Treatment

Finding a treatment to relieve your phantom pain can be difficult. Doctors usually begin with medications and then may add noninvasive therapies, such as acupuncture or transcutaneous electrical nerve stimulation (TENS). More invasive options include injections or implanted devices. Surgery is done only as a last resort. Treatments on the horizon may use virtual reality goggles or mirror boxes to fool the brain into believing the amputated limb is still under its control.

Medications
Although there are no medications specifically for phantom pain, some drugs designed to treat other problems have been helpful in relieving nerve pain. Keep in mind that no single drug works for everyone, and not everyone benefits from medications. You may need to try several different drugs to find one that works for you.

• Antidepressants. Tricyclic antidepressants, such as amitriptyline or nortriptyline, often can relieve the pain caused by damaged nerves. They work by modifying chemical messengers that relay pain signals. Antidepressants also may help you sleep, which can make you feel better.
• Anticonvulsants. Epilepsy drugs — such as gabapentin (Neurontin) and carbamazepine (Carbatrol, Tegretol) — are often used to treat nerve pain. They work by quieting damaged nerves to slow or prevent uncontrolled pain signals. Studies have shown mixed results, however, regarding their effectiveness in reducing phantom pain.
• Narcotics. Opioid medications, such as codeine and morphine, may be an option for some people. Taken in appropriate doses under your doctor's direction, they may help control phantom pain. However, you may not be able to take them if you have a history of substance abuse. Even if you don't have a history of substance abuse, these drugs can cause many side effects such as constipation or sedation.

Noninvasive therapies
As with medications, treating phantom pain with noninvasive therapies is a matter of trial and observation. The following techniques may relieve phantom pain:

• Transcutaneous electrical nerve stimulation (TENS). In TENS, a device sends a weak electrical current via adhesive patches on the skin near the area of pain. This may interrupt or mask pain signals, preventing them from reaching your brain. Although safe and painless, TENS doesn't work for everyone with phantom pain.
• Acupuncture. The National Institutes of Health has found that acupuncture can be an effective treatment for some types of chronic pain. In acupuncture, the practitioner inserts extremely fine, sterilized stainless steel needles into the skin at specific points on the body. It is thought that acupuncture stimulates your central nervous system to release the body's natural pain-relieving endorphins.

Minimally invasive therapies

• Injections. Sometimes injecting pain-killing medications — local anesthetics, steroids or both — into the stump can provide relief of phantom limb pain.
• Spinal cord stimulation. Your doctor inserts tiny electrodes along your spinal cord. A small electrical current delivered to the spinal cord can sometimes relive pain.
• Intrathecal delivery system. This procedure allows medication to be delivered directly into the spinal fluid. Much lower doses of medication are needed with this route of delivery. It can be useful for people who experience pain relief with oral medications but experience intolerable side effects.

Surgery
Surgery may be an option if other treatments haven't helped. Surgical options include:

• Deep brain stimulation. Deep brain stimulation, also known as motor cortex stimulation, is similar to spinal cord stimulation except that the current is delivered within the brain. A surgeon uses a magnetic resonance imaging (MRI) scan to position the electrodes correctly. Although the data are still limited, deep brain stimulation appears to be a fairly promising option in selected individuals.
• Stump revision or neurectomy. If phantom pain is triggered by nerve irritation in the stump, surgical resection or revision can sometimes be helpful. But cutting nerves also carries the risk of making the pain worse.

On the horizon
Newer approaches to relieving phantom pain may involve fooling the brain into thinking it can still control the amputated limb.

• Myoelectric prosthesis. This type of artificial limb has motors controlled by electrical signals that occur during voluntary muscle activation in the remaining limb. Intensive use of a myoelectric prosthesis sometimes results in reduced phantom pain.
• Mirror box. This device contains mirrors that make it look like an amputated limb exists. The mirror box has two openings — one for the intact limb and one for the stump. The person then performs symmetrical exercises, while imagining that the missing limb is moving. This helps relieve phantom pain in some people.
• Virtual reality goggles. The computer program for these goggles mirrors the person's intact limb, so it looks like there's been no amputation. The person then moves his or her virtual limb around to accomplish various tasks, such as batting away a ball hanging in midair. Although this technique has been tested on only a few people, it appears to help relieve phantom pain.

2007-11-09

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