Phantom Limb Pain Treatment
Phantom Limb Pain Treatment
The Ramachandran Method and The NLP Practitioner
All amputees and all who work with them know that a phantom limb is essential if an artificial limb is to be used. Dr. Michael Kremer writes: “Its value to the amputee is enormous. I am quite certain that no amputee with an artificial lower limb can walk on it satisfactorily until the body-image, in other words, the phantom, is incorporated into it.”
Thus the disappearance of a phantom limb may be disastrous, and its recovery, its reanimation, a matter of urgency. This may be effected in all sorts of ways: Weir Mitchell describes how, with faradisation of the brachial plexus, a phantom hand, missing for twenty-five years, was suddenly resurrected. One such patient, under my care, describes he must ‘wake up’ his phantom in the mornings: first he flexes the thigh-stump towards him, and then he slaps it sharply – ‘like a baby’s bottom’ – several times. On the fifth or sixth slap the phantom suddenly shoots forth, rekindled, fulgurated, by the peripheral stimulus. Only then can he put on his prosthesis and walk. What other odd methods (one wonders) are used by amputees?
Oliver Sacks The Man Who Mistook His Wife for a Hat
“Phantom limb” pain has been recorded almost as long as people have been losing limbs and surviving. As we can see on the motor cortex, specific areas function to map out specific parts of the body. Losing a part of the body doesn’t necessarily stop the cortex from continuing to “map” the missing part, adding a slight twist to Korzybski`s, “the map is not the territory.”
Whilst it is common to refer to phantom limbs, “phantom” breasts, penis’s, ears and other “phantom” bodily parts have been reported in patients who have undergone removal of these same parts.
Whilst not all amputees will experience phantom limb pain, there is evidence to suggest that the majority will at least initially continue to perceive the body part as still being present in some form.
For example, one patient of mine required a “bed cradle” prior to amputation to raise the bed linen off her painfully ulcerated legs continued to require the “bed cradle” for at least a week post surgery, lest she sees the sheets rest upon her phantom ulcerated leg, causing severe pain.
Previous attempts at eliminating the phantom pains involved surgery to remove another inch or two from the affected limb/stump or even cutting through the relevant nerve root emerging from the spinal cord. These methods are very rarely found to be effective and generally end up with a surgical “game without end” in a manner described by Ramachandran as “chasing the phantom.”
Patients with this pain will generally refer to the pain being in the spatial location of where the limb would have been or may even continue to experience a deterioration of the limb with an accompanying increase in pain. Curiously, the phantom limb may be painless at first only to develop pain as the phantom limb begins to develop contractures, particularly if the limb was paralysed prior to amputation.
As a generalization, there is less likely to be phantom pain following amputation if the patient is given sufficient analgesia for a 1-2 week period prior to the surgery. Conversely, the greater the pain in the period immediately prior to surgery, the greater the pain is likely to be post-surgery.
NLP Case Study.
I was called to see a lady on a medical unit who had suffered a compound fracture of her femur, which has subsequently become grossly infected resulting in necrosis of the limb and necessitating amputation. The injury had occurred whilst as an in-patient in a neighbouring hospital for an unrelated problem and two of the nursing staff were held to be negligent with regards to the incident that precipitated injury. The unfortunate patient had been transferred to a different hospital whilst litigation was pursued. The patient held a considerable amount of hostility towards the staff involved and was devastated by the injury and loss of her leg. She has also suffered a minor left-sided CVA (stroke) secondary to the fractured femur. By the time of contact, the deficits from the CVA had mostly resolved. The patient was continuing to require high doses of morphine for her “phantom limb pain”.
Method: The patient was asked to close her eyes and describe her healthy hand, which was positioned cataleptic in front of her face. The submodalities were elicited and slight changes in submodalities were suggested as a preliminary “trial run” to later change work. The submodalities of a memory from a distant and unpleasant time were elicited and a submodality swish demonstrated. A representation of a good and pleasant occasion was elicited and submodalities elicited and “tweaked” and positive state anchored and reinforced.
Next step, the representation and submodalities of the healthy limb were elicited and compared to that of the hand, which remained cataleptic in its initial position in front of her face. Note that at this point, the session was interrupted by the surgical team on their “rounds” who made a brief examination of the stump and exchanged a brief communication with the patient, who replied normally and to the satisfaction of the surgeons. During this time, the only evidence of trance was the cataleptic hand which did not move and went unnoticed by the surgical team.
