Article by Greg Morling
Up to 80% of people who have lost an arm or leg often perceive the limb as though it was still there and with this perception there can be pain. This article examines the research and discussion surrounding this fascinating area and outlines how massage therapy may be beneficial in reducing this sometimes frightening and disturbing pain.
All of us, from time to time, meet clients who present with conditions that keep us thinking and reading late into the night as we search for suitable palpatory methodologies that other colleagues may have used to ease the pain or discomfort in their own patients or clients. In 2006, Susan triggered this response for me and initiated my research into how massage therapy may help relieve the pain she was experiencing in her lower left arm that had been amputated five weeks earlier.
Like Susan, some clients may have had an arm amputated because of the presence of a tumour. There are other reasons for amputation; car or bike accidents (trauma), disease, and congenital defects. While the majority of amputations involve the lower limbs I have focused this article, and my research on the amputated upper limb. The reasons for this decision should become clear as possible forms of treatment are discussed. Phantom limb pain can occur immediately following amputation, months, or even years later. In most cases, a phantom arm hangs straight down at the side when the person sits or stands, but it moves in perfect coordination with other limbs during walking – that is it acts like a normal limb. Sometimes, however, the amputee is sure the limb is stuck in some unusual position. One man felt that his phantom arm extended straight out from the shoulder, at a right angle to the body. He therefore turned sideways whenever he passed through doorways, to avoid hitting the wall. Another man slept on his stomach because his phantom limb was bent behind him and made it impossible to sleep on his back.
The eerie and powerful reality of phantom limbs is no more evident than in the classic explanation, from V.S Ramachandran’s book, ‘Phantoms in the Brain’ explained by an 11 year old girl- born without forearms or hands but with vivid phantom hands – of the way she learned to do simple maths at school: She placed her phantom hands on her desk and counted on her out stretched phantom fingers! The first thing that a massage therapist should learn from this 11 year old is the reality of the limb that is not physically present; there is never a phantom limb, rather there is a usually always phantom limb pain.
The sense of reality is also strengthened by the wide range of sensations that a phantom limb can have; pressure, warmth, cold and many different kind of pain are common. A phantom can feel wet. Or it can itch, which can be extremely distressing, although scratching the apparent site of discomfort can sometimes actually relieve the annoyance. Energy workers should take special note of this last fact.
Naturally, of all the sensations in phantom limbs, pain, which as many as 80% of amputees suffer, is the most frightening and disturbing.
A striking feature of phantom limbs, which reinforces the reality still further, is that the phantoms are experienced as part of oneself. That is, clients perceive them as integral parts of the body. Nana Dawson-Andoh, a researcher in this field, describes this as the ‘I-function,’ where the brain retains a very definite sense of self which includes the missing ‘real’ limb. These feelings are sometimes referred to as ‘stump hallucinations,’ is the subjective sensation, not arising from an external stimulus, that an amputated limb is still present.
Amputations are not essential for the occurrence of a phantom. In some accidents, particularly when a rider is thrown off a motorcycle and hits the pavement, the shoulder is wrenched forward so that all the nerves from the arm are ripped from the spinal cord, resulting in brachial plexus avulsion. The resulting phantom occupies the now useless true arm and is usually co-ordinated with it. But if the victim’s eyes are closed, the phantom will remain in its original position when the real arm is moved by someone else. Even though the real flesh and blood arm is incapable of responding to stimulation, the phantom version is usually quite painful. Regrettably, even if the true arm is removed surgically there is no effect on the phantom or on the pain.
Similarly, paraplegics who have no feeling in, or control over, their body below the spinal break – often have phantom legs and other body parts, including genitals. Some paraplegics complain that there legs make continuous cycling movements, producing painful fatigue, even though their legs are lying immobile on the bed.
The powerful impression of a stable, embodied self is taken for granted. But it’s a perception that’s possible only because of the body image created by the brain.
A significant element of that image is a mental map of the body surface, generated by the cortex of the brain using the sensory signals it receives from the skin. Other regions of the cortex control other components, such as the position of the muscles and joints (proprioception), the intention to move, and also the viewing of the body’s movements.
But the brain’s idea of itself can be distorted by the amputation of a limb. Since there is no visual feedback, initiating motor intention does not activate proprioceptors. Over time, phantom limbs are deemed by the amputee to be overflexed, which causes a cramping pain. The question that arises is that if the inconsistency between the intention of the brain and the perception of the body’s action was to be resolved, could the phantom pain be eliminated?
Several theories have been developed over the past 10 years that have attempted to answer this question, most notably, by Ronald Melzack and Vilayanur Ramachandran. Not surprisingly, neither has included a tactile component to possible therapeutic treatment.
