Concept: Phantom limb
Following the amputation of a limb, many amputees report that they can still vividly perceive its presence despite conscious knowledge that it is not physically there. However, our ability to probe the mental representation of this experience is limited by the intractable and often distressing pain associated with amputation. Here, we present a method for eliciting phantom-like experiences in non-amputees using a variation of the rubber hand illusion in which a finger has been removed from the rubber hand. An interpretative phenomenological analysis revealed that the structure of this experience shares a wide range of sensory attributes with subjective reports of phantom limb experience. For example, when the space where the ring finger should have been on the rubber hand was stroked, 93% of participants (i.e., 28/30) reported the vivid presence of a finger that they could not see and a total of 57% (16/28) of participants who felt that the finger was present reported one or more additional sensory qualities such as tingling or numbness (25%; 7/28) and alteration in the perceived size of the finger (50%; 14/28). These experiences indicate the adaptability of body experience and share some characteristics of the way that phantom limbs are described. Participants attributed changes to the shape and size of their “missing” finger to the way in which the experimenter mimed stroking in the area occupied by the missing finger. This alteration of body perception is similar to the phenomenon of telescoping experienced by people with phantom limbs and suggests that our sense of embodiment not only depends on internal body representations but on perceptual information coming from peripersonal space.
The hand area of the primary somatosensory cortex contains detailed finger topography, thought to be shaped and maintained by daily life experience. Here we utilise phantom sensations and ultra high-field neuroimaging to uncover preserved, though latent, representation of amputees' missing hand. We show that representation of the missing hand’s individual fingers persists in the primary somatosensory cortex even decades after arm amputation. By demonstrating stable topography despite amputation, our finding questions the extent to which continued sensory input is necessary to maintain organisation in sensory cortex, thereby reopening the question what happens to a cortical territory once its main input is lost. The discovery of persistent digit topography of amputees' missing hand could be exploited for the development of intuitive and fine-grained control of neuroprosthetics, requiring neural signals of individual digits.
When placing one hand on each side of a mirror and making synchronous bimanual movements, the mirror-reflected hand feels like one’s own hand that is hidden behind the mirror. We developed a novel mirror box illusion to investigate whether motoric, but not spatial, visuomotor congruence is sufficient for inducing multisensory integration, and importantly, if biomechanical constraints encoded in the body schema influence multisensory integration. Participants placed their hands in a mirror box in opposite postures (palm up, palm down), creating a conflict between visual and proprioceptive feedback for the hand behind the mirror. After synchronous bimanual hand movements in which the viewed and felt movements were motorically congruent but spatially in the opposite direction, participants felt that the hand behind the mirror rotated or completely flipped towards matching the hand reflection (illusory displacement), indicating facilitation of multisensory integration by motoric visuomotor congruence alone. Some wrist rotations are more difficult due to biomechanical constraints. We predicted that these biomechanical constraints would influence illusion effectiveness, even though the illusion does not involve actual limb movement. As predicted, illusory displacement increased as biomechanical constraints and angular disparity decreased, providing evidence that biomechanical constraints are processed in multisensory integration.
Phantom pain after arm amputation is widely believed to arise from maladaptive cortical reorganization, triggered by loss of sensory input. We instead propose that chronic phantom pain experience drives plasticity by maintaining local cortical representations and disrupting inter-regional connectivity. Here we show that, while loss of sensory input is generally characterized by structural and functional degeneration in the deprived sensorimotor cortex, the experience of persistent pain is associated with preserved structure and functional organization in the former hand area. Furthermore, consistent with the isolated nature of phantom experience, phantom pain is associated with reduced inter-regional functional connectivity in the primary sensorimotor cortex. We therefore propose that contrary to the maladaptive model, cortical plasticity associated with phantom pain is driven by powerful and long-lasting subjective sensory experience, such as triggered by nociceptive or top-down inputs. Our results prompt a revisiting of the link between phantom pain and brain organization.
Content Analyses of A Priori Qualitative Phantom Limb Pain Descriptions and Emerging Categories in Mid-Southerners with Limb Loss
- Rehabilitation nursing : the official journal of the Association of Rehabilitation Nurses
- Published over 5 years ago
PURPOSE: The purposes of this descriptive study were (a) to identify the relative frequencies of a priori categories of phantom limb pain (PLP) quality descriptors reported by Mid-Southerners with limb loss, (b) to analyze their descriptions for emerging categories of PLP, and © to identify the relative frequencies of the emerging categories. DESIGN: This cross-sectional descriptive verbal survey assessed PLP descriptors. A content analyses determined relative frequencies of a priori PLP descriptors as well as emerging categories that were identified. FINDINGS: The most common a priori PLP quality descriptors reported by 52 amputees with PLP were intermittent, tingling/needles/numb, sharp, cramping, burning, and stabbing. The most common emerging categories reported were pain compared to illness/injury, electrical cyclical, and manipulated/positional. CONCLUSION: The detailed descriptions of PLP provide insight into the vivid experiences of PLP. CLINICAL RELEVANCE: Rehabilitation nurses can use this information with PLP assessment, patient teaching, and counseling.
