1. By Brinder Bhogal and Charmikha Sivakumaran
Phantom limb pain
By Brinder Bhogal and Charmikha Sivakumaran

2. What is phantom limb pain?
Phantom pain is pain that feels like it's coming from a body part that's no longer there
Following traumatic amputation of a limb, many patients report feeling tingling, pins-and-needles, burning, or a stabbing pain where their limb used to be
A common description of the pain is of a limb being in a hyperextended or unnatural posture
Phantom pain often resembles the type of pain experienced before amputation
4 out of 5 people who lose limbs suffer from phantom limb pain
Anesthetic blocks applied to the nerves at the stump have failed to eliminate this pain in some individuals
Physical therapy techniques rarely help
Many resort to morphine-like drugs

3. Severed nerves send occasional pain messages back to the brain
Causes
Unknown
Brain or spinal cord?
PNS
Severed nerves send occasional pain messages back to the brain
neuromas grow out of injured nerve fibers that continue to give off pain impulses
CNS
Non-functional sensory cortex becomes overpowered by functional areas of the brain

4. This can also occur in people who were born without limbs
Symptoms
Most people who’ve had a limb removed report that it sometimes feels as if their amputated limb is still there
This can also occur in people who were born without limbs
Characteristics of phantom pain include:
Onset within the first few days of amputation
Tendency to come and go rather than be constant
Usually affects the part of the limb farthest from the body
May be shooting, stabbing, squeezing, throbbing or burning pain
Sometimes feels as if the phantom part is forced into an uncomfortable position
Weather changes, pressure, emotional stress can influence pain

5. Some factors that may increase risk of phantom pain include:
Risk factors
Some factors that may increase risk of phantom pain include:
Pain before amputation: some researchers have found that people who had pain in a limb before amputation are likely to have it afterward. This may be because the brain holds on to the memory of the pain and keeps sending pain signals, even after the limb is removed.
Stump pain: people who have persistent stump pain, usually have phantom pain too. Stump pain can be caused by an abnormal growth on damaged nerve endings.
Poor-fitting artificial limb

6. Things to do
Write down the symptoms, when they first occurred, how often they occur, triggers
Make a list of key medical information , other conditions, names of medications

7. Describing your pain precisely can help the doctor.
Tests and diagnosis
Although there's no medical test to diagnose phantom pain, doctors can identify the condition by collecting information about symptoms and the circumstances (such as trauma or surgery) that occurred before the pain started.
Describing your pain precisely can help the doctor.
Even though it's common to have phantom pain and stump pain at the same time, treatments for these two problems may differ.

8. Treatments and drugs - medications
Antidepressants: tryciclic antidepressants often can relieve the pain caused by damaged nerves (amitryptyline)
Anticonvulsants: epilepsy drugs (carbamazepine) can be used to treat nerve pain, they work by quieting damaged nerves to slow or prevent uncontrolled pain signals.
Narcotics: opioids (codeine, morphine), may be an option, have to be taken in appropriate doses.

9. Treatments and drugs – non-invasive therapy
Nerve stimulation: In a procedure called transcutaneous electrical nerve stimulation (TENS), a device sends a weak electrical current via adhesive patches on the skin near the area of pain. This may interrupt pain signals, preventing them from reaching your brain. Used properly, TENS is safe.
Electric artificial limb: A type of artificial limb called a myoelectric prosthesis has motors controlled by electrical signals that occur during voluntary muscle activation in the remaining limb. Using a myoelectric prosthesis may reduce 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 watching the intact limb move and imagining that he or she is actually observing the missing limb moving.
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's thought that acupuncture stimulates your central nervous system to release the body's natural pain-relieving endorphins. Acupuncture is generally considered safe when performed correctly.

10. Treatments and drugs – minimally invasive therapies
Injections: pain-killing medications (LA, steroids)
Spinal cord stimulations: electrodes inserted along spinal cord, small electrical current delivered to the spinal cord.
Intrathecal delivery system: medication is delivered directly into the spinal fluid.

11. Treatments and drugs - surgery
Brain stimulation: Deep brain stimulation and motor cortex stimulation are 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, brain stimulation appears to be a 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.

12. Other ways of pain management
Look for distractions
Stay physically active
Take medications
Find ways to relax
Seek support of other people
Take care of the stump