Search for tag: "amputation"

Interviewer: For patients who have lost a limb, phantom limb pain is a very real and very painful condition. And what exactly is it, and how is it treated?

Today, we're joined by two specialists who really treat this kind of condition. Dr. Colby Hansen is Director of Amputee Program at the Craig H. Neilsen Rehabilitation Hospital, and Spencer Thompson, a doctor of physical therapy and a board-certified specialist in neurological physical therapy specializing in the treatment of amputees.

Now, when we're starting to first kind of understand what phantom limb pain is, why don't we go with that question to begin with? Dr. Hansen, what exactly is phantom pain?

Dr. Hansen: Phantom pain is the perception of pain in a limb that has been amputated. For someone who has lost their leg, they may still feel painful sensations as if they are coming from the missing leg, the missing foot, the missing ankle, etc.

Interviewer: What exactly causes that? And correct me if I'm wrong, there are no nerves there to be creating that pain, are there?

Dr. Hansen: Well, it's a good question. Pain signals obviously have to originate from the site of pain, and then travel through the nervous system up to the spinal cord, and then up to the brain.

And in our brain, we have essentially a map that represents signals that pertain to every part of our body. And so, even though we may have lost a limb, we haven't lost that map in our brain. And so it can still perceive signals going to that part of the brain, which may be then perceived as coming from the missing part of the body.

In addition to that, the residual nerve in the remaining part of the limb that would have gone to that part of the limb is still there, and it can also send signals originating from there up to the brain which can be perceived as pain.

Interviewer: And how severe is this pain?

Dr. Hansen: It's very different from person to person. There are some people who may not feel pain, but they may feel the sensation of their limb. We call that phantom limb sensation. And then there are people who may have very severe phantom limb pain, and then there are going to be those who have perhaps only very mild or very intermittent phantom pain experiences.

Interviewer: I want to shift over to Spencer Thompson. Spencer, when you work with these patients, as an outsider, it's a little confusing, right? If someone has a twisted ankle, a physical therapist works on that twisted ankle, right? In this situation, it seems more that there is a neurological almost perceptual type pain happening. How exactly as a physical therapist do you help patients with this condition?

Dr. Thompson: I think understanding first how frequent it's happening for them gives understanding to how to best treat it. But one of the ways that I've found that's an easy way, that's not medication so it doesn't really have any systemic effects on the patient, is something called mirror therapy.

Like Dr. Hansen talked about, that pathway, that map is already in their brain, and sometimes that system gets ramped up where it feels like . . . sometimes people feel like their foot is twisted or contorted in a certain position, or they get those zaps of pain. Because that part of their leg is missing, what we want to do is train the brain in the sense that that part of their limb actually can move without pain. And the way we do that is with the mirror.

Interviewer: Is it a special mirror?

Dr. Thompson: No. I tell people to just buy a door mirror at Walmart for $15 or whatever. What you do is you put that mirror in between your legs. And you can do this with an arm as well, right? But you want to in a sense block your amputated side. And the mirror is going to show the reflection of the intact limb, whether that's the arm or whether that's the leg.

When I teach this to patients, what I tell them to do is their whole focus needs to be on the reflection of that intact leg, so that reflection is covering the leg, their amputated side. It looks like when they're looking over there . . . Say the left leg is amputated, I have the mirror on that left side, but it's showing the reflection of my right leg in that mirror, so when I'm looking in the mirror, it looks like that's actually my left leg, if that makes sense.

Interviewer: Oh, wow. Okay.

Dr. Thompson: Then, what I do, or what we tell patients . . . I work a lot with more lower limb, so I'll just describe what you do for lower limb, but it could be the same for upper limb type of thing.

I tell them, "I want you to keep your whole focus on that mirror, of that reflection of the intact limb, because we want to train your brain that is there, that it can move without pain." And then I teach them to move that ankle up and down, move it in and out, move it through circles in all directions, spell the alphabet with that ankle, kick the leg in and out, move the hip up and down, in and out. Any type of movement like that that can be moved through a pain-free movement, you're sending signals to the brain that that leg can move without pain.

Interviewer: The leg that is not there?

Dr. Thompson: The leg that is not there, but by looking at that reflection, you're sending input into the brain telling the brain that that leg can move without pain.

You can try it yourself, even if you're not an amputee. It's a little trippy at first. When the patients try it, they're like, "That feels so weird." But it's cool.

The biggest kicker with it is it takes consistency. Any time you're training the brain for something, it takes a lot of repetition, it takes consistency, it takes effort.

There's research out there. There are more research studies that need to be done to continue to prove efficacy of this, but protocols that I recommend is doing it for 5 or 10 minutes every day for 4 to 6 weeks.

And people that I've seen that have committed to that, there's a variety of results. Some people, it doesn't work. Some people, it does.

