Zusammenfassung
Phantomschmerz ist eine häufige Folge von Amputationen. Bis zu 80 % aller Amputierten
leiden darunter. Er muss von nicht-schmerzhaften Phantomempfindungen, Stumpfschmerzen
und nicht-schmerzhaften Stumpfempfindungen unterschieden werden. In diesem Artikel
wird ein umfassendes Modell des Phantomschmerzes präsentiert, welches die Rolle von
Schmerz vor der Amputation betont und mit peripheren und zentralen Prozessen in Verbindung
bringt. Insbesondere wird die Bedeutung kortikaler Reorganisation für das Entstehen
von Phantomschmerz diskutiert. Schließlich werden neue Ansätze zur Prävention und
Behandlung von Phantomschmerz vorgestellt, die durch ein Verhindern oder eine Rückbildung
kortikaler Reorganisationsprozesse den Phantomschmerz positiv beeinflussen.
Abstract
Phantom-limb pain is a common sequel of amputation, occurring in up to 80 % of the
amputee population. It must be differentiated from non-painful phantom phenomena,
residual-limb pain, and non-painful residual-limb phenomena. A comprehensive model
of phantom-limb pain is presented that assigns a major role to pain occurring before
the amputation and to central as well as peripheral changes related to it. Special
emphasis is put on the role of cortical reorganization in the development of phantom
limb pain. Finally, new approaches to the prevention and treatment of phantom limb
pain are presented that have a positive influence on phantom limb pain by preventing
or reversing cortical reorganization.
Schlüsselwörter
Schmerzgedächtnis - Plastizität - Phantomschmerz - Reorganisation - chronischer Schmerz
Key words
Pain memory - plasticity - phantom pain - reorganization - chronic pain
Literatur
- 1
Jensen T S, Krebs B, Nielsen J, Rasmussen P.
Immediate and long-term phantom limb pain in amputees: incidence, clinical characteristics
and relationship to pre-amputation limb pain.
Pain.
1983;
21
267-278
- 2
Mitchell S W.
Phantom limbs.
Lippincott's Magazine of Popular Literature and Science.
1871;
8
563-569
- 3
Melzack R.
Phantom limbs.
Scientific American.
1992;
4
90-96
- 4 Jensen T S, Nikolajsen L.
Phantom pain and other phenomena after amputation. In: Wall PD, Melzack RA (Ed) Textbook of pain, 4th ed Edinburgh; Churchill Livingston
1999: 799-814
- 5
Flor H.
Phantom limb pain: characteristics, causes, and treatment.
Lancet Neurology.
2002;
3
182-189
- 6
Merzenich M M, Nelson R J, Stryker M P, Cynader M S, Shoppmann A, Zook J M.
Somatosensory cortical map changes following digit amputation in adult monkeys.
J Comp Neurol.
1984;
224
591-605
- 7
Pons T P, Garraghty P E, Ommaya A K, Kaas J H, Taub E, Mishkin M M.
Massive cortical reorganization after sensory deafferentation in adult macaques.
Science.
1991;
252
1857-1860
- 8
Woolf C J, Mannion R J.
Neuropathic pain, aetiology, symptoms, mechanisms, and management.
Lancet.
1999;
353
1959-1964
- 9 Devor M.
Phantom pain as an expression of referred and neuropathic pain. In: Phantom pain. R.A. Sherman (Ed.) New York; Plenum Press 1997: 33-58
- 10
Recanzone G H, Merzenich M M, Jenkins W M, Grajski K A, Dinse H R.
Topographical reorganization of the hand representation in cortical area 3b of owl
monkey trained in a frequency discrimination task.
J Neurophysiol.
1992;
67
1031-1056
- 11
Jenkins W M, Merzenich M M, Ochs M T, Allard T, Guic-Robles E.
Functional reorganization of primary somatosensory cortex in adult owl monkeys after
behaviorally controlled tactile stimulation.
J Neurophysiol.
1990;
63
82-104
- 12 Menzel R.
Neuronale Plastizität, Lernen und Gedächtnis. In: Dudel J, Menzel R, Schmidt RF (Hrsg) Neurowissenschaft. Berlin; Springer 1996:
485-518
- 13
Wang X, Merzenich M M, Sameshima K, Jenkins W M.
