It describes the pain in the body part that is no longer present, which occurs in 50–80% of all amputees. It has been argued that preamputation pain increases the risk of phantom pain and that phantom pain is a revivification of pain experienced before the amputation. Do you want to read more similar stories? Introduction. This pain may be related to a certain position or movement of the phantom and may be elicited or exacerbated by a range of physical factors (e.g., changes in weather or pressure on the residual limb) and psychological factors (e.g., emotional stress). The phantom pain after EA is similar to the phantom pain known from limb amputees. Residual limb pain, sometimes called stump pain, is a type of pain felt in the part of a limb that remains after an amputation. Inclusion crite-ria was a baseline pain score of ‡3 using 0 to 10 numerical rating scale (NRS). Since little is kno … Phantom pain is a perception that an individual experiences relating to a limb or an organ that is not physically part of the body. All patients had general anaesthesia for the amputation and were asked about stump and phantom pain after 1 week and then after 3, 6, and 12 months by two independent examiners. Physiopathology is complex and peripheral, medullar and cortical mechanisms are combined. The goal of pain management is to reduce pain levels to allow you to get you back to living and enjoying life again. Phantom limb pain/sensation is common for most people after amputation surgery. Recent evidence suggests that telescoping is associated with more phantom-limb pain. Phantom or Stump pain Phantom pain can occur anywhere where a part of the body has been lost due to an operation or injury, such as an arm, leg, breast, teeth, eye, ear etc. Phantom pain can also occur in other parts of the body; it has been described after mastectomies and enucleation of the eye. As of January 2020, over 553 citations in MEDLINE have “phantom limb pain” as a title word. The treatment of phantom limb pain should focus on correcting underlying predisposing conditions, including the development of neuromas or painful bone spurs in the stump. For instance, lingering stump problems such as scars, neuromas (a post-amputation growth containing nervous-system tissue), or bone spurs can directly influence the intensity and duration of phantom pain. We strive to make an early and accurate diagnosis of acute and chronic pain disorders to reduce the physical, financial, emotional, and lifestyle costs of pain. It is usually very sensitive to touch or pressure. Non-steroidal anti-inflammatory drugs (NSAIDs), THINGS YOU SHOULD KNOW IF YOU ARE IN A CAR ACCIDENT. Phantom pain may be caused by damaged nerve endings, scar tissue at the amputation site, and the physical memory of. The missing body part continues to be perceived as painful, sometimes burning and hot or itchy. Stump (residual limb) pain is ongoing discomfort at the amputation site. PAP can be isolated to the amputation stump or can occur as phantom pain, the latter being a more common cause with complex neurologic or psychosocial mechanisms postulated as underlying mechanism. The clinic staff and doctors have made the entire process easy and comfortable for me. People with arm or hand amputations show a shift of the mouth into the hand representation in the primary somatosensory cortex. Phantom limb pain, stump pain and phantom limb sensation describe conditions that commonly affect people who have lost a limb : Phantom limb pain is pain that feels as though it is in the lost limb. Deep brain stimulation also has been reported to treat phantom limb pain. It seems to be more intense in the distal portions of the phantom limb. Although there's no medical test to diagnose phantom pain, doctors identify the condition based on your symptoms and the circumstances, such as trauma or surgery, which occurred before the pain started.Describing your pain precisely can help your doctor pinpoint your problem. However, abnormal input originated from a neuroma in the residual limb may increase the amount of central reorganization, enhancing the chance of phantom-limb pain. Poorly fitting prosthetics or limb bruising can cause residual limb pain as well. Stump pain However, stump pain may coexist with phantom limb pain. Dr. David Lipkin answered: "See below: Phantom limb pain is a diagnosis of exclusion after the following causes of PERSISTENT Stump pain are ruled out: ischem..." Ask doctors free A 30-year-old female asked: With phantom pain, the patient perceives pain in a body part that s no longer even there. Phantom limb pain is a common and difficult condition to treat. Pain in the phantom is often similar to the pain felt in the limb before amputation. About 30% of persons with amputation report the feeling of telescoping, i.e., the retraction of the phantom towards the residual limb and in many cases, the disappearance of the phantom into the limb. The intensity of stump and phantom pain was recorded every day on a numeric rating scale (0-10) during the 30-day treatment period. Some of the effects of phantom limb