The earliest hypothesis regarding the cause of phantom limbs and pain was that of neuromas. These were thought to be nodules comprised of remaining nerves located at the end of the stump. These neuromas presumably continued to generate impulses that travelled up the spinal cord to portions of the thalamus and somasensory domains of the cortex. As a result, treatment involved cutting the nerves just above the neuroma in an attempt to interrupt signalling at each somasensory level. Canadian massage, Anna Kania briefly covered the process of massaging these neuromas at the end of the residual limb and/or the
muscle and soft tissues in a 2004 article published in the Amputee Coalition of America’s Journal. This massage process and other related theories were deemed unsatisfactory because of the fact that the phantom pain always returned, indicating that there was a more complex reason for the persistent phantom limb pain.
Melzack developed the concept of the neuromatrix and the neurosignature. This idea held that the brain contained a neuromatrix or a network of neurons that analyzed the sensory information and allowed the perception of feeling. Then the neurosignature, which consisted of the three primary neural pathways (from the thalamus to the somatosensory cortex, from the reticular formation of brain stem to limbic system, and the parietal lobes) was activated and informed the brain that the detection of sensation were from itself. He also maintained that the neuromatrix, which was essentially a brain map of the body, was pre-wired by genetics. Melzack pointed to his research that showed that people born without a limb could experience phantom pain as well. While they don’t appear to have worked together, V.S. Ramachandran’s description of the little girl’s ‘finger counting’ process seems to give further evidence confirming Melzack’s theory. He postulated that the brain was predisposed to believe that all its limbs existed and so sent out an output signal to it through the neural pathways in the neuromatrix. But because there was no limb, the brain acquired no sensory feedback, and in an attempt to compensate increased the intensity of its signals, which induced the phantom pain. These findings led Melzack to believe that “the body we perceive is in large part built into our brain – it’s not entirely learned. In fact, you do not need the body to feel the body.”
Ramachandran had further answers to the question of phantom limb pain. He was inspired by previous experiments by Michael Merzenich that had studied the homunculus (blueprint representation of the entire body surface, which identifies the locations of sensations felt on the skin) of monkeys. Ramachandran wondered if amputees who complained of phantom pain could be suffering from rearranged body maps, and formulated his cortical remapping theory. He examined the reorganized homunculus of patients with removed limbs. In 1971,
Ashley Montague wrote what I describe as the lost testament for bodyworkers; Touching; The Human Significance of the Skin, in which he also addressed this relationship. The diagrams below represent
The motor homunculus
The sensory homunculus
By using q-tips to brush the face of a patient, Ramachandran was able to produce sensations in their phantom limb. So each time a patient smiled or scratched their face, they stimulated the arm region of the body map causing a sensation in their phantom limb. This part of Ramachandran research has influenced the treatment protocols I suggest a massage therapist might employ therapeutically when working to help eliminate phantom limb pain.
Ramachandran reasoned that in order to move the phantom limb out of discomfort it was necessary to allowing the patient to see the movement they wanted to make with the phantom limb. He developed an ingenious method using mirrors that provided the brain with this visual stimulation. A midvertical sagittal mirror was put in front of the patient, and they placed their remaining limb in an exact mirror-symmetric location opposite to their phantom limb. The reflection the intact limb was optically superimposed on the perceived location of the phantom limb. The graphic shows this rudimentary version of this apparatus (mirror box) that I made and use in my practice. The difference to mirror boxes used by hospitals and rehabilitation centres is the white rectangle at opposite end of the arm hole can be flapped down to providing access to the present limb so it can be viewed as if the amputated limb is present and being massaged. This tactile component enhances the visual impact on the conscious belief that the amputated limb is still present and can be moved and massaged out of the pain, cramp and general discomfort the client may be experiencing.
Ramachandran has been successful with helping patients ease the pain for their phantom limbs using this therapy. His research showed that six of ten patients instantly felt their painful phantom limbs moving, and a few were able to shift their phantom limbs out of painfully awkward positions. One patient even managed to correct his body image, and his phantom limb eventually shrank away to nothing. The tactile component I use adds a further therapeutic process.
Mirror box with massage access flap
The other form of therapy can be administered by both the massage practitioner and the client. The process involves ‘mapping’ the positions on the limb stump that reproduce corresponding sensations on the rearranged homunculus. These sensations occur, from my experience, on the client’s face. By massaging these points I have found that phantom limb pain can be reduced. While both of these massage procedures may be quite useful in reducing phantom limb pain, the tactile mirror box needs the presence of the massage therapist for treatment while the mapping points can be located by the therapists for the client and then a massage protocol can be designed for the individual client to do self-massage.
Diagram showing numbered facial positions that may be massaged to help eliminate hand and arm pain in the phantom limb
This is a very new area for massage therapists and I believe it warrants further research. It also an example of how varied and useful our skills can be as a complement to most conditions and pathologies.