Experimental Brain Research

, Volume 236, Issue 6, pp 1815–1824 | Cite as

Referred cramping phantom hand pain elicited in the face and eliminated by peripheral nerve block

  • Caroline Dietrich
  • Sandra Nehrdich
  • Annette Zimmer
  • Alexander Ritter
  • Gunther O. Hofmann
  • Wolfgang H. R. Miltner
  • Thomas Weiss
Research Article


Phantom limb pain is a restricting condition for a substantial number of amputees with quite different characteristics of pain. Here, we report on a forearm amputee with constant phantom pain in the hand, in whom we could regularly elicit the rare phenomenon of referred cramping phantom pain by touching the face. To clarify the underlying mechanisms, we followed the cramp during the course of an axillary blockade of the brachial plexus. During the blockade, both phantom pain and the referred cramp were abolished, while a referred sensation of “being touched at the phantom” persisted. Furthermore, to identify the cortical substrate, we elicited the cramp during functional magnetic imaging. Imaging revealed that referred cramping phantom limb pain was associated with brain activation of the hand representation in the primary sensorimotor cortex. The results support the hypothesis that referred cramping phantom limb pain in this case is associated with a substantial brain activation in the hand area of the deafferented sensorimotor cortex. However, this alone is not sufficient to elicit referred cramping phantom limb pain. Peripheral inputs, both, from the arm nerves affected by the amputation and from the skin in the face at which the referred cramp is evoked, are a precondition for referred cramping phantom limb pain to occur, at least in this case.


Phantom limb pain Cramping Brachial plexus Referred sensation Sensorimotor cortex 



Thanks to Gerd F. Volk, Winfried Meissner, and Holger Hecht for help with data acquisition. This work was supported by the German Social Accident Insurance (DGUV-FR145 and FR196). DGUV neither influenced the study goals of study design; authors are fully responsible for goals, design, and results. The funding source had no involvement in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

Compliance with ethical standards

Conflict of interest

There is no conflict of interest for any author of this study.


