Phantom pain. What is phantom pain and how to deal with it What is phantom pain after surgery

Description:

Phantom limb pain is one of the most serious pain syndromes. They were first described in 1552 by Ambroise Paré, but the mechanisms underlying them are still not fully understood, and their prospects quick fix very sad.

The percentage of people suffering from phantom pain is surprisingly high. In 72% of people, phantom pain occurred within the first 8 days after surgery, after 6 months they were observed in 65%, and two years later - in 60%. 60% of people continue to complain of pain in the phantom limb after 7 years. However, over time, painful attacks become less frequent.

Symptoms:

Phantom pain is one of the manifestations of a variety of phantom sensations. Pain refers to exteroceptive sensations, along with tactile, temperature, pressure, itching, etc. Kinaesthetic sensations may also occur, which include the perception of the position of the amputated limb, its length, volume, as well as kinetic sensations, including voluntary and involuntary movements in the limb. The most characteristic kinesthetic sensations are the perception of an unusual position of a limb, its shortening, and distortion of size. All these sensations are most vivid immediately after the operation. Over time, the intensity of the sensations weakens.

Causes:

Classic phantom pain occurs after amputation of a limb, but the term also applies to pain that develops after amputation of any part of the body. In almost all patients who have undergone amputation of the limbs, as well as some other organs (breast, penis, anus, nose, ears), phantom sensations appear soon after the nerve is crossed, but they can appear at any time after denervation. These sensations are not always painful and sometimes do not cause complaints from patients. Most experts note that over time, pain decreases significantly in about half of patients.

Treatment:

For treatment the following is prescribed:

Phantom pain is difficult to treat, so it is best to try to prevent it. A decrease in the frequency and intensity of phantom pain in the postoperative period in patients with preoperative pain in the limb is noted after an epidural infusion of local anesthetics or morphine within 72 hours before surgery.

Drug treatment.
With a short history of phantom pain, analgesics demonstrate positive effect. In some cases it is shown long-term use narcotic analgesics.

Nerve block.
Sympathetic nerve blockade usually produces minimal or temporary improvement, but in some cases it is effective enough that even the small likelihood of permanent pain relief justifies sympathetic blockade for refractory pain. The likelihood of achieving a persistent analgesic effect by blocking sensory nerves is lower than with sympathetic blockades; even cases of paradoxical increase in pain after sensory blockades have been described.

Chemical or surgical destruction.
Chemical or surgical destruction of the proximal somatosensory pathways is riskier than temporary blockade because it may worsen the condition and therefore should NOT be used to treat phantom pain.
Injections of local anesthetics into the stump have virtually no effect on phantom pain.

In order to understand what is phantom pain, it is necessary, first of all, to become familiar with phantom sensations. The word "phantom" comes from the Greek phantasma - "ghost". Why are the sensations that appear in people several months or years after amputation or separation of a limb called phantom? A person has lost his leg for a long time, but he begins to feel it all or in parts, and may, it seems to him, even move the missing finger. Phantom sensations sometimes they are so real and vivid that a person tries to stand on his missing leg.

There is no doubt that the root cause of phantom sensations is the painful changes in the stump that occur after amputation. It has been established that different tissues change differently after amputation. If the skin, muscles and other tissues scar quickly and relatively evenly, the cut nerve continues to grow for some time, causing a thickening to form at its end - a neuroma. The scar tissue developing in the neuroma compresses the nerve fibers, irritates them and thus becomes a source of painful impulses entering the spinal cord and brain.

In the occurrence of phantom sensations Apparently, it also matters that sometimes the nerve is walled up, as if compressed by scars formed in the skin and muscles. Sometimes phantom sensations can appear due to inflammatory process in the tissues of the stump.

We haven't listed everything possible reasons origin of phantom sensations. One thing is indisputable: their triggering mechanism is certain changes in the cult. Phantom sensations are often painless. Less commonly, they are accompanied by intense and varied pain.

So, due to these or other reasons, in a person after amputation, pathological nerve impulses enter the spinal cord and brain from the stump. In response to them, persistent foci of excitation arise in the central nervous system. But why does a person still perceive various sensations, and in particular pain, in a part of the body that is not there?

To answer this question, let’s get acquainted with at least general outline with the so-called body schema theory (“body image”).

It turns out that our brain stores memory of all parts of the body, regardless of whether they exist or have already been lost. This memory is formed gradually, strengthened throughout our lives, in the process of repeated various movements and movements of the body in space. The “body image,” stored in the cerebral cortex, contains both past experiences and today’s sensations. In other words, the body diagram is a kind of memory of the cerebral cortex about the structure and proportions of the body. We repeat: life experience is necessary to form this memory. This situation is confirmed by the fact that children under five years of age do not experience phantom sensations.

