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Coping with my own phantom pain {update: vascular congestion and cold skin: compression really helps}

Cite this article:
Wolf Schweitzer: Technical Below Elbow Amputee Issues - Coping with my own phantom pain {update: vascular congestion and cold skin: compression really helps}; published December 17, 2018, 22:07; URL: https://www.swisswuff.ch/tech/?p=9034.

BibTeX: @MISC{schweitzer_wolf_1571390351, author = {Wolf Schweitzer}, title = {{Technical Below Elbow Amputee Issues - Coping with my own phantom pain {update: vascular congestion and cold skin: compression really helps}}}, month = {December},year = {2018}, url = {https://www.swisswuff.ch/tech/?p=9034}}


I have gone after possible sources of my phantom pain, over the past years, to better cope with it.

There are aspects that I can influence directly, and others that I seem to be able to direct only indirectly.

Phantom pain and stump compression experiences

The first thing my prosthetist said, was, that I would need a compression sleeve to ease my phantom pain. I otherwise do not have circulation issues, that is, venous congestion, etc., and never had so far. But my stump always brimmed with stump pain and, more even, phantom pain, due to what indeed appeared to be also congestion issues. So blood flows into the stump, fluid gets squeezed out into the tissues because venous back flow somehow is less than ideal. A permanently ice cold, wet, burning and entrapped immobile painful phantom hand has always been and still is mine here.

Wearing the compression sock or bandage was painful, too, at first: the wound, the raw bone edges underneath, were entirely painful. One learned fast to distrust not wearing a bandage or compression sleeve, and to distrust not wearing one just as well. Pains would at first just shift, not get better. But after a while, like a year or so, compression became, to a degree - if not too mild or too excessive - a good thing. All the while, my stump was, and is, always red, reddish, red-blue, or gray-blue, hardly ever normal, in skin color. If anything, my stump is mostly if not always a cold ice block.

Pains were a lot worse when my stump was exposed to cold ambient temperatures over a more extended period of time, and a hell of a lot worse once it got all puffy and congested. When I would suffer a greatly puffy stump, such as after having it hang down for a day when walking, hiking, or such, then just warming it up by covering it with a sleeve or warming it up with warm water would make the phantom pain go entirely nuts. It would add hot needles to the pain description above. The only thing that really helped, still helps, is moderate - not mild, not hard - compression. Even a warmer for the stump needed to be slightly tight in order to comfortably work as reducer of discomfort, as negotiator of pain. Then, wearing a bandage or compression sleeve on the stump, or just lying on the stump, when in bed or on a beach, even just elevating it a bit, when sitting on a table or in a chair, would always, still does, make everything better, fast.

There are some theories and tons of other "recipes" for phantom pain [webmd, mayoclinic, wikipedia, https://www.reddit.com/r/amputee/search?q=phantom pain].