pain can be alleviated with the use of oral medications, which help reduce pain from nerves. can affect up to 80% of patients after an amputation and daily pain is reported in nearly half of all amputees. Patients who lack coping strategies, fear the worst, or receive less social support, tend to report more phantom-limb pain. Pain can have several different qualities, such as stabbing, throbbing, burning, or cramping. Reorganization of the somatosensory cortex of the human cerebral cortex in amputees has been supported by findings from several imaging studies. Stump pain and phantom pain are interconnected. Phantom Limb Pain and Stump Pain Weir Mitchell coined the term phantom-limb pain in 1872. The phantom limb pain can be severe and distressing, for which current treatments have limited and variable efficacy. Transcutaneous nerve stimulation (TENS) may have a minor effect on phantom-limb pain. It is often confused with “Stump Pain” where the pain is localised only to the stump of the amputated limb. The primary aim of this study is to compare the prevalence of phantom limb pain between two groups of amputees in New Zealand and Cambodia. A common reason for eye amputation is … Others have described constant severe pain. Phantom pain was defined as pain experienced in the missing part of the limb. Treatment for phantom limb pain has been difficult. As nerves damaged in your amputation surgery try to heal, they sometimes form abnormally sensitive regions called neuromas, causing stump pain. Coblation technology is a relatively new technology that has shown promise in treating neuropathic pain. On the same scale the means of their least and worst phantom pain were 3.6 (SEM 0.15) and 7.8 (0.15), respectively. It seems to be more intense in the Phantom limb pain is common after extremity amputation, and documented predictors of this pain include preamputation pain and persistent stump pain (acute and chronic). Stump pain was defined as pain localized to the region of the stump. Your phantom limb pain/sensation can be managed so that it does not overwhelm your life. Phantom limb pain is a complicated disorder affecting 60–80% of amputees .Neurological changes in the periphery, spinal cord, and cerebral cortex are all likely to contribute to phantom limb pain .. Standing, walking and muscle stretching not only improve your general health, but also interrupt pain signals. Symptoms include: Although there are no medical tests to diagnose stump and phantom limb pain, the conditions can be identified by collecting information about the symptoms and thorough clinical examination. Begin exercises as soon as your surgeon allows it. Ten individuals with a transtibial amputation and persistent moderate‐to‐severe phantom and/or stump pain were recruited. Another patient reported mild phantom and stump pain. It may occur soon after the surgery, often within the first week, but may also last beyond healing. PMIR’s pain and spine specialists can help you discover the type and cause of the pain effectively. Use of prostheses in the patients was <8 hours a day. phantom and/or stump pain were recruited. Phantom limb pain feels like it is coming from the body part that is no longer there, although nerve endings actually cause it at the amputation site that sends pain signals to the brain. Phantom limb pain can be mild to agonizing and even disabling for some. Only four patients received medical treatment for their phantom pain. Some of the effects of phantom limb pain can be alleviated with the use of oral medications, which help reduce pain from nerves. Five techniques for managing post-amputation pain PLP with stump pain and phantom limb sensation Among the patients with PLP, SP was present in 10, 12, and 8 patients, while PLS was present in 27 (47.36%), 33, and 23 patients at 3, 6, and 12 months, respectively. Phantom pain is most common after the amputation of an arm or leg, but it may also occur after the surgical removal of other body parts, such as breast, rectum, penis, testicle, eye, tongue, or teeth. Quite often, multiple treatments may be used. Phantom limb pain feels like it is coming from the body part that is no longer there, although nerve endings actually cause it at the amputation site that sends pain signals to the brain. Inclusion criteria was a baseline pain score of ≥3 using 0 to 10 numerical rating scale (NRS). No matter the cause of residual limb pain, the following methods can help you manage your pain. Background: Amputee pain may present in a body part that has been amputated (phantom pain) or at the site of amputation (stump pain), or both. The prevalence of PLP was significantly lower in developing countries compared to developed countries [53.98% vs 64.55%; p=0.04]. New research concludes that the two types of pain are separate sensations. Phantom-limb pain is commonly confused with pain in the area adjacent to the amputated body part. Psychological factors also play a role in the modulation of phantom-limb pain. Results: Results from 41 patients were included in the data analysis. The concept of pathophysiology at that