What Are the Different Kinds of Leg Amputations?

There is no similar disease name in traditional Chinese medicine. Most people think that it is caused by traumatic cutting, phlegm, stasis, and blood stasis, blocking the meridians, dying of heart and liver, dysfunction of the brain, and imbalance of the soul.

Phantom limb pain, also called limb hallucination pain, means that the patient feels that the severed limb is still there, and pain occurs there. Pain often occurs at the distal end of the severed limb, and there are many types of pain, such as electric shock, cut, tear, or burn. Presented with persistent pain and exacerbations. Various medications are often ineffective. There is no unified opinion on the principle of phantom limb pain, and Western medicine lacks effective treatments.

Pathogenesis of phantom limb pain

The first report of acupuncture treatment of phantom limb pain, seen in 1959 [1], is a case of phantom limb pain after amputation. During the sixty or seventy years of research on acupuncture anesthesia and menstrual dysfunction, people found that stimulating the stump of the limb of patients with amputation pain can make the needle feel to the missing part [2]. However, there are few articles on acupuncture to treat this condition. Since the 1980s, there have been many pieces of clinical data. Although the number of cases has not been accumulated, it is basically confirmed that acupuncture has a good effect. Of course, it is still necessary to further explore more effective acupuncture methods and explore their treatment mechanism.

According to clinical reports, more than 50% of patients with amputees have phantom limb pain after surgery. [1,2] However, there is no effective means to relieve phantom limb pain. In recent years, preliminary research in basic medicine and clinical medicine has shown that there is a close relationship between phantom limb pain and "cortical reorganization" [3-8], which provides new ideas for clinical relief of phantom limb pain.

Phantom limb pain amputation and cerebral cortical function reorganization

In the past, it has been thought that the morphological structure and functional division of the cerebral cortex of mammals in adulthood are relatively stable. And recent research results have a new understanding of this. When the median nerve of the adult monkey is cut off for 9 months, the part of the cortex somatic sensory area (SI) that originally felt the median nerve afferent area is transformed into a skin afferent signal adjacent to the cortex that is cut off from the innervation of the innervation. The division of the adult monkey's cerebral cortex is not absolutely constant. In other words, the somatic afferent system in adulthood is likely to have a considerable degree of functional reorganization. Another report showed that [9,10] A monkey with C2 to T4 spinal nerve posterior root resection for 12 years found that the boundary line between the face and the hand representative area of the somatosensory area of the contralateral cerebral cortex was compared with that of the injured cerebral cortex. (face-hand border) Move 10 ~ 14cm to the midline. Functional reorganization may occur in the cerebral cortex after removing peripheral sensory afferents, which has been fully confirmed in animal experiments. [11,12] In addition, the use of non-invasive magnetic resonance imaging (non-invasive magnetic resonance imaging) has revealed the reorganization of cerebral cortex function after amputation in humans. After the amputation of an adult, the facial representative area in the somatosensory area of the contralateral cerebral cortex enlarges, and extends to the midline direction to the representative area of the amputated hand. Using technology, the phenomenon of functional reorganization of the cerebral cortex similar to amputation has been verified. [4 ~ 6,10,11] Therefore, amputation of human beings in adulthood can still lead to considerable reorganization of cerebral cortex function. So what is the physiological significance of functionally reorganized cerebral cortex? In connection with the phenomenon of phantom limb pain that often occurs after amputation, is cerebral cerebral cortical function reorganization related to the formation of phantom limb pain?