Elicitation of the “phantom leg” representation and submodalities provided a shift in state and submodalities were significantly different. This representation was larger, misshapen, confused and full of sounds of screaming. The content of the representation reflected an associated movie of the incident in which the leg was initially fractured. The revulsion expressed by the patient was the appearance of bone through her skin and the hitherto unknown detail that the patient had tumbled from a filled commode and her broken leg had been brought into contact with said contents. This “movie” formed an unpleasant and endlessly playing movie loop.
With this turn of events, the patient was associated into a neutral state and a double dissociation technique used to dissociate her from the traumatic events. With the representation of this event de-potentiated, a submodality and content swish pattern were carried out, swishing the submodalities of the damaged leg for a representation of how the leg/stump would appear once it had fully healed.
This entire procedure, including time for the interruption, lasted approximately 20 minutes.
The patient reported an 80% reduction in her discomfort.
Ramachandran describes an ingenious method for reducing phantom limb pains that reflects his brilliance at working with neurological programming to produce profound change.
He describes in detail the behaviour of phantom limbs that might not necessarily hurt, but will gesture, itch, twitch or even try to pick things up. He also describes that some people’s representations of their limbs don’t actually match what they should be, for example, one patient reported that her phantom arm was about “6 inches too short”.
A common feature is that some people with phantom limbs who find that the limb will gesticulate as they talk. Many people find that sitting on their hands can seriously impede their ability for verbal description. Most of us still gesture when speaking to someone on the telephone. Given the way that the hands and arms are represented on the motor cortex and language centres, this is not surprising. Whilst some people find that their phantom limbs feel and behave as though it is still there, others find that it begins to take on a life of its own, and doesn’t obey what they request it to do.
I placed a coffee cup in front of John and asked him to grab it. Just as he said he was reaching out, I yanked the cup away.
“Ow!” he yelled. “Don’t do that!”
“What’s the matter?”
“Don’t do that,” he repeated. “I had just got my fingers around the cup handle when you pulled it. That really hurts!”
Hold on a minute. I wrench a real cup from phantom fingers and the person yells, ouch! The fingers were illusory, but the pain was real – indeed, so intense that I dared not repeat the experiment.
V.S. Ramachandran Phantoms in the Brain
Like the patient with the bed cradle, visual feedback and expectation appear to play an important role in the phantom limb phenomena. It is this effect that Ramachandran used when he devised his feedback machine consisting of a mirror and a cardboard box.
With the healthy arm through the hole corresponding with the reflective side of the mirror, he manoeuvres his phantom arm through the other hole (be imaginative with this one to help the client do this). Thus now, the client has a reflection of his real arm that, with some manoeuvring, will correspond exactly with the missing limb’s location. This enables the brain of the person to achieve feedback to the motor area of the brain corresponding with the phantom:
Philip rotated his body, shifting his shoulder, to “insert” his lifeless phantom into the box. Then he put his right hand on the other side of the mirror and attempted to make synchronous movements. As he gazed into the mirror, he gasped and then cried out, “Oh, my God! Oh, my God, doctor! This is unbelievable. It’s mind-boggling!” He was jumping up and down like a kid. “My left arm is plugged in again. It’s as if I’m in the past. All these memories from so many years ago are flooding back into my mind. I can move my arm again. I can feel my elbow moving, my wrist moving. It’s all moving again.
Ramachandran asked Philip to close his eyes and Philips phantom arm once again became lifeless until he once again opened his eyes.
Curiously, despite the historical referential experiences that flooded into consciousness, four weeks later following ten minutes a day with the box and mirror, Philip reported that the limb had gone, “all I have now is my phantom fingers and palm dangling from my shoulder.” The pains had significantly reduced (only the fingers still hurt – the rest had gone) and Philip now possessed an altered but more realistic body “image” mapped onto his sensory cortex:
“It’s not clear why his fingers didn’t disappear, but one reason might be that they are over-represented – like the huge lips on the Penfield map – in the somatosensory cortex and may be more difficult to deny.”
Experiments For the NLP Practitioner.
1. Purchase a realistic but fake arm/hand
– Sit at table with one hand resting on the table, the other beneath the table.
– Position the fake arm/hand on the table in the corresponding position as though both hands/arms are resting on the table.
– Have associate tap both real hand that is beneath the table and the fake hand in synchrony as you watch the fake hand.
– Notice how sensations appear to originate from the fake hand/arm.
2. Carry out the same on a naïve associate.
– Once the effect has been achieved for a while, pull out a previously hidden hammer and hit the fake arm/hand.