Mirror therapy made it considerably worse for me. Interestingly, the idea that phantom pains can be treated by mirror therapy somehow relates to cortical representation of the amputated arm and hand parts, which, in the meantime, have been found to exist regardless of phantom pain severity1)Conference: Hand, Brain and Technology 2018, August 26-31 2018, Monte Verita, Ticino, Switzerland. Title: Obtaining and maintaining cortical hand representation: Evidence from acquired and congenital handlessness. Authors: Daan B Wesselink1,2*, Fiona M.Z. van den Heiligenberg2, Naveed Ejaz3,4, Harriet Dempsey-Jones1,2, Lucilla Cardinali3,5, Aurelie Tarall-Jozwiak6, Jörn Diedrichsen3,4, Tamar R Makin1,2 -- 1 Institute of Cognitive Neuroscience, University College London, London, UK; 2 FMRIB Centre, Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK; 3 Brain and Mind Institute, University of Western Ontario, Canada; 4 Department of Computer Science, University of Western Ontario, Canada 5 Unit for Visually Impaired People, Istituto Italiano di Tecnologia, Genoa, Italy; 6 Queen Mary’s Hospital, London, UK. ----- Abstract: Hand representation in the primary somatosensory cortex (SI) is thought to be shaped and maintained by experience. However, although the fine characteristics of digit topography could be fine-tuned by altered behaviour, overall hand structure is highly stable across people and time [1]. Recently, we even showed that three amputees experiencing highly vivid phantom sensations maintain cortical representation of their missing hand [2]. Still, it is unclear whether this persistence of hand representation depends on experiencing vivid phantom sensation, or whether it is immune to the long-term withdrawal of sensory feedback. In this study, we scanned 18 unilateral amputees (17±10 years since amputation) with varying degrees of phantom sensations, as well as individuals with congenital unilateral limb absence (without phantom sensations) and two-handed controls. Inside a 3T MRI scanner, all participants performed individual digit movements with either hands (missing/non-dominant and intact/dominant hand), as well as a more demanding motor synergy task with their intact hand. Using representational similarity analysis, we interrogated the inter-digit (activity) pattern structure within the SI hand area. The deprived cortex, contralateral to amputees’ missing hand, was activated by movement of both phantom digits and the (ipsilateral) intact hand. In both cases, the representational structure of the hand was stable, as we found no differences between the pattern structure of amputees and that of controls. The deprived cortex was stable in all amputees; this did not depend on perceived phantom sensations (assessed using questionnaires). In contrast, the representation of congenital one-handers’ missing hand was severely diminished. Finally, activation of ipsilateral resources (e.g. amputees’ deprived cortex) during high motor demands alluded to a functional role in (intact) hand motor control. Together, our findings suggest that once cortical organisation is formed, it is remarkably persistent, despite drastic loss of afferent input and lack of sensory experience. References [1] Ejaz, N., Hamada, M., & Diedrichsen, J. (2015) Hand use predicts the structure of representations in sensorimotor cortex. Nat. Neurosci., 18, 1034–1040. [2] Kikkert, S., Kolasinski, J., Jbabdi, S., Tracey, I., Beckmann, C.F., Berg, H.J., & Makin, T.R. (2016) Revealing the neural fingerprints of a missing hand. eLife, 5, e15292. Short Biography Daan Wesselink is a PhD candidate at University of Oxford and works both at the Welcome Centre for Integrative Neuroimaging (Oxford) and the Institute of Cognitive Neuroscience (University College London). He uses MRI to study somatosensory representation in the human cortex. More specifically, his work examines the boundaries of sensorimotor plasticity following changes in input..

Sensory feedback through electrodes placed on my arm would eventually jack up my phantom pains to unprecedented high new levels (link).

Medication would not help, and we tried a lot.

Myoelectric arm use wasn't it, either. When I wear a myoelectric prosthesis that primarily chafes, abrades, blisters up or otherwise damages my stump, pains will be bad also, regardless of the permanent whisper of ivory tower representatives about how I needed to wear a myoelectric prosthesis in order to reduce phantom pain. With the myoelectric arm, that just never seems to play out. With a body powered arm, totally different story. Meanwhile, I have gone behind the parts to make it really work well. And that was not the type of arm the ivory tower had recommended, either.

The only thing that repeatedly, reliably and foreseeably worked was treating venous congestion with compression.

And keeping skin damage down, that was a second great idea one never reads about anywhere.

So it appears that I primarily have a venous congestion problem in my stump. Looking at photos of other people, I see their stump skin colors, and from that, I will assume they also have some varied circulation there. It cannot be just me. My prosthetist had warned me (with too much confidence in his own advice in order for that problem not be be totally ubiquitous). It was, you know, like, he knew.

Congestion assessment: indirectly via skin temperature and pain

I used a RICH METERS GM550 infrared thermometer to obtain skin temperatures in various situations. I also wrote down subjective pain levels.

For whatever it is worth: skin temperature on my stump and phantom pains somewhat correlate.

These diagrams just show the current state of affairs here - my pains go off the (that, actually) chart when the arm gets really cold, and I tried, with frost bite after two days of skiing at minus 15 deg C. I was just not in it for the sake of anecdotal science story telling, to go ahead and document higher pain levels.

For protocol, if ever you do that, write down your subjective relative pain level first, then take the temperature maybe both on the tip and the lateral side of the stump. One could take some white-balance calibrated photos, too, but then, this was not a skin color contest. Also, skin color as such may be difficult to read correctly: when I compress my arm and then remove the sleeve, the skin is relatively red and the stump still takes a while before getting more bloated and puffy and painful again.

The skin temperature on the stump is not the direct determinant of the pain, as far as I would say from experience. Much rather, it is an expression of the degree of congestion, and comparing skin temperatures per se only makes sense if ambient temperatures are about the same. So I took the measurements at normal winter room temperatures around 23-24 deg C here.

So the skin on my stump hardly ever exceeds  27 - 27,5 deg C when sitting around at normal ambient room temperatures. If I want it higher (and I tried using a bandage, see the nifty diagrams), I have to compress it. Then, phantom pains silently walk out the door, not entirely, but almost. And the skin on the stump gets (relatively) warmer from inside out. The effect for less pain has to be improved circulation, however: when I go outside even in winter temperatures and I do wear a compression sleeve, pains are not bad even if the absolute temperature is low. So, just or primarily warming the stump (but not compressing it) is not the effective way for me. Compressing it and then, also, in addition, wearing a warm sleeve over it, that seems to be the way to go for me. Incidentally, the stump being colder than the other arm also correlates with pain levels at least anecdotally, subjectively and roughly: the cooler the stump skin as compared to my left forearm, the higher pain levels tend to be.