Painless phantom sensations occur in almost all amputees (95-98%). This phenomenon is considered to be physiological. A person clearly feels movements of the fingers, foot or hand in the missing leg or arm, feels itching and touching them. He “can” voluntarily squeeze or unclench the hand of the missing hand. For some, the perception of a missing body part is bizarre: a missing leg or arm seems too big or small. For some people, when they look at a missing leg or arm, the phantom sensations decrease, for others they remain unchanged.

Phantom pain extremely varied: cutting, tearing, piercing, shooting, breaking, twisting. Especially painful is the burning pain, which doctors call causalgic. The pain can be “concentrated” in one place - in the toe or heel of the missing leg, or it can be diffuse, indefinite in nature.

For many, phantom pain intensifies from difficult experiences, colds, infectious diseases, even with changes in atmospheric pressure.

To reduce pain impulses from the stump, local thermal procedures are used - paraffin and mud applications, ionization with novocaine, x-ray therapy, ultra-high frequency currents.

Novocaine blockade is widely used, intravenous infusions of glucose, calcium chloride, and vitamins are prescribed. It is recommended not to overload the stump - to dose the load.

It is very bad when, starting to use any new method of therapy and not receiving quick relief, patients refuse it, and the idea is affirmed in them that the pain is irreducible.

It is also important that a person believes in the possibility of getting rid of pain, then the treatment will be more successful and will be more effective!

When all conservative methods do not help, they resort to surgery.

This is one of the most mysterious phenomena in medicine. Almost every person who has undergone tamlugation has a feeling that an amputated limb is present, which causes considerable anxiety in patients. But over time, patients get used to it. And as a rule, after a year this feeling goes away completely.

Phantom pain in the limbs causes much more trouble. They vary greatly in intensity - from annoying to completely unbearable. A similar phenomenon occurs in approximately two-thirds of patients who have undergone amputation, especially if they experienced severe pain in that limb before surgery.

Phantom pains are also very diverse in form. People who have suffered them describe their sensations as burning, cramps, tingling, shooting, aching or throbbing pain. Sometimes it seems to them that the amputated leg is in the same place, but only in some extremely uncomfortable and unusual position. For example, it seems to them that the amputated hand is always clenched into a fist and that the nails dig painfully into the palm.

In most cases, phantom limb pain goes away on its own. But sometimes they become chronic and unbearably strong. When the pain is more than real. Experts are still not yet able to explain what causes the phenomenon of phantom limb pain. But they already know how to make them easier.

Convenience and peace. In some cases, phantom pain may worsen. For example, they are much stronger if a person is cold. In this case, wrap your extremities and keep them warm. The feeling of discomfort may also increase under other circumstances if, for example, the amputated limb is in a freely suspended state. Pain may occur when taking a bath, even while yawning. You should first find out what situations cause flare-ups, and then try to avoid them.

Apply bandages. Many patients claim that they feel much better when their amputated limb is in a fixed position, even at night. There are several ways to ensure this. You may wear a rigid plaster cast that fits around your limb; “sock-stump”, providing compression; or a bandage made of an elastic bandage, which is tied around the limb in a figure eight. Ask your doctor or physical therapist for a recommendation.

Try a massage. Massaging the lower part of the amputated limb can help relieve pain. And he suggests lightly and gently massaging the limb for 5-10 minutes twice a day. But just do it especially carefully in the surgical area.
Exercise the limb. You can try rubbing the limb with different tissues so that it gets used to different kinds of sensations. Try sheets, towels, clothing, and other fabrics with a variety of textures.

Use your imagination. Relaxation techniques will help you relieve discomfort. First of all, you need to lie down in bed or get comfortable in a chair, then close your eyes. And imagine the type of activity that before the amputation brought you special joy and pleasure. For example, if you have a partial leg amputation, imagine that you are riding a bicycle, pedaling with both feet. Or imagine sitting on the shore of a lake and dangling your legs. If you lose your arm, imagine yourself swimming or playing catch. Try to move your healthy limb, repeating these movements. And clearly imagine how the amputated limb moves.

Use painkillers. To relieve the intrusiveness, but not too much severe pain, you can use medications such as ibuprofen, aspirin, or acetaminophen. Ask your doctor or pharmacist at your pharmacy to find the right product for you. If it does not help, and the pain intensifies and requires increasingly larger doses, tell your doctor.

Consider other medications. Certain medications, usually prescribed to treat other conditions, may help with phantom pain. Small doses of tricyclic antidepressants (such as Elavil, for example) often help. Some improvement can also be achieved with the help of a muscle relaxant called Baclofen and an anticonvulsant such as Tegretol. Just consult your doctor first about which remedy to choose.

Consult a specialist. If you have not yet seen a physiotherapist, we recommend that you do so. A physical therapist will help you recover from surgery and advise you on how best to manage phantom pain. Contact your healthcare provider or local clinic.

