Phantom Pain

The pain that feels like it is coming from a body part that is no longer there is called phantom pain. Before doctors thought that this post-amputation phenomenon is just a psychological problem but now experts are recognizing it as a real sensation that originates in the brain and spinal cord.

The disorder may also occur after surgeries in a removed body parts such as penis, breast, tongue or eye, but mostly it occurs in people who had their legs and arms removed.

Phantom pain will get better without treatment over time but for other people, they need medications and therapies to manage the pain.

The characteristic symptoms of phantom pain are:

• comes and goes or is continuous;
• onset within a few days of amputation;
• may be described as stabbing, shooting, squeezing, boring, burning or throbbing;
• often affects the part of the limb farthest from the body like an amputated leg or foot;
• may be triggered by emotional stress or pressure on the remaining part of the limb;
• you may sometimes that the phantom part is forced in an uncomfortable position.

For some people they said that they would feel that their amputated limb is still there and this is known as the phantom limb sensation.

Sometimes it occurs to people who were born without limbs, but very rare. With this sensation you may feel warmth, coldness, tingling or itchiness but this is different from phantom pain.

There is no clear cause of the phantom pain but it seems like it came from the brain and spinal cord.

Portions of the brain that had been neurologically connected to the nerves of the amputated limb will show activities when the person feels phantom pain during imaging scans such as positron emission tomography (PET) or magnetic resonance imaging (MRI).

A response to mixed signals from the brain is what experts believed. Areas of the brain and spinal cord after an amputation lose input from the missing limb and will need to adjust to this and as a result, it will trigger the body’s most basic message that something is not right because of the pain.

There is also a research that says when the amputated area is no longer able to receive sensory information and that information will go elsewhere like from a missing hand to a still-present cheek, when the cheek is touched it’s like the missing hand is also being touched and the result can be painful.

Scar tissue at the site of the amputation, physical memory of pre-amputation pain in the affected area and damaged nerve endings are some of the factors believed to contribute to phantom pain.

There are no medical tests to diagnose phantom pain. Doctors can identify the condition by collecting information about your symptoms and the circumstances like surgery or trauma that occurred before the pain started.

Upon visiting your doctor, he will ask you about your symptoms following your surgery.

He may refer you to a specialized pain center. Bring a relative or close friend with you when going to the doctor. Bring a notebook and list down the symptoms that you are experiencing. Write down the medical history and all the medicines and vitamins that you are taking.

Some of the questions that you can ask your doctor include:

• What relief therapies do you recommend?
• Are there medications to stop this?
• What are the possible side effects?
• Is there a risk of being addicted to the drugs?
• Am I a candidate for clinical trials?
• Should I see a specialist?

You have to describe your pain precisely so doctors can recommend something for it. Treatments for phantom pain and stump pain are not the same.

It is hard to find a treatment for phantom pain but mostly it begins with medication and may later on add noninvasive therapies like:

• transcutaneous electrical nerve stimulations (TENS),
• acupuncture.

More invasive options are implanted devices or injections and the last option will be surgery. Some drugs that are designed to treat other conditions are helpful in reducing the pain because there is no medication specifically for phantom pain.

Some of the medication for phantom pain include:

Anticonvulsants

The epilepsy drugs to treat the nerve pain such as gabapentin (Gralise, Neurontin), pregabalin (Lyrica) and carbamazepine (Carbatrol, Epitol, Tegretol), side effects may include suicidal thoughts, anxiety, depression and irritability or allergic reactions like hives and swelling;

Antidepressants

Tricyclic to relieve the pain because of the damaged nerves such as amitriptyline, nortriptyline (Pamelor) and tramadol (Conzip, Ultram), side effects may be dry mouth, sleepiness, weight gain, blurred vision;

Narcotics

Opioid to help control the pain such as codeine and morphine, possible side effects are

• nausea,
• sedation,
• vomiting
• and constipation;

N-methyl-d-aspartate (NMDA) receptor antagonists to relieve the pain such as ketamine that has a mild sedation, hallucinations and loss of consciousness for side effects and dextromethorphan that has no reported side effects.

Some of the noninvasive therapies include:

Nerve stimulation

Transcutaneous electrical nerve stimulation (TENS), a device that sends a weak electrical current using adhesive patches on the skin near the location f the pain and as a result this will mask the pain signals so it will not reach to your brain;

Mirror box

It has two openings, one for the stump and one for the intact limb, this device has mirrors that will look like an amputated limb exist;

Acupuncture

This can be an effective treatment for some types of chronic pain according to the National Institutes of Health, this is done by inserting fine and sterilized needles into specific points in the body, it will release the body’s natural pain relieving endorphins.

For minimally invasive therapies it includes:

• Spinal cord stimulation – this is done by inserting electrodes in your spinal cord and then a small electrical current will flow in your spinal cord to relieve the pain;
• Injection – pain killing medications such as local anesthetic or steroids can relieve pain;
• Nerve blocks – medication that stops the messages between the site of the phantom pain and the brain. Surgery may be an option too and it includes:
• Brain stimulation – that uses magnetic resonance imaging to position the electrodes and the current is delivered in the brain;
• Stump revision or neurectomy – if it is caused by nerve irritation in the stump, revision will be done by cutting nerves that will make the pain worse.
• A new approach – virtual reality goggles – this is done by programming for the goggles mirrors the person’s intact limb making it look like there has no amputation and he will move the virtual limb like waving, this helps relieve phantom pain but has been tested on a few people only.

To prevent phantom pain some doctors recommend regional anesthesia (epidural or spinal) in the few hours or even days leading up to amputation. The risk of developing phantom pain will be higher for people who have experienced pain in the limb before amputation.

This might be helpful and relieve pain after surgery and will reduce the risk of lasting phantom pain.

A few alternative and homeopathic remedies exist for phantom pain.

Hypericum is considered the Arnica of the nerves and this is recommended to reduce the pain after an amputation or for phantom pain.

You may reduce discomfort with regards to the pain and improve your quality of life.

Follow some of these steps:

• Look for distractions or find activities that will take your focus off the pain like reading a book;
• Stay physically active by exercising regularly and doing things you enjoy or are your hobbies such as swimming or gardening;
• Do not forget to drink your medications;
• Find ways to relax to relive you of the stress such as relaxation techniques (meditation, rhythmic breathing);
• Have a warm bath;
• Lie down;
• Seek the support of other people to help you cope with this;
• Take care of your stump by massaging the stump and applying TENS.

Try different techniques to help you with pain but consult your doctor first. It might be difficult for you to live with a phantom pain and sometimes you may get depressed because of it.

You may seek advice from a therapist or counselor or a support group in your area. You can also contact Amputee Coalition at www.amputee-coalition.org for information about their National Peer Network that can get you in touch with a lot of support services including Peer Visitor Program that can give you advices and may share his/her experience.

There are several risks associated with phantom pain.

There is still no reason why people have phantom pain after an amputation.

Some factors that might increase your risk of phantom pain are:

• Pain before amputation: According to research if you are already experiencing pain before the amputation, chances is you are going to have it again after the amputation, this is may be because your brain have a memory of the pain before the amputation and will keep sending pain signals afterwards,
• Stump pain: If this is persistent, you will likely to have phantom pain also, this is because of a damaged nerve endings (neuroma) or an abnormal growth that usually results in painful nerve activity,
• Poor-fitting artificial limb (prosthesis): Ask your doctor if you are putting it correctly or if it fits you properly.