The benefit versus cost or effort that I get for compression is fabulous. Stump compression costs (almost) nothing and works like a charm.

Circulation issues as peripheral cause for phantom pain

It is a good question where to place circulation issues within the problems of phantom pain.

While some neurology and psychology fans still believe that stress, anger, feeling depressed, etc. are primary factors that cause extra phantom pain, I would suggest that these factors will also affect circulation. Alternatively, they may also be secondary factors with a primary factor being peripherally boosted and amplified, centrally pre-programmed, neuropathic pain.

So the presence of phantom pain as issue of cortical organisation in relation to deafferentiation sure may be a thing, but it may not be quite as incapacitating per se - it seems to be the addition of skin injury, rashes for examples, the addition of really dry chafed skin, and then surely the addition of congestion due to vascular issues, that  ultimately drives an otherwise acceptable pain level up. To then address the cortical aspects as a first priority seems interesting, but will probably not work very well unless the triggers all go away first.

Personally that is where I would look first: the triggers of phantom pain.

Circulation problems, venous congestion, skin issues such as injuries or rashes, jacking up pre-existing neuropathic pain, is neither glorious nor mysterious, it is not rocket science or neurosurgery, either. It is profane bare bone somatic medicine that is concerned.

Vascular abnormalities have one of the most striking pain- no pain correlation, which coincides with direct experience of my arm. That seems not the case with mirror therapy or the promise that myoelectric or even added sensory feedback technology reduces phantom pain: for me, it does the reverse. It boosts it, makes it worse.

Just, you know, grease and compress the sucker a bit, move it a bit, and distract yourself.

Neuroma as peripheral cause for phantom pain

I may suggest to check for neuroma before going out on a limb to hunt for the more remote ideas and options.

I certainly have at least two large soft subcutaneous thingies that I can massage and then woo hoo. Neuroma are not exactly rocket science, they are as somatic as problems come. But I was not getting any surgery for these [1].

It helps wearing a prosthetic socket and protecting the tender areas from getting hit or pressed upon. If I wake up at night because the suckers brim too hard, I massage them a bit.

Mental versus somatic: go for what may simply work first, see what problems remain later

Conversely, you will never know: if the phantom mechanisms, whatever they are, if the congested stump, or the entrapped scars possibly pulling on neuroma, really hurt an amputee a lot, sure, ultimately it might be their psyche as the only thing you "see" or understand.

Amputation is a perversely pervasive handicap in on particular way: other people get too much to see, visually, as non-disabled spectators that they are, that they will be convinced that they have "seen" everything there is to see. So you see an amputee with a healed stump, washed and cleaned up neatly, and they are stating they are in pain. Nothing else to see though. Surely they must have psychiatric symptoms as true explanation for their pain, right?

These amputees might even be a bit besides themselves with that type of pain, give or take a few years. Then, anyone would be a bit more irritable. Anxious. Depressed. Aggressive even. You may want to try phantom pain for 3-4 years before jumping to other conclusions yourself, I think it would be the perfect eye-opener for a number if people.

So you as a doctor may offer a trinket, a toy, a tool, a thing you thought up to "treat" phantom pain. And to be frank, from my experience, us people with untreated vascular congestion and pain in their stump will find any distraction a great source of relief. Other amputees may go kill themselves. But I will buy myself a bicycle horn, a hot dog, watch re-re-runs of the Muppet Show, and feel the pains slipping away from the center of attention.

Unless you start by seriously investigating treatable, relatively easy to reduce somatic pain causes, I am not sure what you are really after. And with that, phantom pain may really be quite complex only in theory.

What comes of this?

Phantom pain reduction by pragmatically addressing what can be addressed right here and now is something I did and do and it was a good idea that is evidence based

In my instance, I find that phantom pain parts are unequally distributed, making it a quite practical and accessible subject: a major part of my phantom pains are definitely congestion related. That is vulgar, profane, down to earth, tangible and very somatic. Boring, in fact.

When I do something about it by compressing the arm as explained, it is very little effort and usually significant gain. That is also rather profane. No fMRI needed. Just wrap it up. There are practically no side effects or unwarranted effects.

Doctors and researchers forget that such simple vascular problems might be investigated and treated with relatively little drama, and that is a real pity, because they have no clue about how the actual 1-10 scale of my subjective phantom pain feels like.