I learned about phantom pain from the TV series House. Remember, in one of the episodes main character was able to calm down an angry neighbor with an amputated arm when he showed a trick with a box and a mirror? The doctor suggested and turned out to be right that the neighbor was so irritated because he was in a lot of pain, and his missing limb hurt. For the material in “Health Expert” in Almaty, I found a heroine who has been bothered by phantom pain for 24 years after the amputation of a limb. Honestly, looking at her, you would never guess that a person walks on a prosthesis, much less suffers from phantom pain. But I couldn’t find a doctor in Almaty or at least in Kazakhstan who could competently talk about methods of treating phantom pain - neither a survey of doctors nor a search on the all-knowing Google helped. But the same search engine told me that they know how to treat this type of pain in Moscow - at the Research Institute of Neurosurgery named after. N.N. Burdenko.

When something that isn't there hurts

Emil Davidovich ISAGULYAN, senior researcher at the Research Institute of Neurosurgery them. N.N. Burdenko of the Ministry of Health of the Russian Federation (Moscow), neurosurgeon-algologist (specialist in surgical treatment pain syndromes)

– Emil Davidovich, please tell us about phantom pain. What does modern science and medicine know about pain of this type?

– Phantom pain is usually pain in a missing limb. This can also be pain on the torso - for example, during a mastectomy, but most often it is on the limb. Since there are more cases of leg amputation (ischemic lesions, as well as injuries, can lead to amputation; in both cases, a stump is formed so that a prosthesis can be worn in the future), there are also cases of phantom pain in lower limb more. There is a long phantom - in the absence of the entire leg, and a short phantom - in the absence of the foot.

Why exactly does phantom pain occur? delicate mechanisms– all this is still unknown. There have been many studies on this topic: the same amputation, performed by the same surgeon, under the same conditions, for the same circumstance, in people of the same sex and age, in some cases did not lead to the formation of phantom pain, in others, she did. We know that the "phantom" is formed in the brain. It can be painless, when a person simply has sensations of a phantom limb, or it can be painful. Phantom occurs in approximately 40% of amputation patients. Phantom pain occurs in approximately 25%.

Using functional MRI and PET, carried out while a person is thinking about the movements of the missing limb, due to increased blood circulation, it was found that after the loss of a limb, its representation in the human brain remains. Not always, but in most cases, the devices actually manage to register foci of excitation in the brain. Thus, it has been established that when the brain loses connection with its limb, its representation in the brain remains, the brain continues to send impulses to the lost limb. Without receiving a response - neither motor nor sensory - a focus of excitation is formed in the representation: impulses are generated there that should not normally be generated. It is these impulses that cause phantom pain.

Moreover, the phantom pain begins to take on a life of its own. Since a focus is formed, it can be compared to a focus of epilepsy in the brain (in this case, discharges appear in the focus, provoking convulsions and loss of consciousness). Whether the phantom is painless or painful depends on the extent of the lesion and the level of the discharges that it generates. The lesion may involve adjacent areas and may migrate. Sometimes they are very different from those localizations that should normally be for an arm or leg.

An attack of phantom pain can last from several minutes to several hours. It consists of background pain, which is constantly present, and attacks of increased pain. A person can experience the whole spectrum: a limb burns, aches, is squeezed, twists, twitches, stretches... There are fanciful sensations that are difficult to imagine in reality.

– What causes phantom pain? Are physiological or psycho-emotional reasons leading?

– When there is a pathological focus, it is ready to cause pain at any moment, regardless of the provoking factors; it itself generates pain impulses or other sensations. For example, with so-called complex phantoms, a sensation of a third hand may occur. This phenomenon indicates the involvement of new areas of the brain in the process.

But yes, because we're talking about about the brain, the psycho-emotional state of a person is also very important. A phantom can be triggered by any stress or experience. And vice versa, if a person is very passionate about something and is busy, he can forget about phantom pain for a while. Unfortunately, it is impossible to be seriously immersed in something all the time in order to forget about the pain. Of course, just say to yourself: “Come on, pull yourself together, wimp. Don’t whine” – it won’t work. But learning to immerse yourself in something can be learned. The pain really goes away.

– On the pain scale, how severe are phantom pains?

– There are several scales for assessing pain. If we consider it on a 10-point scale, then this is a fairly high level of pain - 7-8 points, no less. You cannot rate your pain at 10 points; this is the level of impossible pain, on the verge of death. If a person rates phantom pain at 10 points, then you need to immediately think about his mental state. People may say that it hurts 10 points not because it hurts a lot, but because they are very worried. Mental, or, more precisely, psychogenic pain is also pain, but it must be dealt with separately.

– They say that phantom pain has a premonition?

– Just as epilepsy can be with or without an aura, phantom pain can sometimes be with or without an aura. The person feels that something is about to happen. The nature of this phenomenon is not completely clear. There is a point of view that the aura is the beginning of phantom pain, its beginning to increase, and the attack itself will come later.

– How effective is the method of mirror therapy, which is often talked about?

