Dynamic changes in the perceived posture of the hand during ischaemic anaesthesia of the arm.

Contorted 'phantom' limbs often form when sensory inputs are removed, but the neural mechanisms underlying their formation are poorly understood. We tracked the evolution of an experimental phantom hand during ischaemic anaesthesia of the arm. In the first study subjects showed the perceived posture of their hand and fingers using a model hand. Surprisingly, if the wrist and fingers were held straight before and during anaesthesia, the final phantom hand was bent at the wrist and fingers, but if the wrist and fingers were flexed before and during anaesthesia, the final phantom was extended at wrist and fingers. Hence, no 'default' posture existed for the phantom hand. The final perceived posture may depend on the initial and evolving sensory input during the block rather than the final sensory input (which should not differ for the two postures). In the second study subjects selected templates to indicate the perceived size of their hand. Perceived hand size increased by 34 ± 4% (mean ± 95% CI) during the block. Sensory changes were monitored. In all subjects, impairment of large-fibre cutaneous sensation began distally with von Frey thresholds increasing before cold detection thresholds (Aδ fibres) increased. Some C fibres subserving heat pain still conducted at the end of cuff inflation. These data suggest that changes in both perceived hand size and perceived position of the finger joints develop early when large-fibre cutaneous sensation is beginning to degrade. Hence it is unlikely that block of small-fibre afferents is critical for phantom formation in an ischaemic block.