Sure, a bit of humming neuropathic pain still remains with me after getting rid of too much congestion - but, who cares, once most of the pain is gone? Look at it from the flip side: who really cares if it is not gone.

Phantom pain reduction by pragmatically addressing what can be addressed right here and now is something others probably did not do but we can go check

We should really check for scientific studies of papers investigating central nervous system reasons for phantom pains in amputees that do or do not state that "peripheral somatic pain correlates such as vascular causes for phantom pain and neuromata were sought for and excluded in the study group".

The role of prosthetic suspension and sockets in keeping phantom pains down

  • To alleviate phantom pains well, you want a prosthetic socket. Not some other means of mounting the prosthesis. Sockets are great, they compress the problematic stump soft tissues and they make phantom pains go down. Generally.
  • You want the socket to fit well and be relatively narrow. I would not want a socket to match the scanned surface of my flabby stump. Instead, my prosthetist will perform a cast using tension, and compress the case with his hands to make it tighter in selected areas. You cannot replace interactive work on making a well fitted socket that is more comfortable to wear than to not wear otherwise.
  • You want some means to micro-tune the squeeze and fit every day, like, by using socks or wraps or sleeves, possibly in layers.
  • Ridges at the inside of the socket, protruding electrodes, electrodes as such, anything that causes a friction or electrode burn type rash, must be avoided. Skin rashes that burn, itch or are painful otherwise, are not good for phantom pain. So body powered arms win. Tube gauze and Ohio Willowwood liners win.

Reducing the pain and nuisance level directly impacts whether I want to wear the prosthesis. This directly impacts my body image integration of the prosthetic device.

And there is one other thing!

Because, yeah, there is this one other thing. I once had a right hand that, also, was jocked full of thrombosed veins. Incidentally, I was, also, in a lot of pain then. The blood vessels were screwed up, in other words. Not that was the only problem then, there was also a tumor growing and spreading around. The tissue underneath the skin had appeared gray to me. The whole hand thing was weird. The hand was in screaming pain.

Did anyone think of blood thinners? Or some diagnostic to see whether there was a circulation issue? No. They prescribed antidepressants and said it would be great to take walks in the forest to reduce stress.

Ultimately, it was the pathologist that found these diffusely thrombosed damaged vessels in my then amputated hand. So, you may at least somewhat get a rough idea what I personally think of an assessment of pain that aims for my brain or psyche, before considering what I believe are very, very obvious somatic peripheral reasons that can be treated by known treatments. With phantom pains for me: one bandage, can even be an old washed recycled one, or just wearing the slightly tight prosthetic socket - and tada.

Vascular problems in amputees' residual limbs in connection with phantom pain: evidence base

There are a number of studies that examined just that.

One study of 31 amputated limbs [2], excluding amputations for vascular disease, only containing tumor and trauma as indications for the amputation, reported a high correlation of vascular abnormality and phantom pain. When they then raised body temperature without treating or removing the vascular problems, as my experience above, phantom pains would rise.

"The vascularization of the stumps was found to be profuse, sparse, or of an intermediate form. In some instances, the arteriographic appearances were probably pathologic, consisting in sinuous vessels and persisting venous networks. Pathologic vessels of this type were seen only in patients with pain. In those without any form of discomfort, the vascularization was as a rule sparse-unless skin infection was present or the stump had been treated with skin grafting. Skin temperature measurement showed the skin of the stump to rise in temperature when body temperature was raised in patients with phantom pain, while in those without current phantom pain the skin temperature usually did not rise" [2].

Arteriographic findings in 31 amputated limbs Hypervascularisation including tortuosity of wide vessels Arteriosclerotic occlusion Normal
No pain, skin good 0 1 12
No pain, but infection or skin grafting 4 0 0
Moderate pain 5 1 0
Disabling pain 6 1 0

 

One interesting other paper to recommend is that of Reinhardt (1972) [3].

There, it appears that an overarching pathology seemingly is found in arteriovenous anastomoses. People with these in their stump, regardless of other vessel abnormalities, almost always had complaints of pain in their residual limb. That paper also summarizes that the majority of people without symptoms of phantom pain have normal vasculature in their stump, whereas the majority of people with phantom pains have pathological vasculature in their stump.

The problem of such vascular abnormalities have been studied more extensively in lower leg varicosis [4]. There, congestion, and burning pain, are all there, described in detail.

Activating the stump by using its muscles helps to reduce stasis as well [5, 6].

There is no other way than to regard vascular problems as one highly relevant clear peripheral cause for stump problems.