- This is true effective method. It is performed as follows: the mirror is placed parallel to the existing limb, the person sees the reflection instead of the missing limb. As he moves it, he thinks about how it feels like a lost limb is moving. If you do this regularly, with a certain endurance, with a certain exposure, and think intensively about all this, then you can get good result– the pain will become less. Although there will be no motor and sensory response, the brain receives visual information and the pain program is confused, the focus is suppressed. But, unfortunately, it is not always possible to reduce pain in this way. Initially, even before the drugs, we prescribe it - this is the best thing that can be done without drugs. It can be used just at the moment of an attack of phantom pain.

– What other treatment is effective?

– Firstly, medication. At the first stage, special psychotropic drugs are used that suppress pathological activity. They are classified as anticonvulsants - here, too, a parallel can be drawn with epilepsy. Antidepressants are also prescribed when the psycho-emotional factor prevails. Analgesics do not affect phantom pain. At best, there is a placebo effect. The fact is that any analgesics, even narcotic ones, do not affect any damage to the nervous system. This is the problem of phantom pain; with its dissimilarity from other types of pain, it frightens doctors - neurologists, traumatologists, and rehabilitation specialists. To treat phantom pain, you need to be an algologist. If a person right now has unbearable pain from a missing limb, and there is no medicine at home, then, of course, an ambulance should be called. But it is advisable that emergency doctors know the specifics of treating phantom pain. Ketonal and morphine, which they have in their medicine cabinet, will, at best, put a person to sleep for some time. In this case, there should be anticonvulsants and antidepressants.

Secondly, neurostimulation of the cerebral cortex. It is for those cases when none of the above works. This is exactly what we, as surgical pain management specialists, do. There are two types of it: magnetic stimulation and surgical method with implantation of an electrode into the human brain.

– How does magnetic stimulation work?

– It is carried out in a hospital setting, there are also mobile devices. It is performed as follows: a magnetic coil is installed over the area of ​​the brain with a focus of pathological activity - for the left leg or arm, this will be the zone in the right hemisphere of the brain - and rhythmic magnetic stimulation is performed using a special device. It lasts several minutes. At this time, the patient may feel twitching, tingling, and vibration in the missing limb. After this, the patient should feel a decrease in pain at least for some time. For some it lasts 5 minutes, for others half an hour, for others several hours. It is repeated. And if the pain decreases with each repetition, then stimulation can be used as a treatment. It must be used before surgery. Unfortunately, it often turns out to be ineffective - the pain quickly returns. But if there is an effect, then the effect of the surgical method can be predicted.

– How is surgical stimulation performed?

– A trepanation of the skull is performed (a small incision in the bone) and over the membrane of the brain (the membrane of the brain is not opened), where the limb is located, special electrodes with contacts, flat plates, are installed. The wires are brought out under the skin, and the skull fragment is returned to its place. A special navigation program allows you to install the electrodes where you need them: on the screen we see an image of the brain area where the electrodes should be placed. The wires are passed through the back of the head, neck, into the subclavian region, where, using a small incision in the skin, a pulse generator is installed, which in the future autonomously generates pulses, sending them to the cerebral cortex.

Although this is called stimulation, in fact we are talking about the suppression of pathological activity due to certain electrical impulses at the site of phantom pain. As a result, the pain becomes less pronounced, attacks occur less frequently and the person can return to full life. The person also takes medications in lower doses than before the stimulator was installed.

– Who is the installation of such a stimulator indicated for?

– When deciding whether a surgical method is suitable for a person, a psychiatrist is involved. His task is to find out how pronounced the psycho-emotional factor of this pain is in a person. It happens that a person expresses suffering in this way due to the absence of a limb, which he transforms into pain, but in fact there is no phantom pain. If a person cannot otherwise express or find an internal subconscious justification for his condition, then he can find solace in this pain, he clings to it, does not want to part with it. In this case, it is difficult to help: you can mistakenly administer a stimulant, which will not produce any effect. That is why, with the help of psychiatrists and psychoneurologists, we can determine how pronounced the psychoemotional (psychogenic) component of pain is and how neurogenic.

This method is expensive. Depending on the price of the stimulator, such an operation costs from 2000-3000 to several tens of thousands of dollars. But here in Russia it is done free of charge for citizens of the country. If a person needs a stimulant, he receives a federal quota, which covers all expenses.

However, it is important to note that this method is not a panacea. First, it is suitable for no more than 20% of patients experiencing phantom pain. Secondly, unfortunately, it also does not guarantee a complete cure for pain.

– You mentioned a psychiatrist. That is, a psychologist is not helpful in working with phantom pain?

– A psychologist can also help. The following techniques are effective: auto-training, hypnosis. There are also techniques that a competent psychotherapist can select. He can even help much more than a neurologist who will prescribe steroids and analgesics.

– Is there anything important on the topic that I didn’t ask you about?