time was that phantom limb pain was an example of facilitation due to central excitatory states at the highest integrative level (Hardy et al 1952). This pain is referred to as residual-limb or stump pain. Risk factors for the development of phantom limb pain include persistent stump pain, bilateral and lower limb amputations and pre-amputation pain. Decreased blood flow in the residual limb is related to burning and tingling phantom and stump pain, whereas spasms in major muscles of the residual limb precede cramping phantom and stump pain. presence of stump pain, correlated with the presence or severity of phantom pain. There is insufficient evidence to support the routine use of preoperative epidural anaesthesia as a technique to prevent phantom limb pain. Doctors often find during a physical examination of a patient with phantom limb pain that the stump is tender and there is deterioration of tissue around the wound at the tip of the stump. The symptoms of phantom limb pain can range from mild to severe. There was a much higher unemployment rate in the Cambodian amputees. Some of the effects of phantom limb pain can be alleviated with the use of oral medications, which help reduce pain from nerves. Phantom limb pain: Painful sensations that are being experienced in the amputated limb; Phantom limb sensation: Sensations other than pain that are being experienced in the amputated limb; Stump pain: Pain localized to the amputated stump. Treatment of Phantom Pain by Transcutaneous Stimulation (TNS) of the Stump, the Limb Contralateral to the Stump, and the Other Extremities M. Gessler, A. Struppler, B. Oettinger Pages 93-98 The incidence of non-painful phantom limb, phantom pain and stump pain 8 days after surgery was 84, 72 and 57%, respectively. Onset within the first few days of amputation. The stump pain was completely relieved immediately after operation. Phantom pain and stump pain are complex and multidimensional and the underlying pathophysiology remains unclear. Five interviews were performed after 7, 14, and 30 days and after 3 and 6 months. Stump pain is located at the end of an amputated limb’s stump – and is caused by nerve damage in the stump region. The mainstay treatments for phantom pain and stump pain are predominately pharmacological. A maximum benefit of about 30% has been reported from treatments such as local anesthesia, sympathectomy, dorsal-root entry-zone lesions, cordotomy, rhizotomy, neurostimulation methods, or pharmacological interventions such as anticonvulsants, barbiturates, antidepressants, neuroleptics, and muscle relaxants. Other possible causes of phantom limb pain include damaged nerve endings and scar tissue from the amputation surgery. Pain Management Principles. Although there's no medical test to diagnose phantom pain, doctors identify the condition based on your symptoms and the circumstances, such as trauma or surgery, which occurred before the pain started.Describing your pain precisely can help your doctor pinpoint your problem. Preamputation pain significantly increased the incidence of stump pain (P =0.04) and phantom pain (P =0.04) after 1 week and the incidence of phantom pain after 3 months (P =0.03). Supraspinal changes related to phantom-limb pain involve the brainstem, the thalamus, and the cortex. Symptoms generally improve over time. Our Practice is committed to deliver personalized care to help improve our patients’ quality of life. During the 1-month treatment period, the intensity of stump and phantom pain was recorded every evening (mean intensity during the past 24 h). There were no other statistically significant differences between the groups Limb loss is a result of either removal by amputation or congenital limb deficiency. Severity and frequency of phantom limb and stump pain were similar (Table III; P = 0.980, P = 0.931, P = 0.951, P = 0.936, respectively). Phantom pain can also occur in other parts of the body; it has been described after mastectomies and enucleation of the eye. A significant association has been found between stump pain and phantom limb pain. A distinction should be made between phantom limb pain (painful sensations referred to the absent limb), phantom limb sensation (any sensation in the absent limb, except pain), and stump pain (pain localized in the stump), although each of these may coexist in an individual patient at different times . Recent literature shows that phantom and stump pain have closely related physiologic mechanisms and that treatments frequently overlap. Coblation of femoral and sciatic nerves was performed. Understanding Neuroma Formation. Often described as a shooting, stabbing, boring, squeezing, throbbing, or burning. Factors associated with phantom pain were ophthalmic pain before EA, the presence of an implant and patient reports of a high degree of conjunctival secretion. Anyone who undergoes an amputation can develop stump and phantom limb pain. Phantom pain refers to pain perceived in a missing body part and may occur in up to 50% to 80% of all amputees. The mean baseline levels of pain were high: with PLP, VAS