This, totally, matches my hand(s) on experience with this. This really resonates, makes sense, is very plausible. It has been published repeatedly, there is clear correlation between pathological vascular findings and pains, and treatment while not perfect can be somehow approximated real fast and real cheap.

Studies that examine central nervous reasons for phantom pains mostly do not exclude the possibility of obvious peripheral causes explicitly first

As outlined above, I feel that it might be justified on a clear evidence base, to first address obvious frequent and treatable if not peripheral, profane and simple causes for phantom pains before starting to mess with the obscure depths of brain function.

Clearly, neuroma and vascular issues seem to be at the forefront of what could be considered and addressed before going into the realm of neurobiology of central nervous system issues. One particular study that evaluated phantom pain in fact acknowledged neuroma, while not mentioning vascular issues [7].

It is well known that people with somatic illness have been called crazy before. And I am a bit suspicious of writings where not a very clear statement is made about a "somatic first" approach.

Myoelectric prostheses [8, 9] or TENS (Transcutaneous Electrical Nerve Stimulation) [10, 11] have been identified to reduce phantom pain. A clear separation of activating muscle pump [5] or compressing stump for improved blood flow [2, 3, 6] as bare physical mechanisms to reduce pain was not separated from the prosthesis use. So the effect of a prosthesis on phantom pain may be less specific than assumed.

Magnetic Resonance Imaging (fMRI) was performed to investigate after phantom pains [12, 13, 14]. Some two-point discrimination tests did not study whether underlying muscle contractions to improve blood flow happened or did not happen in their study group, nor were any vascular causes or neuromata taken care of according to the manuscripts that got published [15].

There seems to be no mention of what appear to me rather obvious peripheral causes for phantom pains in the study group in the cited papers: neither neuromata nor vascular issues had been considered in their study groups, leave alone examined, or understood, and from these writings, these possible causes also had definitely not been addressed in any attempt of treatment. It thus remains unclear whether simply activating a forearm muscle pump to improve vascular backflow [6] might be one of the pathophysiological mechanism at work here.

No double blind study using distraction was employed either, further weakening the actual evidence base. More importantly, it also remains unclear whether the unfortunate subjects that did suffer pain ever got involved in actually getting a closer look at possibly more relevant examinations for profane peripheral problems, and attempts for directed treatment.

Off-label use character for almost all things concerning prosthetic arms

Last but not the least, chronic use of a prosthesis with usually frequent if not permanently prevalent skin damages may in itself be rather harmful rather than beneficial inasmuch as phantom pains are concerned. For other skin damage, that is, outside the narrow subject of prosthetic overuse of residual limb characteristics, neuropathic pain due to skin damage itself is a known effect [16]. For amputees, that issue likely was never studied.

If any researcher or developer suggesting that the chronic use of myoelectric prosthesis, based on their own, possibly insufficiently investigated research (see above), clearly recommends a more wide and deep, hard and thorough use of myoelectric prostheses, their recommendation will have to be backed up by reliable, trustworthy and sensible caveats and warnings.

At this moment, we appear to be far away from a situation like that. There are no guarantees. They don't know. They really overlook. If they miss, provide sloppy work, we get the hype and we get the unsolved problems that remain. After 10 years of empty promises, I still wrap my stump to reduce pain and a body powered hook is still the best prosthetic arm for real work. Nothing has changed at the front. The amputee is still the only person truly in charge of their problems, doctors or R&D are far too far away.

The rest remains truly experimental.

In terms of neuropathic pain and exacerbation thereof, currently, with just about all that we do - including stump compression to reduce possibly vascular pathology induced pain, avoidance of direct stump skin stimulation to stay clear of neuroma and other injury, to avoid electrode-induced skin burns, even including the apparent recommendation to use a myoelectric prosthesis more despite massive consequences to direct skin damage [link] - is entirely off-label. Heuristically justified, well educated in the attempts, yes, sometimes.

No prosthetic socket or liner ever was approved for real use across any larger cohort of users that yielded a systematic and unabridged feedback or that was available for systematic deep and thorough evaluation for any actual benefits or side effects of wearing these. No prosthetic use pattern ever was really administered in a well based fashion to see what would happen, and the prosthetic options were not varied sufficiently well to compare actual outcomes in comparison to other off-label attempts to reducing phantom pains, to increasing rubber hand illusion, and so on. At a time where amputees are regarded as generally and permanently unfit to cognitive judgement [link], it is also a rather difficult time for anyone to ask for such studies.

If anything, we may have to realize just how fully stalled the whole attempt to have users wear stuff that was just built but never really tested really is.