– In resistant cases, when complex treatment does not produce an effect, you should not perform operations on the stump, because no operations on the stump remove phantom pain. This came to us from the USSR, when they tried to excise the stump, hide the nerve either in the bone or somewhere else, supposedly to get rid of the phantom. It makes sense to operate on the stump when it is impossible to touch the stump due to pain - most likely, we are talking about a neuroma, a thickening of the end of the cut nerve. But this is a different pain, a stump pain. And I would like to emphasize once again that the treatment of neurogenic pain, and not only phantom pain, should be carried out only by a pain specialist - an algologist. Not to be confused with an algologist - a specialist in the study of algae.

The science of algology and algologists have existed all over the world for a long time. Almost any hospital must have a pain treatment department, or, as they are also called, a pain management department - “Pain Management Department”. The bottom line is that, regardless of primary specialization (neurologist, anesthesiologist, surgeon, neurosurgeon, etc.), after undergoing special training in algology, the doctor acquires the necessary knowledge to diagnose and treat severe pain syndromes. So, a neurologist will certainly cope with pain due to radiculopathy due to “osteochondrosis” of the spine, which in most cases will go away without any medications, but, as a rule, most neurologists without special training find it difficult not only to treat, but also to make a differentiated diagnosis between neuralgia and neuropathy of any nerve. We simply need to create a separate specialty and create a school of algology if we want our patients to receive adequate and timely help to relieve their suffering.

What is it like to live with phantom pain?

- I I have been on disability since 1992 after a leg amputation. After a car accident on the Almaty-Balkhash highway, unfortunately, I was taken to a rural hospital. There they amputated my leg, simultaneously causing a Pseudomonas aeruginosa infection (as a consequence, gangrene and general sepsis) and not noticing the condition of a fat embolism (my blood vessels were clogged in my lungs, kidneys and brain; I actually became a vegetable: I couldn’t sit, I didn’t have held head, arms, legs). Why the air ambulance didn’t immediately take me to Almaty, I don’t know. After the amputation, on the second day, through the efforts of my mother and husband, I was transported by ambulance to Almaty, to city clinical hospital No. 4. It was there that my relatives learned the truth about my condition from highly qualified specialists. By the way, regarding fat embolism: when I received disability, the VTEK doctors refused to believe that I survived such a condition - the mortality rate for such a lesion is very high.

I spent two months in intensive care in a state of extreme severity. The health workers told my mother to prepare for my departure. Yakov Natanovich KATS, a brilliant doctor and surgeon, worked with me; he now lives in Israel. He said: “You will live, I don’t know what I will do, but I will get you out. You will still dance with me!” (Looking ahead, I’ll say that I dance, skate, ride horses, and even jumped with a parachute). He put together an intensive recovery program: among other treatments, acupuncture, a pressure chamber (3-4 hours a day), hemosorption - laser blood purification. To make the context clear, in the early 1990s hospitals often didn’t even have bandages. Yakov Natanovich did the almost impossible!

After being transferred to the department, the pain attacks were stopped with strong narcotic substances - this is how my addiction began. I dealt with it myself in about two months with an effort of will - there were no psychologists then, there was nowhere to wait for help. Due to constant bandaging of the stump twice a day, my stump was the size of a gramophone trumpet and the color was black, blue, and green. The green areas are necrotic, dead, that is, they appeared where there was the greatest accumulation of nerve endings. They were cut off under anesthesia. Or the entire damaged area was covered with powder salicylic acid– it was hot, it burned, but it burned away the necrosis.

A correctly formed stump after a competently performed operation does not hurt in itself.

But in recent years Well-formed stumps are extremely rare. I have seen in many young people with primary dentures that their stump looks like a cauliflower. The stump should be smooth, covered with a skin flap, and formed. When the stump was formed incorrectly, incorrectly covered with a skin flap, when the scar is pulled inward or the stump looks like cauliflower, then it is simply unrealistic to walk on such a stump - this pain is incomparable. Of course, there is also pain during prosthetics: standing on a prosthesis for the first time is always unbearably painful, no matter in which area of ​​the leg the amputation was performed. The fact is that the skin in those areas of the lower limb is not adapted to the load or friction. The foot is adapted, but everything higher is not.

I am glad that back in the late 1990s the state began to pay us for German Otto Bock prostheses; we were able to feel the comfort of silicone stockings made by them. Yes, they are expensive, and we pay 50% ourselves, but they cannot be compared with what we had before. We put on ordinary tights, a soft terry sock on top, inserted our foot into the socket of the prosthesis and walked. The slightest wrinkle, hair, crumb - they washed their feet until they hurt. Why am I going into so much detail? Because the longer you go without silicone, the stronger, according to my observations, are the phantom pains you will have throughout your life. There are happy people who never have phantom pain. There are those for whom they last six months after amputation. There are people who don't get them as often as I do. And there are people who have it even more often – several times every day.

While they were giving me pain relief, I didn’t know that phantom pain even existed.

