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EMOTIONAL STATUS IN CANCER PATIENTS WITH PHANTOM LIMB PAIN

Research article
Bortnikova E.G.
Belyaeva S.I.
Kruglova N.E.
DOI:
https://doi.org/10.23670/IRJ.2022.118.4.063
Issue: № 4 (118), 2022
Published:
2022/04/18
PDF

DOI: https://doi.org/10.23670/IRJ.2022.118.4.063

ПСИХОЭМОЦИОНАЛЬНОЕ СОСТОЯНИЕ ОНКОЛОГИЧЕСКИХ БОЛЬНЫХ, СТРАДАЮЩИХ ФАНТОМНОБОЛЕВЫМ СИНДРОМОМ

Научная статья

Бортникова Е.Г.1, Беляева С.2, *, Круглова Н.Е.3, Кондратьева К.О.4

1 ORCID: 0000-0002-3063-5280;

2 ORCID: 0000-0002-8014-5407;

3 ORCID: 0000-0002-0733-1641;

4 ORCID: 0000-0003-3987-1703;

1, 2, 3, 4 Российский государственный педагогический университет им. А. И. Герцена, Санкт-Петербург, Россия

* Корреспондирующий автор (belyaevasveta[at]inbox.ru)

Аннотация

Одной из причин ампутации конечностей является наличие онкологического заболевания. В 47,5 % случаев ампутация сопровождается развитием фантомно-болевого синдрома (далее – ФБС). В статье представлены результаты исследования, проведенного на базе НМИЦ онкологии им. Н. Н. Петрова, посвященного определению роли эмоционального состояния у онкологических больных с ФБС. Выборку составили 12 пациентов с диагнозом злокачественное новообразование костей, перенесшие ампутацию конечности. В исследовании использовались симптоматический опросник Александровича и визуально-аналоговая шкала. Также с пациентами в течение 3 месяцев проводилась комплексная программа профилактики ФБС, включающая зеркальную терапию, психокоррекционную визуализацию, нервно-мышечную релаксацию и транскраниальную электростимуляцию (ТЭС). Комплексная профилактическая программа ФБС проводилась в течение 7 дней, 2 раза в день. Транскраниальная электростимуляция проводилась ежедневно 1 раз в день.

Выявление взаимосвязи между психоэмоциональным состоянием и выраженностью ФБС проводилось с помощь корреляционного анализа. Установлена взаимосвязь между выраженностью ФБС и ипохондрическими реакциями больных, кроме того, на уровне тенденции отмечаются прямые корреляционные связи силы ФБС с беспокойством и напряжением пациентов и неврастенией.

Через три месяца осуществлялась оценка эффективности профилактических мероприятий с помощью сравнительного анализа по критерию Манна-Уитни. Пациенты, прошедшие программу, были разделены на две группы: пациенты с возобновившимся и с не возобновившимся ФБС. Согласно данным симптоматического опросника Александровича было выявлено, что пациенты в большей степени страдают от соматических расстройств, что согласуется со сложным восстановительным послеоперационным периодом. Возобновление ФБС через 3 месяца после операции отмечалось значительно чаще у пациентов, в структуре эмоционального состояния которых обнаружились страхи и фобии. Таким образом, можно предположить, что характер психоэмоционального состояния отражается на выраженности фантомных болей и фантомных ощущений у пациентов, страдающих злокачественными новообразованиями, и перенесших ампутацию конечности. По результатам исследования, можно говорить о необходимости психопрофилактики фобий и психокоррекционной работы со страхами пациентов для снижения риска повторного возобновления ФБС.

Ключевые слова: фантомно-болевой синдром, ампутация, программа профилактики, психоэмоциональное состояние, страхи, фобии.

EMOTIONAL STATUS IN CANCER PATIENTS WITH PHANTOM LIMB PAIN

Research article

Bortnikova E.G.1, Belyaeva S.I.2, *, Kruglova N.E.3,Kondrateva K.O.4

1 ORCID: 0000-0002-3063-5280;

2 ORCID: 0000-0002-8014-5407;

3 ORCID: 0000-0002-0733-1641;

4 ORCID: 0000-0003-3987-1703;

1, 2, 3, 4 Herzen State Pedagogical University of Russia, St. Petersburg, Russia

* Corresponding author (belyaevasveta[at]inbox.ru)

Abstract

Cancer is one of the reasons for amputation of limbs. In 47,5% of cases, amputation is accompanied by the development of phantom limb pain (PLP). The article presents the results of a study in the National Medical Research Centre of Oncology named after N.N. Petrov devoted to determining the role of the emotional status in cancer patients with PLP. 12 cancer patients after limb amputation were examined using Alexandrovich's symptomatic questionnaire and The Pain Visual Analog Scale. The comprehensive PLP prevention program lasted for 3 months and included mirror therapy, visualization techniques, neuromuscular relaxation and transcranial electrical stimulation (tES). The comprehensive PLP preventive program was carried out for 7 days, 2 times a day. Transcranial electrical stimulation was performed daily, once a day.