What can be regarded as actual evidence base with regard to phantom pains needs to be considered also for recommendations and study designs

  • Vascular problems and congestion are a real problem in amputees and they are highly correlated with particularly severe phantom pains [5, 6]. As long as these are not primarily addressed, also in studies investigating other avenues to examine, quantify or understand and even treat phantom pains, they clearly miss this relevant aspect.
  • A main remedy for vascular congestion (but not causal treatment) is the compression of the stump, that also effectively reduces associated pains well known from addressing similar issues in varicose legs [4]. Compression can be effected through bandage, compression stocking or a narrow prosthetic socket and liner. Conversely, one needs to exclude that effect if one wants to examine specific aspects of other phantom pain treatments.
  • A second way to reduce congestion is the activation of the muscles, that improve the vascular perfusion of the stump [2, 3, 6]. Any study that goes beyond that, and, for example, suggests use of a myoelectric arm to improve phantom pains, wants to separate any specific effect of a myoelectric arm from stump compression (socket, liner) and pure activation of the muscle pump alone.
  • Electrode stimulation seems to have some effect on phantom pain [10, 11] but as stated here (above), necessary to look at the other aspects first. A congested stump may react with even more pain from electrode stimulation alone, or at least that was my own experience across myoelectric control without any socket, together with sensory feedback stimulation (link).

 