And when I “jumped off drugs,” I met them. They occur in a person after amputation of a limb; they may still be on the stump that has not healed after amputation. The doctors said that we had to learn to cope, we had to be patient, and they injected us with painkillers. Over time, I learned which drugs work and which don’t, in which situations phantom pain occurs and in which it doesn’t, and what to avoid. But for the entire 24 years that I have been without a leg, I have been living with phantom pain. They visit me quite often - sometimes twice a week, sometimes five times, it all depends on my emotional and physical condition. The emotional factor, as a rule, is more important, but it happens that the phantom is triggered by a physiological factor: you are overexerted, overtired, experienced acute physical pain - for example, you hit your elbow or a tooth was pulled out.

What’s bad about phantom pain is that it doesn’t come immediately, it takes a certain period of time, from several hours to 2-3 days. And, as a rule, it occurs at night, from 2 am to 6 am. But it happens in broad daylight. If I’m really freaking out, it can start in 30-60 minutes. Whether the limb is at rest or not is absolutely unimportant. True, from my own experience, when your leg is in a prosthesis, you press it harder - and it seems to become easier. Or when you walk, your leg moves involuntarily and it also becomes easier. Approximately the same mechanics are inherent in the symmetrical compression method - by pressing on both legs at the same time in the same places, you can relieve pain. The media and films have awarded phantom pains with an aura of romance and mystery. In fact, there is no romance in this.

A phantom is an attack of very severe pain.

Imagine, thumb the legs are torn off with hot iron pincers, and then a sharp hot nail is driven in there and they begin to pick at the inside. The pain changes, it does not subside over time, and then continues to increase. This is an acute, wrenching pain - attacks with a frequency of 20-30 minutes, then they intensify, turning into one constant, endless pain. You feel like your head is going to explode. Another comparison: all your teeth and ears hurt at the same time, and your nails are pulled out. If you don't take action, it can last for days. There are also hidden phantom pains. You just feel a leg or an arm, an organ. It’s as if you can move your fingers, feet or hand that aren’t there. This is also a phantom, but not pain. The amputated limb may also begin to itch - this is very debilitating because it can last for several days.

When I have such pain that I cannot cope with, for example, I woke up at night from unbearable pain, then I call ambulance. Doctors come and give a tramadol injection, then they wait: if it helps you, then good, they leave. But if it doesn’t help, then they give a second injection of tramadol. And this is a very toxic drug. If two injections of tramadol do not help, then they inject something stronger. Antispasmodics help me in everyday life. If I feel a phantom approaching, I drink an antispasmodic. Analgesics don't help at all. Sedatives They also don’t help - the only thing is that if you have phantom pain due to emotional reasons, then it can help, but not always.

Another point: when you are busy with something, working enthusiastically or doing something around the house, phantom pain is easier to bear. I have no time to notice her, and she retreats. I read a lot of scientific literature on this topic, tried many methods, including going to Moscow for magnetic stimulation. I did not consider the option of neural stimulation, because this is craniotomy and after such operations they give the first group of disability.

People deal with phantom pain differently. For many years I have been communicating with patients of the Almaty branch of the Republican Prosthetic and Orthopedic Plant JSC, where I also wear prosthetics (detailed material about how the work of the Republican Prosthetic and Orthopedic Center JSC works was published in Health Expert No. 21, November 2016 year). People cannot stand phantom pain and, as a rule, start drinking alcohol. They say that because of this, some nerve endings and receptors are dulled, and there is an effect on the central nervous system and they feel better. There are people who become injection drug addicts. However, these methods of “pain relief” are the path to degradation.

Still the most effective method of treating phantom pain is the mirror method.

It is performed like this: they sit you down and put a mirror between your legs. You look at your healthy leg, and in the mirror you see its reflection - the brain perceives it as a lost limb. You move your leg, you move your stump and it looks like both your legs are healthy. Essentially, this is a trick of the brain. The method must be used quite often. Once a month, once a week or every day - I can’t say, because everything is very individual. At one time I also used this method, but now I cope with massage, prevention, swimming and the right emotional mood. If you can handle yourself, then you can handle anything.

Previously, there was a barbaric method of dealing with phantom pain - they cut out the nerve. But then, thank God, they abandoned it, proving its ineffectiveness. The fact is that pain is always an impulse from the source of pain in the limb to the brain. It was believed that if this connection was cut, there would be no pain. I have seen many adult Afghan men who have repeatedly gone through this procedure. Everything in our body is duplicated. Therefore, if you remove one channel, the pulse will be triggered on another channel.

Phantom pain has a so-called aura - a premonition that pain will soon appear.