  1. Devor M, Vaso A, Adahan HM, Vyshka G (2014) PNS origin of phantom limb sensation and pain: reply to Letter to the Editor regarding Foell et al. Peripheral origin of phantom limb pain: Is it all resolved? PAIN 155:2207–2208. CrossRefPubMedGoogle Scholar
  2. Ephraim PL, Wegener ST, MacKenzie EJ, Dillingham TR, Pezzin LE (2005) Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. Arch Phys Med Rehabil 86:1910–1919. pii]CrossRefPubMedGoogle Scholar
  3. Flor H, Elbert T, Knecht S et al (1995) Phantom-limb pain as a perceptual correlate of cortical reorganization following arm amputation. Nature 375:482–484CrossRefPubMedGoogle Scholar
  4. Flor H, Nikolajsen L, Jensen TS (2006) Phantom limb pain: a case of maladaptive CNS plasticity? Nat Rev Neurosci 7:873–881. CrossRefPubMedGoogle Scholar
  5. Flor H, Diers M, Andoh J (2013) The neural basis of phantom limb pain. Trends Cognit Sci 17:307–308CrossRefGoogle Scholar
  6. Foell J, Andoh J, Bekrater-Bodmann R, Diers M, Fuchs X, Colloca L, Flor H (2014) Peripheral origin of phantom limb pain: Is it all resolved? PAIN 155:2205–2206. CrossRefPubMedGoogle Scholar
  7. Götz T, Huonker R, Miltner WH, Witte OW, Dettner K, Weiss T (2010) Task requirements change signal strength of the primary somatosensory M50: Oddball vs. one-back tasks. Psychophysiology. PubMedCrossRefGoogle Scholar
  8. Kikkert S, Kolasinski J, Jbabdi S, Tracey I, Beckmann CF, Johansen-Berg H, Makin TR (2016) Revealing the neural fingerprints of a missing hand. Elife 5Google Scholar
  9. Klingner CM, Hasler C, Brodoehl S, Witte OW (2010) Dependence of the negative BOLD response on somatosensory stimulus intensity. Neuroimage 53:189–195CrossRefPubMedGoogle Scholar
  10. Knecht S, Henningsen H, Elbert T et al (1995) Cortical reorganization in human amputees and mislocalization of painful stimuli to the phantom limb. Neurosci Lett 201:262–264CrossRefPubMedGoogle Scholar
  11. Knecht S, Henningsen H, Elbert T, Flor H, Hohling C, Pantev C, Taub E (1996) Reorganizational and perceptional changes after amputation. Brain 119:1213–1219CrossRefPubMedGoogle Scholar
  12. Knecht S, Henningsen H, Hohling C, Elbert T, Flor H, Pantev C, Taub E (1998) Plasticity of plasticity? Changes in the pattern of perceptual correlates of reorganization after amputation. Brain 121:717–724CrossRefPubMedGoogle Scholar
  13. Kuner R, Flor H (2017) Structural plasticity and reorganisation in chronic pain. Nat Rev Neurosci 18:20CrossRefGoogle Scholar
  14. Makin TR, Scholz J, Filippini N, Slater DH, Tracey I, Johansen-Berg H (2013) Phantom pain is associated with preserved structure and function in the former hand area. Nat Commun 4:1570. CrossRefPubMedPubMedCentralGoogle Scholar
  15. Mercier C, Reilly KT, Vargas CD, Aballea A, Sirigu A (2006) Mapping phantom movement representations in the motor cortex of amputees. Brain 129:2202–2210CrossRefPubMedGoogle Scholar
  16. Preissler S, Dietrich C, Meissner W, Huonker R, Hofmann GO, Miltner WHR, Weiss T (2011) Brachial plexus block in phantom limb pain: a case report. Pain Med 12:1649–1654. CrossRefPubMedGoogle Scholar
  17. Price DD, McGrath PA, Rafii A, Buckingham B (1983) The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain 17:45–56 doi. CrossRefPubMedGoogle Scholar
  18. Raffin E, Richard N, Giraux P, Reilly KT (2016) Primary motor cortex changes after amputation correlate with phantom limb pain and the ability to move the phantom limb. NeuroImage 130:134–144CrossRefPubMedGoogle Scholar
  19. Ramachandran VS (1993) Filling in gaps in perception: part II. Scotomas and phantom limbs. Curr Dir Psychol Sci 2:56–65CrossRefGoogle Scholar
  20. Ramachandran VS, Rogers-Ramachandran D, Cobb S (1995) Touching the phantom limb. Nature 377:489–490CrossRefPubMedGoogle Scholar
  21. Rolke R, Baron R, Maier C et al (2006) Quantitative sensory testing in the German Research Network on Neuropathic Pain (DFNS): Standardized protocol and reference values. Pain 123:231–243. CrossRefPubMedGoogle Scholar
  22. Sens E, Knorr C, Preul C, Meissner W, Witte OW, Miltner WH, Weiss T (2013) Differences in somatosensory and motor improvement during temporary functional deafferentation in stroke patients and healthy subjects. Behav Brain Res 252:110–116CrossRefPubMedGoogle Scholar
  23. Sherman RA (ed) (1997) Phantom pain. Plenum Press, New YorkGoogle Scholar
  24. Sherman RA, Gall N, Gormly J (1979) Treatment of phantom limb pain with muscular relaxation training to disrupt the pain-anxiety-tension cycle. Pain 6:47–55. CrossRefPubMedGoogle Scholar
  25. Vaso A, Adahan H-M, Gjika A, Zahaj S, Zhurda T, Vyshka G, Devor M (2014) Peripheral nervous system origin of phantom limb pain. Pain 155:1384–1391CrossRefPubMedGoogle Scholar
  26. Weiss T (2016) Plasticity and cortical reorganization associated with pain. Zeitschrift für Psychologie 224:71–79CrossRefGoogle Scholar
  27. Weiss T, Miltner WHR, Dillmann S, Meissner W, Huonker R, Nowak H (1998) Reorganization of the somatosensory cortex after amputation of the index finger. Neuro Rep 9:213–216Google Scholar
  28. Weiss T, Miltner WHR, Liepert J, Meissner W, Taub E (2004) Rapid functional plasticity in the primary somatomotor cortex and perceptual changes after nerve block. Eur J Neurosci 20:3413–3423CrossRefPubMedGoogle Scholar
  29. Weiss T, Sens E, Teschner U, Meissner W, Preul C, Witte OW, Miltner WHR (2011) Deafferentation of the affected arm: a method to improve rehabilitation? Stroke 42:1363–1370. CrossRefPubMedGoogle Scholar
  30. Winter C, Fritzsche K, Karl A, Huse E, Larbig W, Grusser SM, Flor H (2001) The phantom and stump phenomena interview (PSPI). Schmerz 15:172–178CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Caroline Dietrich
    • 1
  • Sandra Nehrdich
    • 1
  • Annette Zimmer
    • 2
  • Alexander Ritter
    • 3
  • Gunther O. Hofmann
    • 4
    • 5
  • Wolfgang H. R. Miltner
    • 1
  • Thomas Weiss
    • 1
  1. 1.Department of Clinical PsychologyFriedrich Schiller UniversityJenaGermany
  2. 2.Department of Anesthesiology and Intensive Care MedicineUniversity Hospital JenaJenaGermany
  3. 3.Department of Neurology, Section Neurological RehabilitationUniversity Hospital JenaJenaGermany
  4. 4.Berufsgenossenschaftliche Kliniken Bergmannstrost Halle/SaaleHalleGermany
  5. 5.Department of Trauma, Hand and Reconstructive SurgeryUniversity Hospital JenaJenaGermany

Personalised recommendations