How to treat phantom pain

A phantom is something that does not really exist, a fantasy or an appearance. But for Otto K., 62, the so-called phantom pain in his amputated right lower leg is more than real: "On some days, the pain is as sharp as if I were attacking with a knife." On other days, itches and itches in the foot and in other places that are not there anymore. "

Phantom pain in every second amputee

About 60, 000 amputations are performed annually in Germany, of which 70 percent are due to diabetics - even Otto K. lost his lower leg because of a non-healing ulcer. He suffered from the diabetic foot syndrome, which usually arises as a result of a chronically poorly adjusted blood sugar, which in the long term, the nerve endings are damaged. He no longer felt pressure points or injuries, he only noticed wounds very late when they did not heal. In Germany, up to 27, 000 foot amputations are performed every year in people with diabetes.

Over two-thirds of all amputations are caused by arterial circulatory disorders. The number of people suffering from vascular disease is estimated at four to six million in Germany. Seen in this way, the risk potential is far higher than one would initially assume. Accidents cause four percent of all amputations. Equally high is the proportion of amputations caused by infections and tumors. And about every second victim suffers - often for years.

In one part, the pain is constantly present, but more often they occur suddenly. Weather changes, but also stress or stimulants such as coffee can be the trigger.

Pain in the stump

Stump pain, in contrast to phantom pain, is precisely localized in the area of ​​the amputation stump. Almost 60 percent of all amputations can occur spontaneously or after fitting a prosthesis. Patients describe this pain as burning, electrifying, cutting, stabbing or convulsive. Almost always it is a persistent pain, which can be attributed to disorders in wound healing. Pressure points caused by a poorly fitting prosthesis, inflammations such as pus build-up under the skin (abscesses) or osteomyelitis can be the cause, in some cases, circulatory disorders in the stump.

What often happens after severing a limb: At the outer end of a severed nerve arise so-called neuromas, which are benign nodules. They are sensitive and respond to stimulation of any kind with great pain. Even a normal touch can cause severe pain.

Pain remains in the memory

The majority of women and men with amputations suffer from phantom pains. This causes pain in the limbs that are no longer present. It is believed that the brain continues to receive pain signals from the nerves formerly responsible for that body part. Phantom pain is also experienced in other parts of the body in some patients, such as after removal of a breast, after rectal surgery, or after pulling teeth (especially wisdom teeth).

Often the pain is stronger at night than during the day. It is also typical that phantom pain is similar to pain before amputation. Blame is pain memory: with every injury or inflammation, pain receptors send electrical impulses to the spinal cord. From there, the nerve signals are transmitted to the brain. Here is the sensation of pain. With a strong and long-lasting stimulus, the pain can become independent. It creates a difficult-to-erase pain memory.

For example, severe pain before or during amputation can very often leave marks in the spinal cord and brain. Therefore, patients today often receive a so-called cross-stitch prior to amputations, ie spinal anesthesia, in which the nerves in the spinal cord are anesthetized and thus a hypersensitivity of the spinal cord is to be prevented.

Pain therapy with medicines

When treating phantom pain, various options must often be tried until adequate pain relief is achieved. Common pain therapies include severe pain attacks, opiates such as morphine and related drugs. These medications are not over-the-counter like common painkillers (acetylsalicylic acid, ibuprofen). Continuous therapy with continuous or frequent pain can be done with various medications.

It is important that the medication is prescribed by the doctor after a thorough anamnesis and possibly in cooperation with a pain ambulance. Sometimes analgesics are combined with antidepressants, anti-epileptic drugs, or nerve-specific drugs. They raise the stimulus threshold of nerve cells for pain signals.

The hormone calcitonin also counteracts phantom pain in studies. It is a thyroid hormone, a peptide of 32 amino acids, and can slow bone loss in osteoporosis by counteracting calcium release from the bones and lowering the level of calcium in the blood.

In addition, physical methods such as electrical stimulation (TENS) are used: Weak current stimuli that are transferred to the amputation stump with electrodes stimulate new connections between nerve cells in the brain. These "overwrite" the old, painful impressions, but some patients swear by lack of irritation and wear a special stump cover to shield electrical stimuli.

Baths, massages and physiotherapy are useful in many cases, but should be tailored to the individual needs and preferences of patients. Acupuncture can help to relieve pain. Anyone who loses a part of the body, the physicians agree, psychological support for loss management and a behavioral therapy experienced. Again, this is a way to deal with the pain. The fact is, there is still no single therapeutic approach, but some new and promising opportunities.

mirror box

It sounds a little like hocus-pocus, as some doctors, therapists and patients want to outsmart phantom pain: For a cleverly placed mirror it looks to the patient as if the reflection of the healthy is the amputated limb. It is this optical impression that awakens a memory of the missing arm or leg in the brain. It ceases to replace the no longer existing input signals from the nerves of the affected limb by pain.

The method also works in stroke patients who suffer from paralysis or cognitive disorders. Prof. Dr. Christoph Maier and the ergotherapist Susanne Glaudo have developed two training devices that facilitate practicing in front of the mirror and can also be used at home. Again, it is the brain that creates sensations, because there is a kind of image of the whole body in which the sensations from the respective body parts are processed. Now, if the signals from the amputee arm or leg are missing, certain centers in the brain replace this missing information with pain, explains Susanne Glaudo.

The effect can be even more pronounced if the patient with the healthy hand, which he only observes in the mirror, does exercises in skill or looks at the hand or the leg in the mirror, while sensory impressions are eg caused by the touch with a brush or a hedgehog ball,

prostheses

There are even indications that a prosthesis helps to prevent phantom pain. The reason: In order to move the artificial leg, the patient must activate thigh muscles. The brain registers these movements and gets the impression that the leg is intact. Therefore, phantom pain can even be relieved by the regular wearing of an optimally adapted prosthesis. Some of the amputee amputees get better on their own, sometimes even completely disappear. Forecasts can not be the course.

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