3". Behav. Ther. & Exp. Psychiat. Vol. 6, pp. 262-263. Pergamon Press, 1975. Printed in Great Britain.

RELIEF FROM PHANTOM LIMB PAIN BY RELAXATION EXERCISES

R. J. MCKECHNIE*

Crichton Royal Hospital, Scotland

Summary--Observed relief from phantom limb pain is reported in a young male patient with a nine year history of such pain. Relief occurred during and after relaxation exercises focused on the phantom limb, and was facilitated by practice. Six month follow-up revealed continued relief.

ThE EXPERIENCE of pain in a limb which has been removed is reported by up to 35 ~ of amputees (Feinstein, Luce and Langton, 1954), and is one of the most fascinating of pain syndromes. Despite its fascination, our under- standing of the phenomenon remains inadequate. Although it has been suggested (Sternbach, 1970) that progressive relaxation may be useful in the relief of this and other types of pain there are few reported cases in the literature. In the case reported here relief from phantom limb pain was obtained in a patient who was learning relaxation for another purpose.

tempered. He had once been physically aggressive with his 6-year-old son. It was this incident which prompted him to seek psychiatric help. He had suffered headache three or four times per week over the previous eighteen months. His appetite was poor and for three years he had had difficulty getting off to sleep and would wake early. There was no evidence of neurological damage. Tran- quillizers were successful in alleviating his anxiety and overcame his headaches, but did not have any noticeable effect on his pain or initial insomnia. He asked for further help with regard to excessive smoking.

CASE HISTORY

The patient, a male of average intelligence, was involved in a traffic accident in 1962 at the age of 18, in which he sustained a fracture of the right radius and ulna and a severe tear of the brachial plexus involving all roots. The radius was plated, but when there was no evidence of recovery from the brachial plexus lesion after many months, it was decided that amputation of the arm was the only possible course. The amputation was carried out just above the elbow, some thirteen months after the accident, after which the patient received outpatient supervision for some months. An artificial limb was fitted in February, 1964. The patient did not experience pain until a few weeks after he had been fitted with the prosthesis. It varied from a dull ache which could persist for several hours, to a severe sharp pain which would last up to an hour and then give way to the more usual ache. The pain was more severe at night when he tried to sleep, but was unaffected by exercising the stump. This profile had remained fairly stable over the nine and a half years since the artificial limb was fitted. He also reported having some sensation in the fingers of the phantom limb. The areas of pain and sensation were not identical in distribution.

When seen in 1972, the patient complained of ag- gressiveness, anxiety and depression. He reported himself as lacking in motivation, irritable, and quick-

METHOD

As the patient reported that smoking cigarettes gave him tension-relief, it was decided to embark on relaxation therapy following Jacobson (1938). During one of the training sessions he remarked that what prevented him from relaxing completely was the pain in the phantom limb. He reported being aware of his missing fingers and that he could bend them slowly. Since clenching the fist is part of hand and arm relaxation training it was decided to ask the patient to imagine clenching the fist of his phantom limb. On doing this with the rest of his body relaxed he reported that the pain had completely dis- appeared. He was asked to practice the relaxation exercises at home, including his phantom limb. He quickly mastered the relaxation technique and expressed great satisfaction at the relief from pain.

After several successive visits the patient was questioned further about the relief obtained. Unlike concentrating on a task or being distracted, which transiently modified the pain to a mild background ache, the relaxation completely obliterated all pain sensation in the limb. The pain did not immediately return when he stopped actively relaxing, but was absent for up to an hour. Initially the technique was only partially successful in combating the pain when it was severe but after 2 months removed even severe pain, enabling him to embark on a relaxed sleep.

*Requests for reprints should be addressed to R. J. McKechnie, Department of Psychological Research, Crichton Royal, Dumfries, Scotland.

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RELIEF FROM PHANTOM LIMB PAIN 263

Follow-up at 6 months The patient continued to enjoy complete relief from

severe pain for periods of up to one hour when the technique was practised, but relief came more quickly. As he had not found the more dull background ache troublesome he had not attempted blocking it although this had been suggested. He felt that the major gain was to be able to get off to sleep without difficulty. He was also generally more relaxed.

His smoking level was 25 % of that which prompted him to seek help.

COMMENT

This attempt to influence the experience of phantom pain developed from the simple notion that awareness of the phantom limb could perhaps be used to alter the experience of that limb. By focussing attention and giving relaxation "exercise" to the fingers of the phantom

limb (where the patient had sensation) somehow a block of pain sensation resulted. Whether this is due to the focussing of attention or the exercise towards relaxation is not possible to decide. The relaxation component would seem to be important since distraction and con- centration alone do not produce relief.

REFERENCES

FEINSTEIN B., LUCE J. C. and LANGTON J. N. K. (1954) The influence of phantom limb in Human Limbs and Their Substitutes (Edited by KLOPSTEG P. and WILSON P.), McGraw-Hill, New York.

JACOaSON E. (1938) Progressive Relaxation, University of Chicago Press, Chicago.

STERNaACH R. A. (1970) Strategies and tactics in the treatment of patients in pain, In Pain and Suffering: Selected Aspects, C. C. Thomas, Springfield, Illinois.