Personally, I have increasing tension in the back of my head, above the back of my head - it looks like discomfort, as if I didn’t get enough sleep. Then the pain is localized right here - I understand that phantom pain will soon begin. I lived with this for 24 years, but people who just had it happen cannot track these moments; it is very difficult for them. It is very important that at the moment when you are deprived of a limb, there is a competent specialist, a psychologist or someone else nearby who will tell and explain. We do not have such a support mechanism in Kazakhstan. I don’t know what the reason is - no funding or no specialists. I didn’t find such a specialist for myself either, having learned to help myself. And I often share my experience with patients at the prosthetic factory.

It happens that friends invite me to the hospital to see people who have just had their leg/arm cut off. I tell them that the stump needs to be prepared for prosthetics; a massage is required even before the sutures are removed - then the phantom pain can be much weaker. I also talk about life after prosthetics, because the emotional component in this matter is very important. For me, the loss of a leg is just a loss of a leg, but for some it is insurmountable, they are ready to die and die. There was a case with a 35-year-old woman, she was in the hospital with me. She stopped going out into the fresh air, turned her face to the wall and decided that no one needed her. As a result, she died two weeks later. She could not cope with the loss of her leg. She really needed a good psychologist at that moment.

Phantom pain is always easier to prevent.

I'll say a banal phrase now, but we must lead healthy image life. It's not just a matter of giving up cigarettes and alcohol, although smoking can be one of the provoking factors - when we inhale, vasospasm occurs. I noticed that Paralympic athletes or those who are actively and regularly involved in fitness, swimming, and walking a lot, have phantom pain to a minimum.

It is very important to undergo a massage course twice a year, not a massage of the stump or cervical-collar area, but a massage of the whole body - this is a very good relaxing procedure. In general, we need to be very calm about everything that happens around us. We can all control ourselves. If you don’t want to put effort into yourself and react to everything emotionally, then phantom pain will always be with you. As for whether prayers and meditation help, I don’t know. For prayer to help, you need to deeply believe, and we have few deep believers. However, there was a case in my life when a phantom found me far outside the city, there was no painkiller, nothing. I prayed for about 5 hours, and the pain went away.

Today, as before, phantom pain is a mystery not behind 7, but 107 seals - the mechanisms are still not solved, there are no cure methods.

In the 1990s, I was lucky enough to meet the director of the Institute of the Human Brain of the Russian Academy of Sciences, Natalya Petrovna BEKHTEREVA. She was a brilliant neurophysiologist. We met by chance and talked for 40 minutes. I started asking her about everything that happened to me, including about phantom pain. She said that everything is in my head and if I learn to control my head, I can do everything and cope with everything. Jesus Christ also said that if you have faith the size of a mustard seed, you will move mountains. This is true. I am a living example, because I was able to fully recover from a fat embolism and after amputation and I lead a full life, I also help others, I put them on their feet. There are no problems - there is our attitude towards them!

After amputation of limbs (and not only them, but also organs), patients very often experience a conflict syndrome that is incomprehensible in many respects: the brain retains information about the removed part of the body, and the person still feels it, as if it remained in place. But the eyes, as well as attempts to take something with a distant hand, immediately return you to harsh reality. And when the amputated organ is forgotten, it suddenly reminds itself and begins to hurt. Such pains are called phantom pains. What is it and why do phantom pains occur after limb amputation?

The limb is amputated, but it continues to hurt

The nature of phantom pain after amputation of a leg or arm has not yet been clarified. There are a number of theories put forward at different times, with each subsequent hypothesis refuting the previous one. In this regard, it is extremely difficult to treat such a problem, and treatment is more concerned with psychological problems.

• It has been noted that the phantom predominates when the upper limb is removed, and that it is more pronounced in the elderly, as well as in those who suddenly suffered this misfortune (apparently this is why this syndrome is often associated with the stress that inevitably occurs during amputation).
• They also discovered the presence of phantom pain even in persons with congenital absence of limbs, which suggested a genetic cause of this phenomenon.
• Phantom pain can occur during the removal of a tooth, eye, mammary gland, or vertebrogenic surgery affecting the peripheral nerve.

For a long time the disease was classified as a neuropathy, and attempts were made to treat it with appropriate methods, but such treatment did not help get rid of the obsessive pain phantom. And this is not surprising, since phantom pain is a central pain syndrome directly related to the brain.

Basic theories of phantom pain

Neuroma theory

Initially, it was believed that a neuroma, which forms at the site of nerve interruption on the amputated limb, is to blame for the occurrence of a phantom:

• The afferent (sensitive) pathways leading from the remote limb to the central nervous system are disrupted.
• Protein ion transport channels are blocked, thanks to which sodium, potassium and other impulse-transmitting ions are delivered through the cell membrane.
• Along the edges of the stump, new cells are formed that interact with ion channels - as a result of the discharge of these channels, phantom pain occurs.

The neuroma theory is supported by the positive results of treating phantom pain with ion channel blocking drugs. What was against it was the fact that removal of the neuroma did not lead to the cessation of pain, but rather the opposite: a new source of phantom appeared - the operated stump.

