imaging of the brain, cranial electrophysiological testing, and electroencephalogram. A 52-year-old woman with history of migraine without aura for 40 years exhibited focal right facial involuntary tonic contracture accompanying chronic severe pain over the same area after gum resection. She reported a daily sensation of having two extra upper canine teeth pressing on her tongue, simulating vampire's ("Dracula's") teeth. She had high-frequency bilateral sensorineural deafness. Her computerized tomography studies, brain magnetic resonance imaging, and cranial electrophysiological testing were normal. This patient with chronic migraine had atypical cranial dystonia beginning after a dental procedure. Her dystonia was complicated by the unusual phenomenon of phantom supernumerary teeth. This condition may be misdiagnosed as atypical or psychogenic facial pain when facial dystonia is localized or subtle and is, therefore, confused with an idiosyncratic gesture or habitual spasm. Her signs and symptoms are reminiscent of Wynne syndrome.

The phantom and stump phenomena interview (PSPI)

A structured German-language interview was developed for the assessment of painful and non-painful phantom and stump phenomena after amputation. The aim was a thorough assessment of the quality, quantity and time course of these phenomena, which is of scientific as well as therapeutic relevance. Each phenomenon was assessed using visual analogue scales as well as qualitative descriptors adapted from the McGill Pain Inventory and from literature reports. The factor structure and psychometric properties of the interview were evaluated in a sample of 139 upper and lower limb amputees. Test-retest coefficients were obtained in a subset of 20 amputees. As expected, all pain-related scales showed a two-dimensional internal structure with the factors "affective pain" and "sensory pain". For the non-painful phantom sensations, three factors "general/kinesthetic phantom sensations", "phantom movements" and "paresthesias" were obtained, while for non-painful stump sensations only one general factor emerged. The internal consistency was high with respect to the pain-related scales and was still satisfying for the scales that cover nonpainful phantom and stump phenomena. All scales have sufficient validity. Test-retest coefficients suggest a satisfactory stability of all scales that assess present phenomena, while the stability of the retrospective scales is markedly lower and in some cases insufficient. The phantom and stump phenomena interview is a highly reliable and valid instrument to assess present perceptual phenomena after amputation. Only the included retrospective scales apparently show low stability scores over time. This raises the more general question of the validity of retrospective pain reports.

Phantom Limb Sensation: A Need for More Elaborated Studies

University of Rochester Medical Center, Rochester, New York. sheldon_isaacson@urmc.rochester.eduIn Reply:—We thank Drs. Bromage, Melzack, and Gentili for their interest in our work. Both letters express concern about the relatively short duration of observation in our study.Our study differs from that of Gentili et al. 1and Bromage and Melzack 2in two respects. (1) We exclusively studied lower extremity phantom proprioception after subarachnoid block. The difference in local anesthetic onset between subarachnoid block in the 3- to 8-min range 3and major peripheral and epidural blocks in the 10- to 30-min range, 4depending on local anesthetic used, or the potential for variable or incomplete anesthetic blockade with these nonsubarachnoid blocks may account for the delayed phantom phenomena emergence that these authors observed in their studies. Our observations clearly show that a phantom sensation can develop within 10 min, especially in the originally flexed limb. (2) Our subjects were forced to limit their limb position perception to either bent or straight. Limiting the subject response to a two-category variable of bent or straight may have resulted in a greater and possibly earlier yield of phantom perceptions in our study. These yields are clearly documented for each time point. In addition, it should be pointed out that the study of Drs. Bromage and Melzack and the study of Dr. Gentili involved phantom observations of affected limbs that necessitated surgery. Our study evaluated normal, healthy limbs that were not being operated on. The confounding influence of pathophysiologic pain or injury on the incidence of phantom sensations has yet to be determined and may result in different phantom yields.We were well-aware of the work by Moriyama et al. and Gentili et al. ; however, they were not cited because full manuscripts have not been published to date. In developing our study design, our protocol attempted to balance time of onset of sensory and proprioceptive block with surgical time delay concerns. In addition, a surgical procedure scheduled for 45–60 min would not be able to tolerate plain lidocaine spinal anesthesia with a research delay longer than 12–15 min. However, neuroplastic phenomena do show change with time, as clearly demonstrated by numerous experimental works on hippocampal long-term potentiation. 5Proprioceptive phantom sensation as a manifestation of spinal cord neuroplasticity may exhibit time-dependent changes as well.We do not claim a formal opposition between the existence of any classic body schema and the neuroplastic processes that we documented. Our observations suggest that a neuroplastic processes seems to override or dominate any existing default “position of rest” or “tetrapod” settings for the period of our observations. In this respect, a longer observation time using our protocol may yield more information either to confirm our initial observations or to reflect subsequent migration to any default settings observed at later times from the noted authors’ studies.