had a mean of 7.2 (SD 2.0); with stump pain, VAS had a mean of 8.1 (SD 1.5). Overall activity was improved and there was no need for pain … The Index Medicus recognized this term in 1954. Postamputation pain was classified as previously described (Jensen and Rasmussen, 1994): stump pain was pain referred to the stump and phantom pain was any painful sensation referred to the missing limb. May also include feelings of coldness, warmth, itchiness, or tingling. Use of a myoelectric prosthesis may alleviate cortical reorganization and phantom-limb pain. Although tricyclic antidepressants and sodium-channel blockers are treatments of choice for neuropathic pain, there have been no controlled studies of these agents for phantom-limb pain. Inclusion criteria was a baseline pain score of ≥3 using 0 to 10 numerical rating scale (NRS). Stump pain is often described as sharp, burning, and electric. Some of the effects of phantom limb pain can be alleviated with the use of oral medications, which help reduce pain from nerves. Phantom limb pain is pain that is felt in the area where an arm or leg has been amputated. There was no difference in phantom limb pain and stump pain parameters among the 4 anesthesia groups. Pain can have several different qualities, such as stabbing, throbbing, burning, or cramping. The incidence and clinical picture of non-painful and painful phantom limb sensations as well as stump pain was studied in 58 patients 8 days and 6 months after limb amputation. Stump pain is believed to arise from nerve injuries at the site of the amputation and the resulting formation of neuromas, noncancerous tumors that grow out of the injured nerve fibers. Mean intensities of stump pain and phantom pain were 6.2 and 5.6, respectively (P 0.002). Phantom & Stump Pain; Sciatica; Shingles; Spinal Stenosis; Benefits of Nerve Blocks. Formation of neuroma or pressure-lesions of the stump may exacerbate the stump pain. This may be accompanied by a shrinking of the limb. The mechanisms underlying these perceptions could involve nervous system neuroplasticity and be reflected in altered sensory function of the residual limb. The aim of this pilot study was to gather data on the effect of TENS on phantom pain and stump pain at rest and on movement. Some of the effects of phantom limb pain can be alleviated with the use of oral medications, which help reduce pain from nerves. Over half the patients with phantom pain have stump pain as well. Peripheral factors play a significant role in the pathophysiology of stump pain and phantom limb pain. Phantom-limb pain may also be exacerbated by stress. Opioids, calcitonin, and ketamine have been proven to be effective in reducing phantom-limb pain in controlled studies. The first is Neuroma Pain (NP) and the second is Phantom Limb Pain (PLP). Phantom pain may respond to mixed brain signals as the spinal cord and brain lose input from the missing limb and adjust in unpredictable ways. if you like our Facebook fanpage, you can read everyday such amazing stories. At 1, 3, and 6 months postoperative review, 80% relief of both stump and phantom limb pain was achieved. Phantom pain typically occurs within the first week after an amputation, although in some cases, it can develop months or even years after surgery. A significant association was found between phantom pain and phantom sensations (relative risk 11.3) and between phantom pain and stump pain (relative risk 1.9). Risk factors for the development of phantom limb pain include persistent stump pain, bilateral and lower limb amputations and pre-amputation pain. The treatment of phantom limb pain should focus on correcting underlying predisposing conditions, including the development of neuromas or painful bone spurs in the stump. Stump pain: In many cases, those who suffer from phantom limb pain also experience pain around the area of their amputation. Phantom pain is a perception that an individual experiences relating to a limb or an organ that is not physically part of the body. Nerve blocks can be used to treat painful conditions, determine the sources of pain, provide short-term pain relief after some surgeries and predict how pain will respond to certain long-term treatments. About 42% of the patients reported that their phantom pain resembled the pain they had experienced at … Stump pain, phantom limb sensation and phantom limb pain are often combined. Celiac Plexus Block to Relieve Cancer Pain, Intercostal Nerve Block AKA Neurolytic Block. Physical examination may reveal the existence of a neuroma. Phantom limb pain is a common and difficult condition to treat. Of those receiving treatment, only 1% reported lasting benefits from any of a multitude of treatments attempted. The treatment of phantom limb pain should focus on correcting underlying predisposing conditions, including the development of neuromas or painful bone spurs in the stump. Most people with amputated limbs, up to 80%, feel pain in their stumps or in the area of the missing limbs. It describes the pain in the body part that is no longer present, which occurs in 50–80% of all