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Amputation

Phantom Pain

01/07/2010

Question:

I had a AKA 5 yrs ago, and have been suffering from Phantom Pain, (intermittently) since. I have tried numerous pain medications as well as Lyrica. Nothing seems to help. This is a strange case where in the morning and through the day, there is mostly no phantom pain. This phantom pain seems like it has a mind of its own. By this I mean everyday, AT 3:00PM, it starts and lasts until I go to bed. Believe it or not, 3:00PM everyday. You can actually sit there and watch the clock, and when 3:00PM rolls around, the pain starts. It mostly is there when I sit there and read or do something that doesn`t mean moving. If I get up and walk, then it will go away. But I can`t walk ALL OF THE TIME. Is there any other medication I can try? Some people have mentioned that it could be a mixture of "Phantom Pain" AND "Restless Leg Syndrom", so I started taking Requip. No help. Also, worth mentioning, I never had pain before the amputation, even though I had gangrene, which was the reason for the amputation. 

Would appreciate any suggestions that I can try.

Thanks.

Answer:

Phantom pain following an amputation can obviously be difficult to control. The longer any pain symptoms last, the less likely a complete "cure" will be achieved due to a chronic pain cycle having become established, which is felt to be based in the central nervous system (spinal cord and brain). This is the reason, according to this theory, why medications such as Lyrica (Pregabalin) which can help seizures (epilepsy) can also help chronic pain - by reducing excessive nervous system activity. The dose of Lyrica used in your case may or may not have been maximized. In general, the doses of the various medications used to treat chronic pain are increased until benefit results, the maximum dose is reached, or side effects occur. Also, it is typically necessary to use more than one type of medication to treat chronic pain.

For "neuropathic pain" such as phantom pain, medications which are frequently prescribed and which often provide benefit include anti-seizure medications (such as Pregabalin, Gabapentin, and others), anti-depressant medications (Duloxetine, Venlafaxine, Nortriptyline, and others), and such "muscle relaxants" as Baclofen or Tizanidine. Benefit may also result from trial use of anti-inflammatory medications (Naproxen, Ibuprofen, etc.) and opioid analgesics - or "pain medications" (Tramadol, Tapentadol, Methadone, and others). Topical medications applied to the site of pain include Lidocaine patches, Capsaicin, and topical Diclofenac, among others.

Non-medication interventions can include, in your case, making sure prosthetic fit and function are optimal, trial use of a TNS unit (portable electrical stimulator), desensitizing massage, behavior modification, and mind-body psychological techniques as can be provided/taught to patients by psychologists who specialize in chronic pain management. If you have not already done so, consultation with a physician Pain Specialist may be helpful.

Finally, as to why your phantom pain symptoms occur so predictably at 3PM, although there's no obvious nor easy answer which I can provide, your symptoms may nevertheless benefit from implementation of one or more of the above suggestions.

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Response by:

Brian L Bowyer, MD Brian L Bowyer, MD
Clinical Associate Professor
Physical Medicine & Rehabilitation
College of Medicine
The Ohio State University