Perceptual phenomena after unilateral arm amputation: a pre-post-surgical comparison

Painful and non-painful phantom phenomena occur frequently after amputations but are rarely investigated in the perioperative stage. The goal of the present study was the assessment of phantom phenomena, pain and changes in primary somatosensory cortex prior to and after upper limb amputation. Two patients who suffered from metastatic carcinoma were examined 2 days prior to and 7 days after the amputation of an arm using comprehensive psychometric assessments and neuroelectric source imaging. Both patients reported phantom limb pain that was similar to their pre-amputation pain. In one patient, reorganization of the mouth area into the deafferented hand area took place immediately after the amputation. In the other patient reorganization had occurred prior to the amputation possibly related to non-use of the arm several years prior to the amputation.

The relationship of perceptual phenomena and cortical reorganization in upper extremity amputees

In this study 16 unilateral upper extremity amputees participated in a comprehensive psychophysiological examination that included the assessment of painful and non-painful phantom and stump sensations, thermal and electric perception as well as two-point discrimination thresholds, the detailed analysis of referred sensation and the measurement of reorganizational changes in primary somatosensory cortex using neuroelectric source imaging. Reorganization of the primary somatosensory cortex was associated with increased habitual phantom limb pain, telescoping, non-painful stump sensations and painful referred sensation induced by painful stimulation. It was unrelated to non-painful phantom sensations, non-painful referred sensation elicited by painful or non-painful stimulation, painful referred sensation elicited by non-painful stimulation, perception thresholds and stump pain. These data substantiate the hypothesis that painful and non-painful phantom phenomena are mediated by different neural substrates.

Distressing upper extremity phantom limb sensation during intravenous regional anesthesia

Background and Objectives: The objective of this article is to describe a case of distressing upper extremity phantom limb sensation during intravenous regional anesthesia (IVRA). Case Report: A 33-year-old American Society of Anesthesiologists (ASA) status I female with an uncomplicated intrauterine gestation presented for endoscopic carpal tunnel release. Following gravity-assisted exsanguination of the vertically positioned left upper extremity, she underwent an IVRA. Within minutes of her arm being repositioned for surgery she remarked that the arm felt as if it was still in the vertical position. This sensory disturbance was described as fatiguing and exhausting. Despite reassurance and medication with intravenous narcotics, her symptoms became intolerable. Her phantom sensation disappeared upon dissipation of the IVRA. Conclusions: There are no previous reports regarding the development of phantom phenomena during an IVRA. The occurrence of distressing phantom sensations during an otherwise adequate IVRA may be interpreted as block failure and may lead to conversion to general anesthesia. Practitioners are encouraged to consider these phenomena when performing IVRA. Reg Anesth Pain Med 2001;26:72-74.

552 Participation of the intact hemisphere of the brain in the recovery of the somatic sensibility after unilateral injury

Painful and non-painful phantom phenomena occur frequently after amputations but are rarely investigated in the perioperative stage. The goal of the present study was the assessment of phantom phenomena, pain and changes in primary somatosensory cortex prior to and after upper limb amputation. Two patients who suffered from metastatic carcinoma were examined 2 days prior to and 7 days after the amputation of an arm using comprehensive psychometric assessments and neuroelectric source imaging. Both patients reported phantom limb pain that was similar to their pre-amputation pain. In one patient, reorganization of the mouth area into the deafferented hand area took place immediately after the amputation. In the other patient reorganization had occurred prior to the amputation possibly related to non-use of the arm several years prior to the amputation.