Cerebral cortical function reorganization and phantom limb pain

Recent studies have shown that reorganization of cerebral cortex function after amputation is likely to be one of the central mechanisms for phantom limb pain. [5,6] In patients with phantom limb pain after amputation, there is obvious functional reorganization in the cerebral cortex, but in patients without phantom limb pain after amputation, there is no obvious reorganization of cortical function. The degree of cerebral cortical function reorganization is related to the degree of phantom limb pain, and there is no obvious relationship with non-painful phantom limb. [5] If brachial plexus anesthesia is applied to patients with phantom limb pain after upper limb amputation, and those who have phantom limb pain significantly relieved after anesthesia, the boundary between the face and hand sensory representative area after functional recombination (shifted to the midline) During the period of pain relief, it will shift to the outside, that is, it will return to the position before the functional reorganization. After the anesthesia did not relieve phantom limb pain and painless phantom limb sensation, there was no obvious shift of the boundary between the face and the hand representative area before and after anesthesia. This study further suggests that reorganization of cerebral cortex function after amputation may be directly related to the development of phantom limb pain.

Using positron emission tomography (PET) technology, normal humans induced neural activity induced by painful stimulation in the anterior cingulate cortex, but the cortical activity in the somatosensory representative area did not change significantly. It is suggested that the nociceptive area of normal adult cerebral cortex may be different from that of chronic pain (including phantom limb pain).

Phantom limb pain surface trigger zone

After amputation, stimulating certain areas of the body surface may induce phantom limb sensations. These areas are called "trigger zones." People with high amputation of one side of the upper limb and accompanied by phantom limb sensation can find multiple groups of triggering areas on both sides, neck, upper chest and upper back. If the stimulation area is given painful stimulation, it can often cause phantom limb pain. The more obvious the phantom limb pain after amputation, the greater the number of trigger zones that can cause phantom limb pain, and the greater the degree of cerebral cortical function reorganization. [3,5] In this group of subjects with upper limb amputation, no trigger zone was found in the waist, lower abdomen and both lower limbs. The size of the trigger zone can change over time, but there is always a clear correspondence with phantom limbs.

The neural mechanism of phantom limb pain

The specific processes leading to functional reorganization of the cerebral cortex are multifaceted and may exist at different levels in the peripheral and central nervous systems.

In patients with phantom limb pain, the degree of cortical function reorganization becomes smaller after brachial plexus anesthesia, suggesting the importance of peripheral afferent signals in cerebral cortical function reorganization. [6] Functional reorganization also occurs in the somatosensory region of the cerebral cortex in patients with chronic low back pain. [13] shows that the introduction of peripheral noxious stimuli may be one of the main causes of cerebral cortical function reorganization.

The formation mechanism of phantom limb pain may be different at different times after amputation. In the early postoperative period, nociceptive stimuli from damaged nerves are introduced and "unmasked", and some of the functions of "nerve fiber connections" that are normally present may be related to the formation of phantom limb pain and trigger zone in the early stage . Since then, successive changes in plasticity at the central level and persistent nociceptive stimuli from damaged nerves and trigger areas from the body surface may further promote the functional reorganization of the cerebral cortex. When the functional reorganization of the cerebral cortex reaches a certain level, the phenomenon of phantom limb pain and body surface trigger zone that may occur for a long time may be formed.

New trends in clinical nursing of phantom limb pain

In summary, the root cause of phantom limb pain after amputation may be the plasticity change of the central nervous system, especially the functional reorganization of the somatosensory region of the cerebral cortex. Peripheral sensory afferents constitute the main factor affecting the reorganization of cortical function. These findings have certain guiding significance for the clinical nursing work of phantom limb pain.

Psychological and clinical manifestations of phantom limb pain

In the early stage after amputation, the patient was psychologically unable to accept the facts that already existed, and could not get rid of the psychological trauma caused by the injured limb. Amputation makes patients lose their complete self, which is different from ordinary people. As far as basic people are concerned, it can cause inconvenience in life and work, often requiring people to take care and care, and inconvenience people around them. In an increasingly competitive society, there is a crisis of job loss, that is, a society in which patients are deprived of their survival. People with physical disabilities are often in the limelight of the public, and may be given strange looks by the world, bringing mental stress and suffering to patients. This also allows patients to often recall the beautiful scenes of the past and the joy brought by the complete limbs. Therefore, it is difficult for patients to change their original thinking and movement habits after a short period of amputation. A patient with a lower limb amputation always feels residual limb pain after the prosthesis is installed. The reason is that the patient cannot accept the fact that the injured limb still exists. Therefore, psychological disorders are closely related to phantom limb pain.