Remodelling of hand representation in adult cortex determined by timing of tactile
stimulation.
Nature.
1995;
378
71-750
- 14
Elbert T, Flor H, Birbaumer N, Knecht S, Hampson S, Larbig W, Taub E.
Extensive reorganization of the somatosensory cortex in adult humans after nervous
system injury.
NeuroReport.
1994;
5
2593-2597
- 15
Yang T T, Gallen C C, Ramachandran V S, Cobb S, Schwartz B J, Bloom F E.
Noninvasive detection of cerebral plasticity in adult human somatosensory cortex.
NeuroReport.
1994;
5
701-704
- 16
Sanes J N, Suner S, Lando J F, Donoghue J P.
Rapid reorganization in adult rat motor cortex somatic representation patterns after
motor nerve injury.
Proc Natl Acad Sci (USA).
1988;
85
2003-2007
- 17
Chino Y M, Kaas J H, Smith E L, Langston A L, Cheng H.
Rapid reorganization of cortical maps in adult cats following restricted deafferentation
in retina.
Vision Res.
1993;
32
789-796
- 18
Fuhr P, Cohen L G, Dang N, Findley T W, Haghighi S, Oro J, Hallett M.
Physiological analysis of motor reorganization following lower limb amputation.
Electroen Clin Neurophysiol.
1992;
85
53-60
- 19
Mühlnickel W, Elbert T, Taub E, Flor H.
Reorganization of primary auditory cortex in Tinnitus.
Proc Natl Acad Sci USA.
1998;
95
10 340-10 343
- 20
Rösler F, Röder B, Heil M, Hennighausen E.
Topographic differences of slow event-related brain potentials in blind and sighted
adult human subjects during haptic mental rotation.
Cog Brain Res.
1993;
1
145-159
- 21
Neville H J, Schmidt A, Kutas M.
Altered visual-evoked potentials in congenitially deaf adults.
Brain Res.
1983;
266
127-132
- 22
Sterr A, Müller A, Elbert T, Rockstroh B, Taub E.
Development of cortical reorganization in the somatosensory cortex of adult Braille
students.
Electroen clin Neurophysiol Suppl..
1999;
49
292-298
- 23
Pascual-Leone A, Torres F.
Plasticity of the sensorimotor cortex representation of the reading finger in Braille
readers.
Brain.
1993;
116
39-52
- 24
Ramachandran V S, Rogers-Ramachandran D, Stewart M.
Perceptual correlates of massive cortical reorganization.
Science.
1992;
252
1857-1860
- 25
Weiss T, Miltner W H, Huonker R, Friedel R, Schmidt I, Taub E.
Rapid functional plasticity of the somatosensory cortex after finger amputation.
Exp Brain Res.
2000;
134
199-203
- 26
Woolf C J, Doubell T P.
The pathophysiology of chronic pain - increased sensitivity to low threshold A beta-fiber
inputs.
Curr Opin Neurobiol.
1994;
4
525-534
- 27
Flor H, Braun C, Elbert T, Birbaumer N.
Extensive reorganization of primary somatosensory cortex in chronic back pain patients.
Neurosci Let.
1997;
224
5-8
- 28
Katz J, Melzack R.
Pain „memories” in phantom limbs: review and clinical observations.
Pain.
1990;
43
319-336
- 29
Gracely R H, Petzke F, Wolf J M, Clauw D J.
Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia.
Arthritis Rheum.
2002;
46
1333-1343
- 30
Juottonen K, Gockel M, Silen T, Hurri H, Hari R, Forss N.
Altered central sensorimotor processing in patients with complex regional pain syndrome.
Pain.
2002;
98
315-323
- 31
Flor H, Elbert T, Wienbruch C, Pantev C, Knecht S, Birbaumer N, Larbig W, Taub E.
Phantom limb pain as a perceptual correlate of cortical reorganization.
Nature.
1995;
357
482-484
- 32
Flor H, Elbert T, Mühlnickel W, Pantev C, Wienbruch C, Taub E.
Cortical reorganization and phantom phenomena in congenital and traumatic upper extremity
amputees.
Exp Brain Res.
1998;
119
205-212
- 33
Flor H, Mühlnickel W, Karl A, Denke C, Fritzsche K, Grüsser S, Taub E.