[1] G. Riddoch, "Phantom limbs and body shape.," Brain: A Journal of Neurology, 1941.
[Bibtex]
@article{riddoch1941phantom,
  title={Phantom limbs and body shape.},
  author={Riddoch, George},
  journal={Brain: A Journal of Neurology},
  year={1941},
  publisher={Oxford University Press}
}
[2] U. Erikson and A. Hulth, "Circulation of amputation stumps: Arteriography and skin temperature studies," Acta Orthopaedica Scandinavica, vol. 32, iss. 1-4, pp. 159-170, 1962.
[Bibtex]
@article{erikson1962circulation,
  title={Circulation of amputation stumps: Arteriography and skin temperature studies},
  author={Erikson, Uno and Hulth, Anders},
  journal={Acta Orthopaedica Scandinavica},
  volume={32},
  number={1-4},
  pages={159--170},
  year={1962},
  publisher={Taylor \& Francis}
}
[3] K. Reinhardt, "Uber den Wert der Stumpfarteriographie für die Diagnostik und ätiologische Klärung von Stumpfbeschwerden," DMW Deutsche Medizinische Wochenschrift, vol. 97, iss. 07, pp. 249-252, 1972.
[Bibtex]
@article{reinhardt1972wert,
  title={Uber den Wert der Stumpfarteriographie f{\"u}r die Diagnostik und {\"a}tiologische Kl{\"a}rung von Stumpfbeschwerden},
  author={Reinhardt, K},
  journal={DMW Deutsche Medizinische Wochenschrift},
  volume={97},
  number={07},
  pages={249--252},
  year={1972},
  publisher={{\copyright} Georg Thieme Verlag, Stuttgart}
}
[4] H. Haimovici, C. Steinman, and L. H. Caplan, "Role of arteriovenous anastomoses in vascular diseases of the lower extremity.," Annals of Surgery, vol. 164, iss. 6, p. 990, 1966.
[Bibtex]
@article{haimovici1966role,
  title={Role of arteriovenous anastomoses in vascular diseases of the lower extremity.},
  author={Haimovici, Henry and Steinman, CHARLES and Caplan, LAWRENCE H},
  journal={Annals of Surgery},
  volume={164},
  number={6},
  pages={990},
  year={1966},
  publisher={Lippincott, Williams, and Wilkins}
}
[5] R. Dederich, "Plastic treatment of the muscles and bone in amputation surgery," The Journal of Bone and Joint Surgery. British volume, vol. 45, iss. 1, pp. 60-66, 1963.
[Bibtex]
@article{dederich1963plastic,
  title={Plastic treatment of the muscles and bone in amputation surgery},
  author={Dederich, Rolf},
  journal={The Journal of Bone and Joint Surgery. British volume},
  volume={45},
  number={1},
  pages={60--66},
  year={1963},
  publisher={The British Editorial Society of Bone and Joint Surgery}
}
[6] P. D. Faghri, "The effects of neuromuscular stimulation-induced muscle contraction versus elevation on hand edema in CVA patients," Journal of Hand Therapy, vol. 10, iss. 1, pp. 29-34, 1997.
[Bibtex]
@article{faghri1997effects,
  title={The effects of neuromuscular stimulation-induced muscle contraction versus elevation on hand edema in CVA patients},
  author={Faghri, Pouran D},
  journal={Journal of Hand Therapy},
  volume={10},
  number={1},
  pages={29--34},
  year={1997},
  publisher={Elsevier}
}
[7] C. M. Kooijman, P. U. Dijkstra, J. H. Geertzen, A. Elzinga, and C. P. van der Schans, "Phantom pain and phantom sensations in upper limb amputees: an epidemiological study," Pain, vol. 87, iss. 1, pp. 33-41, 2000.
[Bibtex]
@article{kooijman2000phantom,
  title={Phantom pain and phantom sensations in upper limb amputees: an epidemiological study},
  author={Kooijman, Carolien M and Dijkstra, Pieter U and Geertzen, Jan HB and Elzinga, Albert and van der Schans, Cees P},
  journal={Pain},
  volume={87},
  number={1},
  pages={33--41},
  year={2000},
  publisher={Elsevier}
}
[8] C. Dietrich, K. Walter-Walsh, S. Preißler, G. O. Hofmann, O. W. Witte, W. H. Miltner, and T. Weiss, "Sensory feedback prosthesis reduces phantom limb pain: proof of a principle," Neuroscience Letters, vol. 507, iss. 2, pp. 97-100, 2012.
[Bibtex]
@article{dietrich2012sensory,
  title={Sensory feedback prosthesis reduces phantom limb pain: proof of a principle},
  author={Dietrich, Caroline and Walter-Walsh, Katrin and Prei{\ss}ler, Sandra and Hofmann, Gunther O and Witte, Otto W and Miltner, Wolfgang HR and Weiss, Thomas},
  journal={Neuroscience Letters},
  volume={507},
  number={2},
  pages={97--100},
  year={2012},
  publisher={Elsevier}
}
[9] T. Weiss, C. Dietrich, S. Preißler, H. Möbius, H. Gube, F. Torma, W. Miltner, and G. Hofmann, "Nutzung einer myoelektrischen Unterarmprothese mit Biofeedback," Trauma und Berufskrankheit, vol. 15, iss. 3, pp. 207-215, 2013.
[Bibtex]
@article{weiss2013nutzung,
  title={Nutzung einer myoelektrischen Unterarmprothese mit Biofeedback},
  author={Weiss, T and Dietrich, C and Prei{\ss}ler, S and M{\"o}bius, H and Gube, H and Torma, F and Miltner, WHR and Hofmann, G},
  journal={Trauma und Berufskrankheit},
  volume={15},
  number={3},
  pages={207--215},
  year={2013},
  publisher={Springer}
}
[10] V. Finsen, L. Persen, M. Lovlien, E. Veslegaard, M. Simensen, A. Gasvann, and P. Benum, "Transcutaneous electrical nerve stimulation after major amputation," The Journal of bone and joint surgery. British volume, vol. 70, iss. 1, pp. 109-112, 1988.
[Bibtex]
@article{finsen1988transcutaneous,
  title={Transcutaneous electrical nerve stimulation after major amputation},
  author={Finsen, V and Persen, L and Lovlien, M and Veslegaard, EK and Simensen, M and Gasvann, AK and Benum, P},
  journal={The Journal of bone and joint surgery. British volume},
  volume={70},
  number={1},
  pages={109--112},
  year={1988},
  publisher={The British Editorial Society of Bone and Joint Surgery}
}
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[Bibtex]
@article{mulvey2010transcutaneous,
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  journal={Cochrane Database of Systematic Reviews},
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  year={2010},
  publisher={John Wiley \& Sons, Ltd}
}
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[Bibtex]
@article{flor1998cortical,
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  author={Flor, Herta and Elbert, Thomas and M{\"u}hlnickel, Werner and Pantev, Christo and Wienbruch, Christian and Taub, Edward},
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}
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[Bibtex]
@article{lotze1999does,
  title={Does use of a myoelectric prosthesis prevent cortical reorganization and phantom limb pain?},
  author={Lotze, Mi and Grodd, W and Birbaumer, N and Erb, M and Huse, El and Flor, H},
  journal={Nature Neuroscience},
  volume={2},
  number={6},
  pages={501},
  year={1999},
  publisher={Nature Publishing Group}
}
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[Bibtex]
@article{maciver2008phantom,
  title={Phantom limb pain, cortical reorganization and the therapeutic effect of mental imagery},
  author={MacIver, K and Lloyd, DM and Kelly, S and Roberts, N and Nurmikko, T},
  journal={Brain},
  volume={131},
  number={8},
  pages={2181--2191},
  year={2008},
  publisher={Oxford University Press}
}
[15] H. Flor, C. Denke, M. Schaefer, and S. Grüsser, "Effect of sensory discrimination training on cortical reorganisation and phantom limb pain," The Lancet, vol. 357, iss. 9270, pp. 1763-1764, 2001.
[Bibtex]
@article{flor2001effect,
  title={Effect of sensory discrimination training on cortical reorganisation and phantom limb pain},
  author={Flor, Herta and Denke, Claudia and Schaefer, Michael and Gr{\"u}sser, Sabine},
  journal={The Lancet},
  volume={357},
  number={9270},
  pages={1763--1764},
  year={2001},
  publisher={Elsevier}
}
[16] G. R. Hadley, J. A. Gayle, J. Ripoll, M. R. Jones, C. E. Argoff, R. J. Kaye, and A. D. Kaye, "Post-herpetic neuralgia: a review," Current Pain and Headache Reports, vol. 20, iss. 3, p. 17, 2016.
[Bibtex]
@article{hadley2016post,
  title={Post-herpetic neuralgia: a review},
  author={Hadley, Graham R and Gayle, Julie A and Ripoll, Juan and Jones, Mark R and Argoff, Charles E and Kaye, Rachel J and Kaye, Alan D},
  journal={Current Pain and Headache Reports},
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  year={2016},
  publisher={Springer}
}