Phantom limb pain psychological care

Patients often think that the pain of phantom limb pain is caused by residual limbs, and expect local measures to relieve it. In fact, the root cause is the central nervous system. Local treatment of residual limbs, such as taking analgesics, is actually a kind of analgesia that cannot reach the final effect. effect. In order for patients to change their perception of phantom limb pain, they must first accept the fact that they are amputated. Not only do they see the harm and pain caused by injured limbs, they also realize that amputation can save lives. Psychological comfort, care and help in life, combined with the patient's interest, guide them to distract, such as physical activity, entertainment and learning to relieve mental stress, strengthen the training of the limbs is an effective distraction Method. Through training, patients can change their previous exercise habits, re-adapt to life and work, and move towards society. Experiments have shown that when one (some) centers are excited, they have an inhibitory effect on other centers (protecting the pain center), enabling patients to forget their painful memories.

Local care for phantom limb pain and stump

In view of the fact that local nociceptive introduction of residual limbs may promote the reorganization of cortical function and the formation of phantom limb pain, [5,6] and non-noxious stimulation can induce phantom limb pain. We recommend that all types of stump stimulation should be minimized. This is often the case in clinical practice. Patients use local stroking, massage, and heat therapy to temporarily alleviate the degree of phantom limb pain, which actually has little effect. The data in this review suggest that reducing the introduction of various types of stimuli locally (especially early postoperatively) is more conducive to controlling the degree of phantom limb pain. At the same time, it should be pointed out that commonly used analgesics can not reduce the introduction of noxious stimuli from the periphery. It is one of the feasible ways to remind patients to reduce local massage. This measure is an effective method to help patients distract.

Phantom limb pain needs to be discussed in practice

The trigger zone phenomenon of patients with phantom limb pain in the face, neck, upper chest and stump is a question worthy of further investigation. It appears that reducing painful stimulation in the trigger zone is beneficial in reducing phantom limb pain. However, whether certain stimuli can be administered to the body surface to influence the process of cerebral cortical function reorganization after amputation to achieve the purpose of controlling the degree of phantom limb pain remains to be further studied.

According to most people who have undergone amputation, they feel that they have an unreal limb shortly after the amputation. After a few months, nearly 30% of the amputated patients felt phantom limb pain, and nearly 5% complained sadly that they felt The amputated limb was extremely painful. A small number of patients with phantom limb pain can cause or greatly increase this pain even when they touch other parts of the body or emotional disturbances. So far, this phenomenon cannot be explained by the existing physiological knowledge, and cutting the spinal thalamus bundle can not permanently eliminate this phantom pain.

Phantom limb pain treatment

Phantom limb pain body needle plus needle

(A) acupoints

Main point: divided into 2 groups. 1. Fengchi, Fengfu, Four Gods Cong, Shenting, Neiguan, Shenmen. 2. 1/5 on the sensory area (head acupuncture point).

Acupoints: waist ridges, ring jump, Zhibian, Yanglingquan, Zusanli, Fenglong, hanging bell, Taichong.

(II) Governing Law

The main acupuncture points are taken one group at a time, the scalp acupuncture points are taken on the healthy side, and the double points are taken on both sides. The two groups can be used alternately. In addition to the acupoints, the acupoints are taken on both sides, the ring side and the rank side are taken on the affected side, and the remaining points are taken on the healthy side. Take 2 to 3 points each time, alternately. With a 28-inch 1.5-inch needle, pierce and relieve diarrhea after piercing. Needles are not left in Fengfu and Fengchi, and the remaining points are left for 30 minutes. When acupuncture, pay attention to induce the feeling of needle to the thigh, calf or foot, and often enhance the analgesic effect. After inserting the needle to the required depth, switch on the electro-acupuncture instrument. Use a continuous wave with a frequency of 200 times per minute. The current intensity should be tolerable as a degree. Apply electricity for 30 to 40 minutes. If the stump of the affected limb is locally cold, moxa sticks can be used for moxibustion there until the skin becomes flushed. The method should be applied once a day for 3 to 4 weeks.