Detection of connection between the emotional status and the severity of PLP symptoms was checked by correlation analysis. The connection between the severity of PLP symptoms and hypochondriacal reactions has been established, there are direct correlations between the severity of PLP symptoms and anxiety, tension and neurasthenia.

Three months later, the effectiveness of preventive measures was evaluated using a comparative analysis according to the Mann-Whitney criterion. The patients who completed the program were divided into two groups: patients with resumed and non-resumed PLP. According to the data of Alexandrovich's symptomatic questionnaire, it was revealed that patients suffer more from somatic disorders, which is consistent with a difficult postoperative recovery period. The resumption of PLP 3 months after the surgery was noted much more often in patients whose structure of emotional state revealed fears and phobias. Thus, it can be assumed that the nature of the emotional status is reflected in the severity of phantom pains and phantom sensations in patients after limb amputation. According to the results of the study, we can talk about the need for preventive measures of phobias and psychological correction with patients' fears to reduce the risk of recurrent PLP.

Keywords: phantom limb pain, limb amputation, prevention program, emotional status, fears, phobias.

Introduction

Phantom limb pain (PLP) is a type of neuropathic pain that occurs as a result of the removal of an organ, for example, after limb amputation. According to ICD-10, this disorder is noted in section G 54, 6 and 54,7. After amputation, there may be various sensations, paresthesia, non-physiological position of the phantom limb. According to D. Probstner et al., phantom pain sensations occur after amputation in cancer patients in 47,7% of cases, while sensory impairments are more common – 90,7% [17].

After the operation, the part of the sensory cortex responsible for the amputated limb remains active and needs constant peripheral stimulation, but due to the fact that there are no nerve endings information does not enter the sensory cortex. As a result, the sensations of this limb are borrowed from memory in the form of somatosensory memory [14]. Along with this, the pathological determinant of the central nervous system, which appeared during amputation, is emotionally colored, which determines the ways of the recurrence of PLP, since in long-term memory the pathological determinant is preserved as an affect. After that, the emotional reaction in any pain syndrome that has appeared for another reason is activated and includes the previous pain or paresthetic reaction in the missing limb. In addition, according to some studies [3], [7], [9], [10] a sharp decrease in mood also leads to activation of the phantom pain.

Thus, the aim of the study was to determine the role of emotional state in PLP of cancer patients with limb amputation. Research objectives:

  1. Determination of the relationship between the level of severity of PLP and the emotional state of the patient.
  2. Identification of the relationship between the emotional state of the patient and the effectiveness of comprehensive prevention of PLP.

Methods

The emotional state of the patients was studied by Alexandrovich's Symptomatic Questionnaire, the severity of PLP was studied by a Visual Analog Scale (VAS)

The following methods were included in the prevention complex:

  1. Mirror therapy [18] stimulates the necessary part of the sensory cortex through reversion.
  2. Visualization methods for the formation of a motor program after limb amputation [11].
  3. Neuromuscular relaxation helps to stabilize the emotional state [2].
  4. Transcranial electrical stimulation (TES) is a non-invasive physiotherapeutic method used to stabilize homeostasis during stress. In particular, tES stabilizes the emotional state and reduces pain [1], [8].

 The comprehensive preventive program of thePLP was carried out for 7 days, 2 times a day. Transcranial electrical stimulation was performed daily 1 time a day.

12 patients (7 men, 3 women) after limb amputation aged from 35 to 67 years (mean age 55, 2 years) were studied. All patients had malignant bone cancer.

Results

The relationship between the emotional state and the severity of PLP was determined using correlation analysis r Pearson (p=0,05). The study by Alexandrovich 's Symptomatic Questionnaire revealed: somatic disorders (M=63,9); anxiety, tension (M=21,1; r=0,41); neurasthenic disorders (M=19,5; r=0,371); hysterical disorders (M=17,5); fear, phobias (M=15,9); depressive disorders (M=14,9); sleep disorders (M=14,1); hypochondriac disorders (M=12,5; r=0,587); asthenic disorders (M=10,3); obsessions (M=9,7); sexual disorders (M=9); difficulties in social contacts (M=8,1); derealization (M=6,9).

Somatic disorders have the greatest severity, since the patients were in the postoperative period. Correlation analysis has shown that there is a relationship between the severity of PLP and hypochondriac reactions of patients. In addition, there are direct correlations of the strength of PLP and anxiety and tension of patients and neurasthenia. Therefore, we can say that the nature of the emotional state is reflected in the severity of phantom pain and phantom sensations.

To assess the effectiveness of preventive measures, a comparative analysis was carried out using the Mann-Whitney criterion, at p=0,05. The first group consists of patients whose phantom sensations and pains have not resumed after 3 months after comprehensive prevention of PLP – 6 patients; the second group consists of patients with renewed PLP – 6 patients.