Neural network theory

Ronald Melzack suggested that subjective painful sensations, coming from a limb that no longer exists, are caused by a response signal emanating from a complex neural network - nodes located between the thalamus and the cerebral cortex (gm), the cortex and the limbic (circular) system of the brain surrounding the thalamus (it includes structures g . m, responsible for memory, smell, emotions, sensations, etc.). He called this network, connected to all senses, the neuromatrix.

According to Melzack's theory, a phantom appears due to a malfunction of the thalamic system and a disordered neurohumoral regulation, which is why somatic sensory impulses from the amputated organ continue to flow into the neuromatrix.

The fact that phantom pain is also possible in people with congenital absence of one or another limb or organ was explained by Melzack by genetic factors.

Body schema theory by Ramachandran and other scientists

Indian neurologist Ramachandran suggested that from birth in every person, a unique body diagram is formed in the cerebral cortex (in the postcentral gyrus), that is, the brain, as it were, creates a model of the body in the cortex, with all the limbs, organs, systems and interactions between them.

When a limb or organ is removed, the body diagram in the brain is disrupted: a lack of sensory signals occurs in the central gyrus of the cortex, and it begins to perceive a signal from a neighboring area located near the center of the removed organ as a signal from this organ, which manifests itself in phantom pain.

The hypothesis was confirmed by the occurrence of pain in the amputated arm and the activation of the signal in the area of ​​the postcentral gyrus of the cortex corresponding to the arm on the MR encephalogram, when the patient began to rub or pinch the skin of the face (as is known, the centers that process sensory signals from upper limbs and faces, located in the cortex of the g.m. nearby.).

However, later scientist Makin explained the theory of the body map and its role in the occurrence of phantom pain by changes occurring in the areas of the cerebral cortex responsible for the removed limb and the areas bordering them. At the same time, she also conducted experiments using MRI: experiments with attempts to move an amputated limb showed activation in the cortex of the brain only in the region of this limb, and when participants were asked to move their lips during the experiment, the brain tomogram did not reflect any changes in this area .

Another scientist, Simmel, added the following observations to Ramachandran's body map theory:

• Experience and skills play a large role in the formation of phantom sensations, since pain occurred after removal only in those who managed to master the removed limb.
• The longer the experience of using an amputated arm or leg, the stronger the manifestation of phantom sensations turned out to be (therefore they are always sharper and longer in an elderly person).
• Pain occurs as a result of the sudden deprivation of a limb: their gradual destruction does not lead to phantom pain (Simmel was helped to come to this conclusion by observing lepers in whom the disease led to ugly deformations of the fingers).

Proprioceptive theory

A number of scientists (Sharon, Weeks, Gentili, Harris) have put forward another completely reasonable theory that links phantom pain with the proprioceptive sensitivity of the brain, thanks to which we have developed a spatial sense of the body, and we are able to move freely, without thinking about how exactly we need to do things. every movement. Proprioceptive memory remembers and associates the position of each member of the body.

Phantom pain occurs due to a conflict between proprioceptive memory (the brain retains a spatial sense of the amputated limb) and the visual center (the eyes do not see the removed limb). The theory is confirmed by the fact that patients most often feel the removed arm or leg in the position in which it was before the amputation.

But an unambiguous and firm answer to the question of why phantom pain occurs in amputated limbs has still not been obtained.

Symptoms of phantom pain

The nature of pain from a phantom can be the same as from a real limb:

• The pain can be dull, pulling, sharp, throbbing, burning, convulsive, similar to an electric discharge.
• When you try to move a ghost limb, the pain sign intensifies.
• The syndrome can occur when the weather changes or after stress.
• The nature of the sensation of a non-existent limb may be different: the patient may feel it abnormally enlarged, swollen, or, on the contrary, shrunken and atrophied.
• Over time, the phantom pain may gradually calm down and finally stop. However, there are cases when it does not go away even after decades.

Treatment of phantom pain

Conventional methods of pain relief (analgesics, local anesthesia, blockade of nerve pathways) are ineffective for phantom pain.

Phantom sensations must be treated with antidepressants, psychotherapy, hypnosis, and acupuncture. Non-standard techniques are also used, for example, biofeedback training based on biofeedback.

Biofeedback training for phantom limbs

The biofeedback method is based on this:

• With the help of various sensors and a computer, a complete picture of what is happening in the patient’s body during phantom pain is created, about which the patient is informed in detail by the doctor.
• Changes in physiological processes during a phantom are mainly related to blood circulation, muscle tension in the stump (it often precedes pain) and psychological factors.
• For convulsive pain, surface electromyography is used, for burning pain, temperature biofeedback training is used, simultaneously with a psychotherapeutic session.
• The doctor finds out what factors could lead to the pain, draws the patient’s attention to them, and then the patient consciously tries to eliminate them from his life.

Mirror therapy

Mirror therapy, invented by Ramachandran, is also used in the treatment of phantom limbs.