(Three) evaluation of curative effect

Efficacy criteria: relief: complete disappearance of pain and other symptoms; marked effect: reduction of pain level by more than 50%; effective: reduction of pain level by more than 25%; ineffectiveness: slight or no improvement in pain and other symptoms.

This method mainly treats phantom limb pain in the lower limbs, and a total of 24 cases are treated. Results: 5 cases were relieved, 8 cases were markedly effective, 7 cases were effective, and 4 cases were ineffective.

Phantom limb pain needle

(A) acupoint

Main points: Divided into 2 groups: 1. Ruler, Neiguan, Shoulder Yu, Quchi, Hegu; 2. Ring jump, Yanglingquan, Weizhong, Zusanli, Hangzhong, Yongquan.

Matching points: also divided into 2 groups. 1. Tianquan, Shaohai, Shenmen, Waiguan, Houxi, old-age care; 2. Yinlingquan, Sanyinjiao, Gongsun, Ditch, Chengfu, Kunlun.

(II) Governing Law

Adopt the giant thorn method, that is, take Jianbian acupoints for treatment. Among them: the first group of main and matching points is for upper limb phantom limb pain, and the second group is for lower limb phantom limb pain. The main acupuncture point should be added. The acupuncture point should be slightly downward when acupuncture is applied. After acupuncture is applied, a large amount of lifting or twisting should be applied to spread the acupuncture downward. Leave the needle for 10 minutes. Once a day, 7 eyes is a course of treatment, and the course of treatment is 3 days apart.

(Three) evaluation of curative effect

It has been observed that this method has a better effect on phantom limb pain, and generally can be cured in a course of treatment [5].

Acupuncture needles for phantom limb pain

(A) acupoint

Main point: Shenmen, corresponding point.

Acupoints: subcortical, adrenal.

Correspondence point location: refers to the pain sensitive points found by the missing limb at the corresponding part of the auricle.

(II) Governing Law

The main acupuncture point is used. When the effect is not obvious, add or switch to matching points. Take 1 or 2 points each time. Take the affected side as much as the contralateral or bilateral. After the auricles are routinely and strictly sterilized, a pin-type intradermal needle is inserted with the forceps. When the needle is inserted, it is better that the patient feels pain or bloating. The depth of the needle insertion is to penetrate cartilage without penetrating the opposite skin, and it is fixed with adhesive tape. Ask the patient to press the needle 2 to 3 times a day for 5 to 10 minutes each time. If phantom limb pain occurs, press at any time. Replace once every 3 to 5 days. Caution: During the needle implantation, do not wet or contaminate the auricle to prevent infection. As soon as there is local swelling and pain in the buried needle, you must call your doctor immediately.

(Three) evaluation of curative effect

A total of 13 cases were treated by the above method, which had better analgesic effect on phantom limb pain [6].

main reference

[1] Department of Neuropsychiatry and Department of Traditional Chinese Medicine, Second Military Medical University. Chinese Journal of Neuropsychiatry 1959; : 217.

[2] Ed. Research Progress of Acupuncture. People's Medical Publishing House 1979: 33, Beijing.

[3] Xing Guifang. Acupuncture treatment of 9 patients with phantom limb pain. Journal of Traditional Chinese Medicine 1995; 32: 729.

[4] Xing Guifang. Acupuncture treatment of 15 patients with phantom limb pain. Journal of Beijing University of Traditional Chinese Medicine 1994; 17: 34.

[5] Wang Shengbo, etc. Treatment of phantom limb pain with giant thorn method. Jilin Traditional Chinese Medicine 1986; : 16.

[6] Liu Guiliang. Buried auricular acupuncture needles for limb hallucinations Journal of Guiyang College of Traditional Chinese Medicine 1990; : 36.