The Role of Psychological Interventions in the Treatment of a Psychogenic Jumpy Stump
Divya Parashar
Clinical and Rehabilitation Psychologist, New Delhi, India
Date of Submission 02-Jul-2016
Date of Acceptance 31-Jan-2020
Dr. Divya Parashar
Back 2 Fitness, G-6 Triveni Commercial Complex Sheikh Sarai-Phase 1, New Delhi - 110 017
DOI: 10.4103/jotr.jotr_24_16
The aim of the study was to describe (i) the role of a psychologist in the assessment and management of a jumpy stump with a clinical picture of severe pain, fasciculations, and psychological symptoms and (ii) the key role of the psychological intervention of acceptance and commitment therapy (ACT) in working with symptoms of severe pain concomitant with emotional and behavioral disruptions. This was a case study done at a pain clinic at a private hospital. A 14-year-old boy presented to the hospital with an above knee amputation due to a congenitally malformed leg. The psychological intervention was based on the ACT and noninvasive physical therapy modalities. The main outcome measures were Self-Report for Childhood Anxiety Related Disorders, Mood and Feelings Questionnaire, and the Pain Catastrophizing Scale. A significant reduction in pain and fasciculations in the stump along with an improvement in the psychological functioning of the patient was observed after the intervention by the pain management team. The fact that the somatic symptoms responded to psychological interventions rapidly and consistently points to the jumpy stump being psychogenic in etiology. A thorough psychological evaluation and intervention must be done in movement disorders arising out of peripheral nerve injury because psychological stressors are now increasingly being known to influence these conditions.
Keywords: Acceptance and commitment therapy, amputation, jumpy stump, rehabilitation
Parashar D. The Role of Psychological Interventions in the Treatment of a Psychogenic Jumpy Stump. J Orthop Traumatol Rehabil 2020;12:150-2
Parashar D. The Role of Psychological Interventions in the Treatment of a Psychogenic Jumpy Stump. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2021 Jan 20];12:150-2. Available from: https://www.jotr.in/text.asp?2020/12/2/150/305080
Jumpy stump is defined as a movement disorder that Occurs after a limb amputation, and although its pathogenesis remains to be elucidated, it has been documented to be related to a peripheral nerve injury.[1],[2] While a known organic cause is often the reason for the jerky movements, the occurrence of a psychogenic jumpy stump has been reported in the literature,[3] wherein paroxysmal rhythmical jerking movements of the stump were associated with palpable muscle activation in the proximal limb. Several features consistent with a psychogenic origin, including variability, distractibility, and comorbid psychiatric features were found to be dominant. To further elaborate on the occurrence of a psychogenic jumpy stump, we report such a case which demonstrated the efficacy of a psychological intervention.
A 14-year-old boy had presented with severe pain along with involuntary jerky movements in the right thigh stump 2 years after an above knee amputation due to a congenitally malformed leg. The patient was asymptomatic for the first 2 years after amputation when he started experiencing involuntary jerky movements in the stump region, which increased over a few minutes. These involuntary contractions were intermittent, initially not associated with any kind of pain, usually appeared after removing the prosthesis repeating every few minutes and disappeared during sleep. There were no phantom sensations or pain in the absent limb. The previous treatments included a stump neuroma excision, botulinum toxin injection locally into the stump, after which the pain increased substantially, and oral medications such as anticonvulsants (pregabalin and gabapentin) which had no effect on the pain or the involuntary movements. On examination of the stump, there was a patch of hypoesthesia at the tip. No hyperesthesia, allodynia, or temperature difference was observed between the two extremities. The jerky movements started once the child removed the prosthesis, from the distal portion of the stump gradually increasing to involve the entire stump. He appeared to be anxious and depressed and had reported absenteeism from school for the past 6 months. A psychological assessment was planned, and noninvasive treatments with cold packs, transcutaneous electrical nerve stimulation (TENS), and laser at 15 J/cm2 were started simultaneously.
The psychological case conceptualization began with the child's presenting problems of severe pain and the jerky movements in the stump which interfered with mood, attendance and participation at school, and his interpersonal relationships. Psychological assessment included interviews with the child and his parents, Mood and Feelings Questionnaire – Self and Parent, Self-Report for Childhood Anxiety Related Disorders (SCAREDs) – Self and Parent, and Pain Catastrophizing Scale (PCS). The assessments revealed the following specific components: a clinical interview with the parents and the child that reported: behavioral: absenteeism from school, social withdrawal, crying, physical aggression, passivity, and being manipulative; emotional: sadness, anxiety, and irritability; interpersonal: no friends; repeated criticism and rebukes from father, increase in family conflicts, and resulting in both parents being distressed; physiological: headaches, pain and fasciculations in the stump, and disrupted sleep; excessive sweating; and cognitive: catastrophizing thoughts such as "My pain will never end." "I just can't go on like this anymore."