Some people feel like the edge of their phantom pain is taken off. We call it telescoping. The phantom pain may be on the distal end of their leg, in their foot. But sometimes that pain travels up, so it's not necessarily in their foot. It kind of travels up a little bit, and it's not as intense.

And some people, it helps out quite a bit. Or if they have an intense phantom pain session, they do it, and it just kinds of melts that pain away.

But biggest thing I would say is . . . I talk to people, and I'm like, "Have you tried mirror therapy?" They're like, "Yeah. I tried it, but it didn't work." When I kind of explore a little bit more, I find out that they haven't really done it on a consistent basis. They've tried it four or five times and it didn't really maybe have the effect they wanted, and so they stopped doing it.

And so my biggest thing was if you really want to see if it works, give it a shot, but be consistent with it. Shoot for every day. Put a timer on your phone for five minutes and be consistent with it and see what happens.

Interviewer: Now, Dr. Hansen, I guess I'm just a bit of a layperson here, but a $15 mirror that you can get at a big box store can significantly help with your pain. What exactly is happening, I guess, in the brain, in the nerves, with this therapy to have it work?

Dr. Hansen: Yeah, it's a good question. I think the simplest way to maybe try to conceptualize what's going on here is we have obviously five senses, right? Touch, smell, taste. Vision is one of our strongest senses and drives some of that pathway to that part of the brain represented by that missing limb. I think we can start to replace some of those pain signals going there with healthy, normal-feeling normal movement type of signals going there.

When we can have this visual input that's looking as if we're looking at our missing limb and that it's there, and if we can harness that input, which is very strong, to then do some of those things that Spencer was mentioning, move the phantom limb through the mirror in these different ways and not reconnect but sort of drive some of that pathway to that part of the brain represented by that missing limb, I think we can start to replace some of those pain signals going there with healthy, normal-feeling, normal movement type of signals going there.

Interviewer: Dr. Hansen, say there is a listener who either they themselves have an amputated limb or there's a loved one with an amputated limb, and they are dealing with some of these phantom sensations, phantom pain. Where do they start? Is it a general practitioner, is it a specialist, is it a physical therapist? If they need some help, where do they go?

Dr. Hansen: Good question. I would say the place to go is a high-level rehabilitation center that sees a lot of these complex types of patients. There may be some sort of small community rehab centers that don't see this very often. Usually at bigger centers, not just academic medical centers, although most academic medical centers should have the expertise. I am a rehabilitation physician, but not all rehabilitation physicians do amputee care. Sometimes orthopedic surgeons may do amputee care and do a very good job.

But I would say you start by looking for a large medical center that sees and treats complex rehabilitation types of patients, and then likely you'd be plugged into hopefully an amputee clinic at our institution run by myself as a rehabilitation doctor, but also that incorporates other expertise, like physical therapy or rehabilitation psychology, etc.

Interviewer: Spencer, for a patient who might be dealing with this kind of pain, what is something that you tell either them or their loved ones about what they can expect with working with a physical therapist to treat this condition?

Dr. Thompson: PTs, I think sometimes people think we're just mean people, that we just like to . . . We have this tagline that's "PT stands for pain and torture." I mean, yes, it does take work and sometimes pain, just like working through anything to improve, but we're here as huge advocates for you. We're on your team. PTs, our goal is to help improve your daily function and mobility and to get you back to living life to its fullest.

I would say for patients, give yourself some grace, some compassion. You've been through a lot. Your body has been through some significant changes. Just take a minute and breathe and just acknowledge all that you've been through and all the . . .

I tell all patients that I think the media sometimes does the amputee population a disservice in some aspects, because we see all these Olympians that are doing these amazing things, which is awesome that they are, but people sometimes have this expectation of, "Once I get my prosthetic limb, I'm going to be out running, doing all these amazing things." But the media doesn't also show the phantom limb pain that people experience or just the different trials that they do experience.

And so don't compare yourself to what's shown in the media. Just take it a day at a time. You're going to have good days, you're going to have days that are harder, but just be patient with yourself and just know that day-by-day, it's going to get better.

There is hope. There's help out there. There are great resources. We run an amputee support group here through the University of Utah that I run. There's a company called the Amputee Coalition. There's support out there. You're not alone in this. Talk to other people that get it, talk to professionals that understand, and I think just build your team around you that can help support you, and be patient and give yourself grace in this healing process.

Interviewer: Amputees move prosthetic hands with their thoughts. Up next, on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Interviewer: I'm talking with Dr. Greg Clark, Associate Professor of Bioengineering at the University of Utah. Dr. Clark, I love you work because you're turning what sounds like science fiction into reality. Tell us what you're doing.