A neural substrate of nonpainful phantom limb phenomena.
Neuroreport .
2000;
11
1407-1411
- 34
Grüsser S M, Winter C, Mühlnickel W, Denke C, Karl A, Villringer K, Flor H.
The relationship of perceptual phenomena and cortical reorganization in upper extremity
amputees.
Neuroscience.
2001;
102
263-272
- 35
Grüsser S M, Winter C, Schaefer M, Fritzsche K, Thunn P-U, Benhidjeb T, Schlag P,
Flor H.
Development of phantom phenomena and cortical reorganization in unilateral arm amputees:
a pre-post-surgical comparison.
Neurosci Let.
2001;
302
13-16
- 36 Huse E, Larbig W, Montoya P, Gerstein J, Lukaschewski T H, Birbaumer N, Flor H.
The effects of pre-emptive analgesia, preoperative pain and other preoperative predictors
on phantom limb pain. Pain (im Druck)
- 37
Flor H, Birbaumer N, Sherman R A.
Phantom limb pain.
Clinical Pain Updates.
2000;
8
1-4
- 38
Flor H, Birbaumer N.
Phantom limb pain: Cortical plasticity and novel therapeutic approaches.
Curr Opin Anesthesiol.
2000;
13
561-564
- 39
Birbaumer N, Lutzenberger W, Montoya P, Larbig W, Unertl K, Grodd W, Flor H.
Effects of regional anesthesia on phantom limb pain are mirrored in changes in cortical
reorganization.
J Neurosci.
1997;
17
5503-5508
- 40
Florence S L, Taub H B, Kaas J H.
Large-scale sprouting of cortical connections after peripheral injury in adult macaque
monkeys.
Science..
1998;
282
1062-1063
- 41
Lotze M, Grodd W, Birbaumer N, Erb M, Huse E, Flor H.
Does use of a myoelectric prothesis reduce cortical reorganization and phantom limb
pain?.
Nat Neuroscience.
1999;
2
501-502
- 42
Flor H, Denke C, Grüsser , S , Schaefer M.
Effect of sensory discrimination training on cortical reorganization and phantom limb.
Lancet.
2001;
357
1763-1764
- 43
Garraghty P E, La Chica E A, Kaas J H.
Injury-induced reorganization of somatosensory cortex is accompanied by reductions
in GABA staining.
Somatosens Mot Res.
1991;
8
347-354
- 44
Ziemann U, Chen R, Cohen L G, Hallett M.
Dextromethorphan decreases the excitability of the human motor cortex.
Neurology.
1998;
51
1320-1324
- 45
Kilgard M P, Merzenich M M.
Cortical map reorganization enabled by nucleus basalis activity.
Science.
1998;
13
1714-1718
- 46 Wiech K, Preissl H, Kiefer T, Töpfner S, Pauli P, Grillon C, Flor H, Birbaumer N.
Prevention of phantom limb pain and cortical reorganization in the early phase after
amputation in humans. Anesthesiology (im Druck)
- 47
Nikolajsen L, Ilkjaer S, Christensen J H, Kroner K, Jensen T S.
Randomised trial of epidural bupivacaine and morphine precention of stump and phantom
pain in lower-limb amputation.
Lancet.
1997;
35
1353-1357
- 48
Nikolajsen L, Hansen C L, Nielsen J, Keller J, Arendt-Nielsen L, Jensen T S.
The effect of ketamine on phantom pain: a central neuropathic disorder maintained
by peripheral input.
Pain.
1996;
67
69-77
- 49
Nikolajsen L, Gottrup H, Kristensen A G, Jensen T S.
Metamine in the treatment of neuropathic pain after amputation or sugery: a randomized,
double-blind, cross-over study.
Anest Analg.
2000;
91
960-966
- 50
Huse E, Larbig W, Flor H, Birbaumer N.
The effect of opioids on phantom limb pain and cortical reorganization.
Pain.
2001;
90
47-55
Prof. Dr. Herta Flor
Lehrstuhl für Neuropsychologie an der Universität Heidelberg, Zentralinstitut für
Seelische Gesundheit Mannheim, J 5
68159 Mannheim
eMail: flor@zi-mannheim.de