The severity of PLP one day after amputation was recorded at an average level of 5,73 points according to VAS. After comprehensive prevention of FBS, this value decreased to 1-2 points, in some cases to 0. Consequently, the severity of PLP did not affect the effectiveness of preventive measures. But the subsequent resumption of PLP was observed in 50% of cases, especially among patients prone to phobic reactions, along with a tendency to anxiety, tension and hypochondriac response.

A statistically significant difference was found only on the scale of fear and phobias, the average results on this scale were significantly higher in the second group (M1=10; M2=30,4; U=4). Hence, the resumption of phantom pains and sensations is noted in patients whose emotional state is characterized by presence of fears and phobias.

Discussion

The analysis of the results of the study revealed the relationship between PLP and the emotional state of patients, which is consistent with the data of other domestic [12] and foreign studies [13], [15], [16].

Patients with phantom pain have reactions to cancer diagnosis, fear of surgical treatment, feelings associated with loss, the need to form a new mental and physical adaptation.

First of all, the diagnosis of cancer is stigmatized in the modern society and is sometimes perceived as threat to life. Secondly, patients has been subjected to a crippling operation. In addition, the postoperative period is associated with such a pronounced pain syndrome that the use of narcotic drugs is required for its relief. Detection of the absence of a limb after surgery, or the fact that the limb could not be preserved, as expected before the operation, includes the experience of annoyance, or only loss. A violation of the patient's body schema and the experience of sensations in the phantom limb reveals itself. Along with this, there is a need to develop new skills to adapt to the prevailing circumstances. New ways of psychophysical adaptation, developed through pain, the need to learn to walk again, or perform habitual actions in another way leads to overwork and exhaustion of the patient. Thus, there is a picture of pronounced emotional tension, contributing to strengthening of PLP.

Alexandrovich 's Symptomatic Questionnaire presents the entire spectrum of emotional and somatic disorders, correlations between the severity of PLP and oemotional disorders in patients are found in relation to those scales that have a higher average value, the only exception is the scale of somatic complaints. This makes it possible to assume the dependence of the strength of the manifestation of PLP on the degree of tension of the emotional state.

Phantom pain becomes chronic due to the formation of a pathological dominant - a stable connection of emotional reactions and somatic disorders [6]. Therefore, PLP cannot be chronic during the first 7 days after surgery, since somatic complaints are not yet associated with the strength of phantom pains and sensations.

  1. P. Il'in pointed out that the strongest emotional reaction of a person is fear [4]. The feeling of fear causes the PLP after discharge from the hospital. Thus, psychological prevention and correction of feelings of fear are required, which will reduce the risk of recurrence PLP.

The results of the study indicate the importance of the patient's emotional state in relation to the severity of phantom sensations and pains. The effectiveness of comprehensive prevention of PLP depends on the motivation of the patient and his emotional reactions. From a practical point of view, the detection of a tendency in patients to react to stress with a sense of fear requires special attention from psychologists. In this case, it is recommended to conduct additional psychotherapeutic sessions in order to prevent such reactions that cause an increase PLP.

Conclusion

  1. The emotional state of cancer patients has a relationship with the severity of PLP after limb amputation. The connection with hypochondriac reactions is mainly expressed.
  2. The relationship between the effectiveness of comprehensive prevention of PLP and the emotional state characterized by fears and phobias was found.
Конфликт интересов Не указан. Conflict of Interest None declared.

 

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  14. Flor H. Phantom limb pain: cortical plasticity and novel therapeutic approaches / H. Flor, N. Birbaumer // Curr Opin Anaesthesiol.– 2000, 13(5). – P. 561-4. DOI:11097/00001503-200010000-00013
  15. Flor H. Phantom-limb pain: characterics, causes, and treat-ment / H. Flor // lancet Neurol. – 2002. Vol. 25, № 4. – 272–274. DOI:10.1016/s1474-4422(02)00074-1
  16. Khotkova H. Current and future options for the management of phantom-limb pain / H. Khotkova, A. Cruciani,  V. M. Tronnierand others //J. Pain res. – 2012. Vol. 5. – P. 39–49. DOI: 10.2147/JPR.S16733
  17. Probstner D. Phantom limb phenomena in cancer amputees / D. Probstner, L.C.S. Thuler, N.M. Ishikawaand others // Pain Practice. – 2010. 10(3). – P. 249-256. DOI: 10.1111/j.1533-2500.2009.00340.x
  18. Ramachandran V. S. Plasticity and functional recovery in neurology / V. S. Ramachandran // Clin Med. – 2005. Vol. 5. – P. 368-373. DOI: 10.7861/clinmedicine.5-4-368
  19. Scott J. Graphic representation of pain / J. Scott, E. C. Huskisson // Pain, 1976. 2 (2). – P. 175–184.