Footnotes   [ + ]

1. Conference: Hand, Brain and Technology 2018, August 26-31 2018, Monte Verita, Ticino, Switzerland. Title: Obtaining and maintaining cortical hand representation: Evidence from acquired and congenital handlessness. Authors: Daan B Wesselink1,2*, Fiona M.Z. van den Heiligenberg2, Naveed Ejaz3,4, Harriet Dempsey-Jones1,2, Lucilla Cardinali3,5, Aurelie Tarall-Jozwiak6, Jörn Diedrichsen3,4, Tamar R Makin1,2 -- 1 Institute of Cognitive Neuroscience, University College London, London, UK; 2 FMRIB Centre, Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK; 3 Brain and Mind Institute, University of Western Ontario, Canada; 4 Department of Computer Science, University of Western Ontario, Canada 5 Unit for Visually Impaired People, Istituto Italiano di Tecnologia, Genoa, Italy; 6 Queen Mary’s Hospital, London, UK. ----- Abstract: Hand representation in the primary somatosensory cortex (SI) is thought to be shaped and maintained by experience. However, although the fine characteristics of digit topography could be fine-tuned by altered behaviour, overall hand structure is highly stable across people and time [1]. Recently, we even showed that three amputees experiencing highly vivid phantom sensations maintain cortical representation of their missing hand [2]. Still, it is unclear whether this persistence of hand representation depends on experiencing vivid phantom sensation, or whether it is immune to the long-term withdrawal of sensory feedback. In this study, we scanned 18 unilateral amputees (17±10 years since amputation) with varying degrees of phantom sensations, as well as individuals with congenital unilateral limb absence (without phantom sensations) and two-handed controls. Inside a 3T MRI scanner, all participants performed individual digit movements with either hands (missing/non-dominant and intact/dominant hand), as well as a more demanding motor synergy task with their intact hand. Using representational similarity analysis, we interrogated the inter-digit (activity) pattern structure within the SI hand area. The deprived cortex, contralateral to amputees’ missing hand, was activated by movement of both phantom digits and the (ipsilateral) intact hand. In both cases, the representational structure of the hand was stable, as we found no differences between the pattern structure of amputees and that of controls. The deprived cortex was stable in all amputees; this did not depend on perceived phantom sensations (assessed using questionnaires). In contrast, the representation of congenital one-handers’ missing hand was severely diminished. Finally, activation of ipsilateral resources (e.g. amputees’ deprived cortex) during high motor demands alluded to a functional role in (intact) hand motor control. Together, our findings suggest that once cortical organisation is formed, it is remarkably persistent, despite drastic loss of afferent input and lack of sensory experience. References [1] Ejaz, N., Hamada, M., & Diedrichsen, J. (2015) Hand use predicts the structure of representations in sensorimotor cortex. Nat. Neurosci., 18, 1034–1040. [2] Kikkert, S., Kolasinski, J., Jbabdi, S., Tracey, I., Beckmann, C.F., Berg, H.J., & Makin, T.R. (2016) Revealing the neural fingerprints of a missing hand. eLife, 5, e15292. Short Biography Daan Wesselink is a PhD candidate at University of Oxford and works both at the Welcome Centre for Integrative Neuroimaging (Oxford) and the Institute of Cognitive Neuroscience (University College London). He uses MRI to study somatosensory representation in the human cortex. More specifically, his work examines the boundaries of sensorimotor plasticity following changes in input.
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