On the initial assessment, the child reported a score of 25 on the Mood and Feelings Questionnaire, while the parents reported a score of 19, both indicating the presence of a depressive disorder (cutoff score of 12 or higher). On the SCARED, the child reported a score of 23, and the parents reported a score of 41, both indicating the presence of anxiety. The PCS and the Pain Self-Efficacy Questionnaire were administered over two intervals with a gap of 8 weeks between each assessment.
Initial interviews with the patient and his parents showed a high variability in his reports of pain and fasciculations which appeared discrepant with clinical observations and reports by the physiotherapist and parents. He continued to show avoidance toward school, complained of insomnia and anxiety, was preoccupied with the pain and fasciculations, demonstrated pain catastrophizing behaviors and reduced self-efficacy in coping with pain, and remained socially withdrawn.
Virtual reality sessions were done and it was found that the muscle spasms or pain were almost absent when he was engrossed in gaming or other activity. The patient did not respond significantly to the initial intervention by the physical therapist, during which time the psychologist's opinion was sought. After 2 weeks of daily physiotherapy and psychotherapy sessions, the child's pain improved by around 20% and fasciculations improved by 40% as reported by him.
The psychological intervention strategy chosen was acceptance and commitment therapy(ACT) with its focus on the restoration of effective and adaptive functioning within a context of continuing pain.[4] The clinical goals of ACT include the general loosening of verbally based influences on behavior, the strengthening of present-focused awareness, and increasing flexibility in responding to aversive experiences so that this response is more congruent with a vital and meaningful living.[4]
The core therapeutic processes[5] that were adopted were as follows:
Contacting the present moment: After establishing an effective therapeutic relationship with the child, an attempt was made to enable him to engage in whatever is happening in the present moment, with a focus away from the distressing thoughts and worries about the future, so that he is able to flexibly bring awareness to both the physical environment and the psychological resources within
Defusion: Cognitive defusion focused on enabling the child to step back and detach from the catastrophizing thoughts related to the pain and his experiences at school. He was guided to see his thoughts for what they were and the debilitating impact they had on him
Acceptance: This process enabled an experience of opening up and making room for painful feelings, sensations, and emotions. Using mindfulness techniques with a focus on coping, the painful symptoms and resulting complications were seen as they are. Instead of getting overwhelmed, the child was taught to open up to them and to let them be
Pure awareness: To enable the child to have access to a psychological space wherein he could observe his own experiences without being caught up in it. It provided a safe viewpoint from which to observe and accept his maladaptive thoughts and behaviors to recognize that there is a place inside where no matter how great the pain is, it cannot harm him
Values: An attempt was made to engage the child in seeing onward, his focus in life, what was important to him, what he wanted to attain, and what truly brought him joy and purpose. Uncovering those important core values guide ongoing action
Committed action: The child was guided into taking effective action, guided by his important life values. This gave rise to a wide range of thoughts and feelings, both pleasant and unpleasant using the behavioral interventions of goal setting, assertiveness skills training, behavioral activation, and problem-solving coping.
At the end of the 2 months, the child reported a 100% improvement in pain, with a complete elimination of the jerky movements. His mood and coping behaviors improved along with his interpersonal relationships, and he returned to school. The scores on the postintervention assessments are also presented in [Table 1].
Table 1: Psychological evaluation on admission and postintervention
A jumpy stump is defined as a movement disorder that occurs after limb amputation presenting either as myoclonic spasms, jerky movements, or tremulous movements. Most of the movement disorders are attributed to disorders of extrapyramidal system, but in some involuntary movement disorders such as amputation stump dyskinesias, a peripheral origin is relatively well established, though a direct causal association is not recognized. It is thought that pain and movement disorder after peripheral nerve injury are closely related and that pain might be a specific trigger for the subsequent development and persistence of involuntary movements, the fact that in our case pain followed the involuntary spasms.
The patient however showed several features consistent with a psychogenic origin including distractibility, variability, and other comorbid psychological features. The child was found to be anxious and depressed, in line with an adjustment disorder, demonstrating a typical illness behavior along with avoidance behavioral patterns. The fact that these abnormal myoclonic spasms were absent during the use of the prosthesis, also while he was engaged in a pleasurable activity, during sleep, and also the reduction in pain and jerky movements resulting from the psychological intervention further reinforced our clinical observation that perhaps this jumpy stump might be psychogenic.
ACT was the chosen intervention method with this child because of its inherent appeal of being action oriented, getting in touch with the innermost feelings and values, taking mindful action, and the easy implementation and selection of the plethora of psychological skills that enable the client to handle painful thoughts and feelings effectively.
Similar case reports are available in the literature, and we would believe that in all such cases of jumpy stump, a thorough psychological evaluation and intervention must be done because conditions such as stress, anxiety, and depression, and possibly factitious disorders are known to have an effect on such movement disorders arising out of peripheral nerve injury.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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