The clinical use of mirror visual feedback was initially introduced to alleviate phantom pain by restoring motor function through plastic changes in the human primary motor cortex. It is a promising novel technique that gives a new perspective to neurological rehabilitation. Using this therapy, the mirror neuron system is activated and decrease the activity of those systems that perceive protopathic pain, making somatosensory cortex reorganization possible. This paper reports the results of the mirror therapy in three patients with phantom limb pain after recent lower limb amputation, showing its analgesic effects and its benefits as a comprehensive rehabilitation instrument for lower limb amputee geriatric patients.
Development of a Clinical Framework for Mirror Therapy in Patients with Phantom Limb Pain: An Evidence-based Practice Approach
- Pain practice : the official journal of World Institute of Pain
- Published over 3 years ago
To describe the development and content of a clinical framework for mirror therapy (MT) in patients with phantom limb pain (PLP) following amputation.
We characterized the effect of virtual visual feedback (VVF) on supernumerary phantom limb pain (SPLP) in a patient with high cervical cord injury. The subject was a 22-year-old man diagnosed with complete spinal cord injury (level C2) approximately 5 years ago. We applied the ABA'B' single-case design and set phases B and B' as intervention phases for comparison. SPLP significantly improved in comparison of phase A with phase B and phase A with phase B'. We suggest that VVF reduces SPLP and the effect lasts after VVF.
The role of cortical activity in generating and abolishing chronic pain is increasingly emphasized in the clinical community. Perhaps the most striking example of this is the maladaptive plasticity theory, according to which phantom pain arises from remapping of cortically neighbouring representations (lower face) into the territory of the missing hand following amputation. This theory has been extended to a wide range of chronic pain conditions, such as complex regional pain syndrome. Yet, despite its growing popularity, the evidence to support the maladaptive plasticity theory is largely based on correlations between pain ratings and oftentimes crude measurements of cortical reorganization, with little consideration of potential contributions of other clinical factors, such as adaptive behaviour, in driving the identified brain plasticity. Here, we used a physiologically meaningful measurement of cortical reorganization to reassess its relationship to phantom pain in upper limb amputees. We identified small yet consistent shifts in lip representation contralateral to the missing hand towards, but not invading, the hand area. However, we were unable to identify any statistical relationship between cortical reorganization and phantom sensations or pain either with this measurement or with the traditional Eucledian distance measurement. Instead, we demonstrate that other factors may contribute to the observed remapping. Further research that reassesses more broadly the relationship between cortical reorganization and chronic pain is warranted.
The experience of post-amputation pain such as phantom limb pain (PLP) and residual limb pain (RLP), is a common consequence of limb amputation, and its presence has negative effects on a person’s well-being. The continuity hypothesis of dreams suggests that the presence of such aversive experiences in the waking state should be reflected in dream content, with the recalled body representation reflecting a cognitive proxy of negative impact. In the present study, we epidemiologically assessed the presence of post-amputation pain and other amputation-related information as well as recalled body representation in dreams in a sample of 3,234 unilateral limb amputees. Data on the site and time of amputation, residual limb length, prosthesis use, lifetime prevalence of mental disorders, presence of post-amputation pain, and presence of non-painful phantom phenomena were included in logistic regression analyses using recalled body representation in dreams (impaired, intact, no memory) as dependent variable. The effects of age, sex, and frequency of dream recall were controlled for. About 22% of the subjects indicated that they were not able to remember their body representation in dreams, another 24% of the amputees recalled themselves as always intact, and only a minority of less than 3% recalled themselves as always impaired. Almost 35% of the amputees dreamed of themselves in a mixed fashion. We found that lower-limb amputation as well as the presence of PLP and RLP was positively associated with the recall of an impaired body representation in dreams. The presence of non-painful phantom phenomena, however, had no influence. These results complement previous findings and indicate complex interactions of physical body appearance and mental body representation, probably modulated by distress in the waking state. The findings are discussed against the background of alterations in cognitive processes after amputation and hypotheses suggesting an innate body model.