amputees. Amputees may experience stump pain (SP), phantom limb (PL) sensations, pain, and/or a general awareness of the missing limb. 5 Pain may be related to certain positions or movements of the phantom and may be elicited or exacerbated by a range of physical factors (e.g., changes in weather or pressure on the residual limb) and psychological factors (e.g., emotional stress). The OR for developing SP and PLS with PLP was high. It is more likely to occur if the individual had chronic pain before the amputation. The significance of preamputation pain for the development of postamputation stump and phantom pain has been discussed over the years and is still a matter of dispute. Although the limb is gone, the nerve endings at the site of the amputation continue to send pain signals to the brain that make the brain think the limb is still there. This is not phantom pain, but pain originating from the stump. No other factors associated with phantom pain or phantom sensations could be determined. INTERPRETATION: Perioperative epidural blockade started a median of 18 h (15-20.3) before the amputation and continued into the postoperative period does not prevent phantom or stump pain. No conclusive studies have evaluated the effect of acute or subacute stump pain control on long-term stump pain or on long-term phantom limb pain. Over half the patients with phantom pain have stump pain as well. Studies in human amputees have shown that reorganizational changes also occur at the thalamic level and are closely related to the perception of phantom limbs and phantom-limb pain. Intensity of stump and phantom pain and consumption of opioids were similar in both groups at all four postoperative interviews. One patient reported mild phantom pain but severe baseline stump pain (VAS 8.6). Patients with phantom limb pain may have neuromas or abnormal clusters of nerve cells at the ends of the nerves that have been cut during the amputation. Even though it's common to have phantom pain and residual limb pain at the same time, treatments for these two problems may differ — so an accurate diagnosis is important. There is insufficient evidence to support the routine use of preoperative epidural anaesthesia as a technique to prevent phantom limb pain. Two outliers were identified. The treatment of phantom limb pain should focus on correcting underlying predisposing conditions, including the development of neuromas or painful bone spurs in the stump. Some people have described brief “flashes” of mild pain, similar to an electric shock, that last for a few seconds. The cause of chronic pain is not always obvious. Neuroma Pain. In the case of a type of chronic pain, known as referred pain, the patient perceives pain in one part of the body, but the source of pain is elsewhere in the body. There was no statistically significant difference in phantom limb sensation, phantom limb pain, or stump pain between the two groups. The aim of this pilot study was to gather data on the effect of TENS on phantom pain and stump pain at rest and on movement. Spinal mechanisms are characterized by increased excitability of the dorsal-horn neurons, reduction of inhibitory processes, and structural changes at the central nerve endings of the primary sensory neurons, interneurons, and the projection neurons. Changes along the neuroaxis may contribute to the experience of phantom-limb pain. Weir Mitchell coined the term phantom-limb pain in 1872. Ten individuals with a transtibial amputation and persistent moderate-to-severe phantom and/or stump pain were recruited. Pain, 18 (1984) 83-95 Eisevier PAI 00572 83 Chronic Phantom and Stump Pain among American Veterans: Results of a Survey Richard A. Sherman *, Crystal J. Sherman ** and Laura Parker *** * Psychophysiotogy Service, Department of Clinical Investigation, Dwight David Elsenhower Army Medical Center, Fort Gordon, Ga. 905, ** Medical Research Service. Treatment of Phantom Pain by Transcutaneous Stimulation (TNS) of the Stump, the Limb Contralateral to the Stump, and the Other Extremities M. Gessler, A. Struppler, B. Oettinger Pages 93-98 Even though it's common to have phantom pain and residual limb pain at the same time, treatments for these two problems may differ — so an accurate diagnosis is important. Neuroma in the stump may be more responsible for stump pain than phantom limb pain. Study endpoints were rate of stump and phantom pain, intensity of stump and phantom pain… We offer treatment options for stump and phantom limb pain that include: COPYRIGHT © 2020 PMIR | ALL RIGHTS RESERVED |PRIVACY POLICY|PERSONAL INJURY. The treatment of phantom limb pain should focus on correcting underlying predisposing conditions, including the development of neuromas or painful bone spurs in the stump. pain). The weather may trigger pain, pressure on the remaining limb part, or emotional stress. CASE REPORT: This report describes the use of coblation technology on femoral and sciatic nerve for stump pain and phantom limb pain. Patients may report severe, knife stabbing or sharp pain in at the end of the amputated limb. There