Dr. Clark: One example of what we're trying to do is to restore sensory function and motor function back to people who may have lost their hands and long term amputations. So one of the limitations with present prostheses is having enough control over them. The limitation isn't simply in making a hand. That's an engineering challenge for sure, and a very real one. But even if you have that hand, the problem is how does the user control it? Especially if they've lost a lot of their limb, they don't have very many muscles left. So what do they use?
And one idea is to plug that hand right into the user's own nervous system. The brain thinks about moving, just as it normally does with a normal hand. The signals come flying down the nerve, just as they normally would. And if we could wiretap into that nerve, and capture those signals, and translate them, and send them into the artificial hand, the hand would move just as it always did. So one of the beautiful aspects of that approach is that the person doesn't have to learn anything new. They don't have to learn anything counter intuitive.

Interviewer: Well, and I think one of the amazing things is that this has gone beyond the planning stages. I mean, you've actually been able to try parts of this with people, correct?

Dr. Clark: Yes, and we're not the only ones. This actually builds on a pioneering technology and set of studies here done a long time ago, or a decade ago at the University of Utah, by one of my present colleagues Dr. Douglas Hutchinson and Ken Horchin, and others. And they showed that, perhaps surprisingly, the nerves that used to be attached to the hand still work after the hand is lost. And that opens up lots of possibilities both for capturing motor signals, but also talking back to the user and providing sensory experiences.

Interviewer: And that's another interesting aspect of it. Is that the user will not only be able to just move their hand, like you said, they can also feel the hand. What will they be able to feel? Just pressure, or pain, or...?

Dr. Clark: We're hoping to not activate pain, if that's your question. So there's really two important aspects of this, and the best way to think about this is to imagine yourself picking up an object. So imagine picking up, say, a Styrofoam cup filled with water. Close your eyes, reach out, grab that cup. Pick it up, and you know what it is. That's almost self-evident, but think about what it means.
So in our brains, without our even being consciously aware of it, we take all of this type of sensory information and build this mental image. So, although we call it a sense of touch, it's actually conveys lots of information about pressure. That's one example. About vibration when we first hit it. About where our hand is in space. The shape of our hand, both from stretch receptors in our skin, and also from joint receptors that tell us what our joint angle is, and also from muscle receptors that tell us how we're contracting our muscles.

So the two basic types of sensory experience we want to be able to restore are the sense of touch, and the sense of movement so that the person can move his or her own hand through space and know where it is, without having to watch it, but actually feel it. And in the end, we hope that this very rich sensory experience will allow the person to integrate the hand into their own body image, and so the hand will feel like part of themselves.

Interviewer: So you're really sort of the technology behind this ability to move things with their thoughts, and to feel, and...

Dr. Clark: There's many aspects to that technology, and one is actually developing the electrodes, the actually interface that will plug into the nervous system. But if you think about it just a moment more, there's other aspects about that that are very challenging and extraordinarily important. And one reason this is a huge multidisciplinary project is that all of these have to work in order for it to work together.
So for example, suppose I had the perfect electrode technology and I could record the neural signals coming down the nerve, I still have to know how to interpret those, and then send them to the muscle.

So a big part of our project is doing what's called the decode. That is the interpretation of the signals. Another aspect of it is talking back to the nervous system so that the user can understand that the hand has just touched something, or that it's moving through space. And that's called the encode problem. That is sending information into the brain in such a way that the user understands what's out there in the real world. And then there's the whole clinical aspect of it, and then we also have testing the user's ability to use a real physical hand. And so the real benchmark is how well does this prosthetic hand compare with a real biological hand?

Interviewer: This must have an incredible kind of emotional, or psychological impact on the person who's using it.

Dr. Clark: Indeed it does. Today we've done four human subjects. They've been able to control an advanced prosthetic hand on, in virtual realities. That is on a computer screen, and they've also been able to get a sense of touch and movement back from that virtual hand. And it truly is as emotional as you say. One user describes it as, "The loss of hand is like losing a family member, except you're reminded of it every day of your life." And so, as he sat there using it for the first time, it turned out that we provided movement back to him 21 years to the day after he lost his hand, and he could watch it and see it move again.
And one time we began to also provide sensory feedback to it. He could feel his hand, and he described what he had been through. He had been through some 10 surgeries, and after his hand was first damaged they tried to save his thumb, and it didn't quite work. And he went back again, over and over again, 10 times, to try to save his hand. And ultimately it didn't work, and he said, "Just please it out. Take it away." And that day it woke up again for the first time and he could feel it and he could move it, and it was truly overwhelming experience for him. And that's we hope to be able to do. To restore a sense of touch and motion back to individuals, included wounded warriors who have given their, literally their arms for our country, but also we hope this technology to disseminate into the larger community.

Interviewer: What was your reaction when you saw this technology work with a real person?

Dr. Clark: One of the truly poignant aspects is that you do get to know them. We work together with them, and they become truly a part of the team. They tell us what it's like, and what they like and what they don't like, and we try to incorporate that into present work and future designs. And, to be honest, they win your heart as well as your mind. And when you begin to restore some of that sensation and motion back to them, and see how important it is to them, you share a little bit in that joy.

Announcer: Interesting, informative, and all in the name of better health. This is the Scope Health Science Radio.