551 Relationship of phantom phenomena and somatosensory cortical reorganization in amputees

The present study was designed to investigate differences in neural processing of pain-related semantic information in amputees with and without chronic phantom limb pain and healthy controls. One-hundred-and-twenty words (40 neutral, 40 body-related, 40 pain-related) were presented in pseudorandom order to probe group differences in the perception of pain-related information. Visual evoked potentials (VEP) to the words were recorded from 11 scalp locations, EMG was measured at the stump and the contralateral side and bilaterally from the M. corrugator. In addition, heart rate and skin conductance responses were obtained. Both early and late VEP components were altered. Pain-free amputees showed a reduced N100 amplitude compared to phantom limb pain patients and healthy controls whereas the phantom limb pain patients displayed a significantly enhanced late positivity (500–800 msec after word onset). VEP components were unaffected by word type. The peripheral EMG responses were significantly different among the groups: phantom limb pain patients showed larger EMG reactions on the stump than on the contralateral side, whereas pain-free amputees showed the opposite effect. The data suggest an enhanced central and peripheral processing of visual stimuli in phantom limb pain patients.

Phantom sensation and phantom pain 1: an overview of the literature

This article, the first of two, reviews the literature relating to patients' experiences of phantom sensation and phantom pain and looks at recommendations for education and support during rehabilitation. In the past the lack of a firm physiological explanation led health-care professionals to assume a psychological origin. Recent research has established that phantom phenomena have a neurophysiological basis involving a complex interaction of peripheral and central mechanisms. The literature now supports preoperative or early postoperative education about the likely occurrence and basis of phantom phenomena as an effective step in the management of this complex problem. However, there is a lack of published guidelines which are readily available to professionals working in the rehabilitation of amputees.

Cortical reorganization and phantom phenomena in congenital and traumatic upper-extremity amputees.

The relationship between phantom limb phenomena and cortical reorganization was examined in five subjects with congenital absence of an upper limb and nine traumatic amputees. Neuromagnetic source imaging revealed minimal reorganization of primary somatosensory cortex in the congenital amputees (M=0.69 cm, SD 0.24) and the traumatic amputees without phantom limb pain (M=0.27 cm, SD 0.25); the amputees with phantom limb pain showed massive cortical reorganization (M=2.22 cm, SD 0.78). Phantom limb pain and nonpainful phantom limb phenomena were absent in the congenital amputees. Whereas phantom limb pain was positively related to cortical reorganization (r=0.87), nonpainful phantom phenomena were not significantly correlated with cortical reorganization (r=0.34). Sensory discrimination was normal and mislocalization (referral of stimulation-induced sensation to a phantom limb) was absent in the congenital amputees. The role of peripheral and central factors in the understanding of phantom limb pain and phantom limb phenomena is discussed in view of these findings.

Pathogenesis and mechanisms of phantom pain

Although phantom limb pain is a well-known syndrome, phantom sensation or pain may affect virtually any part of the body (somatic or visceral) that is accessible to sensory perception. This review begins with a novel classification system of this diverse group of clinical conditions. Attention is then devoted to the mechanisms responsible for the pathogenesis of phantom pain, notably, deafferentation and nerve injury. The mechanisms of how regional anesthesia may prevent, or sometimes reactivate, phantom pain are discussed. Finally, a consideration is given to the various theories and models that have evolved to explain phantom phenomena, with particular emphasis on the “neuromatrix paradigm.”

Society for Obstetric Anesthesia and Perinatology

Society for Obstetric Anesthesia and Perinatology

Phantom-limb pain as a perceptual correlate of cortical reorganization following arm amputation.