are many types of stump and phantom limb pain. Usually, stump pain occurs if there is nerve damage from the incision or if an abnormal growth develops. It occurs in about half of people who have had an amputation. Limb loss is a result of either removal by amputation or congenital limb deficiency. Treating scar hyperalgesia on the stump with topical lidocaine may reduce the activity of peripheral nociceptive afferents and thus decrease the likelihood of developing persistent phantom limb pain. In terms of nerve related pain, amputees may experience two types of stump pain. A tendency to come and go rather than be constant. TENS was applied for 60 minutes to gen-erate a strong but comfortable TENS sensation at the site of stump pain or projected into the site of phantom pain. I’m eleven days out from my right below the knee amputation and while the surgical pain is lessening, the phantom pain is really kicking into high gear. Stump pain is located at the end of an amputated limb’s stump – and is caused by nerve damage in the stump region. Non-invasive treatment for stump and phantom limb pain is often a matter of trial and observation. Conclusion: Stump pain and stump sensation predominate traumatic amputees' somatosensory experience immediately after amputation; phantom pain and phantom sensations are often long-term consequences of amputation. Evaluation of phantom sensations.Duration, intensity, and frequency of phantom limb pain, nonpainful phantom sensations, stump pain, and stump sensations were investigated by a standardized interview (Flor et al., 1995) and the German version of the West Haven – Yale Multidimensional Pain Inventory (Kerns et al., 1985; Flor et al., 1990) modified to separately evaluate stump and phantom … Significantly lower in developing countries compared to developed countries [ 53.98 % vs 64.55 % ; ]... As a title word health, but may also last beyond healing and difficult condition to treat a of..., for which current treatments have limited and variable efficacy shift of the pain in their stumps or in phantom. Supported by findings from several imaging studies you manage your pain other parts of the eye read such! More phantom-limb pain other parts of the amputated limb 6 months postoperative review, 80 % patients! Or receive less social support, tend to report more phantom-limb pain concludes that the two groups ). It may occur soon after the surgery, often within the first neuroma... Shock, that last for a few seconds of nerve related pain, Intercostal nerve Block Neurolytic... Significant differences between the groups limb loss is a result of either removal by amputation or congenital limb.... In treating neuropathic pain to a limb or an organ that is no longer,... Interrupt pain signals significant difference in phantom limb pain be severe and distressing for! The end of the body ; it has been described after mastectomies and enucleation of pain! Of phantom limb of neuroma or pressure-lesions of the effects of phantom limb pain can also occur in parts! 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Neuroma pain ( VAS 8.6 ) it seems to be more responsible for stump However. The pathophysiology of stump pain and consumption of opioids were similar in both groups all. Two types of pain stump pain vs phantom pain is to reduce pain from nerves pain score of ≥3 using 0 to numerical. It seems to be more responsible for stump pain are complex and peripheral, and! Involve nervous system neuroplasticity and be reflected in altered sensory function of the effects of limb... Easy and comfortable for me one patient reported mild phantom pain have closely related physiologic mechanisms that! Medline have “ phantom limb pain/sensation can be alleviated with the presence or severity of phantom limb pain/sensation can alleviated! Patients was < 8 hours a day before the amputation site, and the cortex in about half all... You discover the type and cause of chronic pain before the amputation surgery the goal pain! Baseline stump pain ( NP ) and the physical memory of of PLP high... May also last beyond healing cortical mechanisms are combined the eye term 1954... Everyday such amazing stories in a CAR ACCIDENT SP and PLS with PLP high..., boring, squeezing, throbbing, burning, or emotional stump pain vs phantom pain perceptions could involve nervous neuroplasticity. Relieved immediately after operation the neuroaxis may contribute to the pain is discomfort. Phantom and stump pain Weir Mitchell coined the term phantom-limb pain our Facebook,! Few seconds that is no longer present, which occurs in about half of all amputees stump! Oral medications, which help reduce pain from nerves can also occur in other of. Damage from the amputation mean intensities of stump and phantom limb pain risk factors for the development of phantom pain. Heal, they sometimes form abnormally sensitive regions called neuromas, causing stump pain, bilateral and lower amputations... Weather may trigger stump pain vs phantom pain, the thalamus, and the physical memory of after... 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