I have been remiss, I have broken my promise, mea culpa. Enough of that crap, I’ve just been lazy and haven’t written the journal on the phantom limb and the progress of both the physical and the mental aspects of an amputation. In my defense I’ll say that there hasn’t been that much daily change – but there have been further realizations.
Firstly let me offer a non-medical analysis of the processes that seem to be involved. We all know that the knee bone is connected to the thigh bone – and that all our sensory (and motor) nerves (excepting those that originate above the neck)are connected to the “spine bone”. Our brain is the central authority, and it has various levels of function, but I think I’ll leave out the autonomic (early brain) matters as they aren’t relevant to this discussion.
The perception of sensation (pain, touch, etc.) is actually in the brain (it’s all in your head). The sensory nerves in your big toe run up your leg and join the bundle of nerves in your spinal cord where they are relayed to your brain. Sometimes this network of nerves can be confused, even in someone with no permanent damage. A pain may be felt in an extremity when there is no stimulus there, perhaps some “cross talk” in the spinal cord (cross talk being a term from telephony, and now data communications). There can even be a bit of cross talk in the brain that causes a phantom sensation.
OK, given that let’s look at my recent experience. I have had occasional “random pain” in the phantom limb – but very little. I believe that that “random pain” is the popular understanding of the sensation of the phantom limb. The phantom limb is a real thing, it is the psychokinetic awareness of the limb that was there, not the random instance. I mentioned in my introduction that when my foot “should be on the floor” I feel a contact with the floor (given that my other foot is on the floor, so as to give my brain a relative position). Over six weeks now, and that is still there. I sit here typing at my computer, my left foot is on the floor and my right foot exists only in my mind. If I twist my right knee (thankfully the amputation was below my knee) I can feel my right foot changing its position in space. If my left ankle itches I can turn my right leg to the exact position to scratch it with my non-existant right big toe. At this moment I can’t feel the contact of my right foot with the floor, perhaps because I’m writing about it and am conscious of the lack of the appendage. But if I’m not thinking about it I will feel that contact.
The random pain in the phantom limb is obviously generated by irritation in the nerve endings in the stump, the nerves that used to go down the rest of my leg and to my foot. If the right one is “tickled” it will tell my brain that there is a problem in the missing parts. The psychokinetic awareness of the position of my missing foot must be a function of “motor feedback”, the same process that allows us to pass the “field sobriety test” of touching finger to nose with our eyes closed (assuming that we actually are sober). So we have a “nerve generated” random pain in the phantom, and a brain generated location sensation (brain in combination with the motor nerves and their feedback, and the positional feedback of the sensory nerves in the remaining parts of the extremity). A brain memory that if this is here then that is there, I feel it now sitting in my chair as the lack of the weight of my lower right leg, and the lack of contact of that foot with the floor, makes my knee turn outward – so I feel that the missing foot is extended laterally to my right (should be bumping into the “tower” of my computer, so I’m automatically bending the knee a bit to hold my “foot” back from it).
OK, that is two aspects of the phantom limb, but I have found a third. Many years ago I broke my right ankle (actually a break in the fibula just above the ankle) and it was poorly set. For forty years I’ve had occasional minor pain at that old break, I find that I sometimes have it now in the phantom limb. This seems to be a bit more complex, a brain memory of the specific injury that is triggered by some random annoyance in the stump. The feeling is very specific, a linear and horizontal pain at the exact location. So this would appear to be a combination of the irritation in the stump and the brain generated feeling of the presence of the limb. In fact as I write about it I’m feeling it – another indication of the complex interplay of the sensory aspects of the brain and consciousness.
I’ll make a last comment, for now, on this topic. I’ve led a long and active life – and as such have had a number of occasions when I’ve been on crutches because of a leg that is “out of commission”. In the handouts I was given about amputation there is mention of the danger of trying to stand up on the missing leg. It happens! I’m often sitting down with my left leg on the floor and go to stand up and take a step onto my missing right leg. So far, so good – I’ve always caught myself. So what is the difference between having a missing leg and one that is inoperative? It is the very lack of pain, or the sensation of being handicapped. The cast on a broken leg, the pain of a gout attack, or any of a number of things, tell you not to put that foot down on the floor. But when the leg is missing, and the phantom limb is there, it is easy to feel that you can stand up normally. At least once a day I catch myself shifting my weight in the chair to put the missing foot down, one of these days I’ll be concentrating on something else and find myself crashing to the floor as I go to put weight on the missing leg. That “oh shit, I forgot my parachute” moment.
For any of you who read this who have had an amputation recently, and I hope that some of you will, let me tell you a bit more. My own wound is healing slowly, by now I should be working with learning to use a prosthetic leg. But in the last four weeks I’ve set up a workshop in our new apartment – most of my heavy power tools had been moved by me before the amputation, but not set up. If you are careful with using your crutches you can do anything except moving things a long distance. This afternoon I cut the wooden base for a heavy bandsaw to mount it on a rolling table, I mounted the base (after drilling locational pilot holes for the bandsaw to be screwed in). I mounted the base to the table, then tried to lift the bandsaw to the table while sitting in the rolling “secretary’s chair” I immediately bought after the amputation. No way, too heavy for me to lift the bandsaw from the floor to the 3 foot high table without the strength of my legs. OK, a milk carton. Still couldn’t lift it. OK, lift a part of it and lever it up. Made it, but now another two feet to go. Prop it from the milk carton to the stump leg, then lift the other end to the good leg, then push a corner of it onto the table. It took a while, and I was sitting with a seventy pound bandsaw in my lap for a while, but it is now solidly mounted and bolted down to the table – which has been rolled into position so that I can sit in the “bar stool” I also bought after the amputation and pull it out into an operating position. You will find a way to do things, just take the time to think and use leverage and balance. It is a big step out of my front door, I installed a grab handle inside and found I could get in, but was reluctant to go out for fear of falling on my face. Easy, when you think about it – if you can get in then just reverse the process and go out backwards.
One major caveat, never lose concentration when maneuvering with a missing leg. Close your ears to the call “look at this”. Unlike the man with the cast that you may have been when previously on crutches you have nothing to wave around to catch your balance, when you lose it you go down hard. Stop, take tiny steps with crutches and the remaing leg, turn your body to the source, then answer. You can move well in a straight line, set a rhythm and you can step out smartly – just keep your eyes on the ground you are covering. Your PT will have shown you how to go up or down a step (down with the bad, up with the good) but if they haven’t themselves been limited to crutches they may miss some subtleties. When going down a shallow grade bend the good knee a bit and set the crutches near ahead, then bring the leg forward and extend it so that you seem to stay level. Do the reverse uphill, land on a bent leg so you don’t risk falling backwards. Shift your shoulders up and down with the crutches so as to simulate level ground whichever way you are going.
When you have to walk a distance, on level ground, stand tall and take the weight on your hands. You will get less tired. When you have to maneuver in tight quarters balance on the good leg and shift the crutches in small increments. You’ll find that you are able to “crab walk” even when limited to a narrow “tripod”. Set yourself before each change of direction, then take off with full confidence. When walking to your car in a mall parking lot choose a direction and a destination. Look for the traffic first – go directly to your “way point” and stop, then when on balance look for traffic again. Do not look up when walking, you don’t have the balance of the guy with the cast.
When you are in tight quarters don’t lift the good leg, toe and heel the good foot as you shift the tripod of the crutches – and at all other times remember to pick up that good leg as you move, one of the easiest things to do is to trip on the drag of the good foot.
I digressed a bit from the phantom limb, but as some readers might be themselves amputees I thought the suggestions might help.