Although phantom-limb pain is a frequent consequence of the amputation of an extremity, little is known about its origin. On the basis of the demonstration of substantial plasticity of the somatosensory cortex after amputation or somatosensory deafferentation in adult monkeys, it has been suggested that cortical reorganization could account for some non-painful phantom-limb phenomena in amputees and that cortical reorganization has an adaptive (that is, pain-preventing) function. Theoretical and empirical work on chronic back pain has revealed a positive relationship between the amount of cortical alteration and the magnitude of pain, so we predicted that cortical reorganization and phantom-limb pain should be positively related. Using non-invasive neuromagnetic imaging techniques to determine cortical reorganization in humans, we report a very strong direct relationship (r = 0.93) between the amount of cortical reorganization and the magnitude of phantom limb pain (but not non-painful phantom phenomena) experienced after arm amputation. These data indicate that phantom-limb pain is related to, and may be a consequence of, plastic changes in primary somatosensory cortex.

Reactivation of Phantom Limb Pain after Combined Interscalene Brachial Plexus Block and General Anesthesia

Reactivation of Phantom Limb Pain after Combined Interscalene Brachial Plexus Block and General Anesthesia

The prevalence of phantom sensation and pain in pediatric amputees

Phantom sensations and pain occur with an unknown frequency in children. We hypothesized that such experiences are common among children, and occur more often than is recognized by health-care personnel. Children and adolescents, ages 5–19 years, who had undergone limb amputation in the past 10 years, served as subjects for this retrospective study. Subjects were divided into three major groups depending upon the indication for amputation: congenital deformity (CD), trauma/infection (TI), and cancer (Ca). Surveys assessing phantom sensations and phantom pain were mailed to children and their parents/guardians. The incidence of phantom sensations was 100% in each group, and phantom pain occurred in the overwhelming majority. Both types of phantom phenomena began within days of surgery for almost all patients. Seventy-five percent of children and adolescents who had experienced phantom pain also had preoperative limb pain. At the time of the study, phantom pain had resolved in only 35% of the subjects. Phantom pain was documented in the medical records of only 40% of those answering positively to questions regarding phantom pain on the questionnaire. We conclude that phantom pain occurs commonly in children and adolescents. The association of preoperative pain in the diseased extremity and the later occurrence of phantom pain suggests that preoperative regional anesthesia may prevent phantom pain.

Dynamic reverberation. A unified mechanism for central and phantom pain

Central and phantom pains remain unexplained by current pathophysiological hypotheses. Newer theories suggest that these may be the result of an altered processing inside a network of neurons extending throughout wide-spread areas of the brain, precluding neurosurgical treatment. On the basis of a literature review of cases with spontaneous resolution of the pain, it is argued that both central and phantom pain depend on a localized corticothalamic reverberatory loop, which is at the basis of the steady components of both. In this case, selective stereotactic lesions of the corona radiata deep to the frontoparietal sensorimotor strip may achieve a permanent cure. This theory refutes the neuromatrix hypothesis of phantom phenomena. It is speculated that electroconvulsive therapy might block the pathologic reverberation in both central and phantom pains.

Note on phantom phenomena and groups of self-homotopy equivalences

Note on phantom phenomena and groups of self-homotopy equivalences

The phantom phenomenon

Although phantom sensations and phantom pain are quite common sequelae of amputation and other related surgical procedures, these phenomena are not well understood. There are many, often conflicting theories which attempt to explain their nature and causes, and to provide a foundation for more effective treatment. This paper reviews recent literature on this topic. The review encompasses information about the prevalence and nature of phantom phenomena; evidence from empirical studies concerned with identification of possible predictors; and various psychological and neurophysiological theories that have been proposed in an attempt to explain why phantom sensations and pain are experienced. It is concluded that the fragmented approach adopted in the past has resulted in pockets of knowledge that are not too well integrated. There is therefore an outstanding need for a general theory to synthesise the knowledge gained to date about the multiplicity of factors associated with phantom phenomena. In this context, Melzack and Loeser's (1978) concept of "pattern generating mechanisms" may offer the most useful model for future research.