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Microsoft word - recommended treatments for phantom pain v1.doc

No one treatment has proven to be completely effective for all sufferers. However, there are many different treatments, which may be helpful to some people. If you suffer from PLP you should always consult your Rehab Consultant, Prosthetist, GP or a specialised pain nurse / clinic. Some suggested palliatives, as they cannot be called cures, are listed below. Medications / Drugs • Anti-seizure drugs (such as Gabapentin, Pregabalin, Carbamazepine and Valproic Acid) act directly on the nerves and brain to alter neurotransmission. They have a calming effect on the residual limb, which may have become overactive after amputation. • Antidepressants (such as Amitriptyline and Nortriptyline). • Opioids (such as Morphine, Oxycodone, Methadone, Tramadol, Codeine and Pentanyl). These mimic the pain-killing chemicals released by the brain. Effective immediately following surgery, but often addictive. • Others medications include Calcitonin, Baclofen, Dextromethorphan, Capsaicin, Clonidine, Ketamine • Preoperative – It is general practice to give an individual scheduled to undergo amputation surgery an epidural in the 72-hr period prior to amputation. It is believed that the pain prior to amputation can be imprinted on the brain and create what is called a “pain pathway”. The epidural injection can block the pathway and reduce the pain imprint on the brain. • Post Operative Anaesthetics – These are used to block the transmission of pain from the nerve cells to the brain. These work for a limited period of time. (Examples include Mexiletine, Lidocaine, Marcaine, Novocaine, Pontocaine and Xylocaine). • Nerve Blocks - Injections into the nerve, which chemically deaden the relevant nerve endings. Medications used include local anaesthetics, steroids and opioids. • Spinal cord stimulation (SCS) - This is a reversible surgical procedure for the management of chronic pain. It is a therapy that involves the stimulation of nerve fibres in the spinal cord. This stimulation inhibits, or blocks, the transmission of pain signals to the brain. It is generally used when all other pain treatments have failed. • Acupuncture - A method for treating medical conditions by pricking certain points on the skin with needles. The needles are then stimulated manually or by passing a low electric current through them. There are a number of theories on why acupuncture works, including the belief that the needles stimulate the body’s own natural painkillers (Endorphins). • Massage - A method of rubbing and kneading the skin, muscles and joints. Massage increases circulation and stimulates the muscles, which can alleviate discomfort. • Chiropractic - A method of manipulating joints, especially the spinal cord and vertebrae. It is believed that if the spine is out of alignment the tension can create an imbalance, affecting the nervous system. A Chiropractor will try to realign the spine, to alleviate pain. • Cranial Sacral Therapy – This is a restorative therapy, where the cranium and spine are gently massaged. The missing limb may also be massaged while the patient visualises the lost limb. The Therapist uses specific techniques on the head and spine, down to the sacrum, to release tension and energy blocks. This therapy can be used in conjunction with medication and visualisation techniques. • Desensitisation – Nerve endings obviously become highly sensitive following an amputation. Rubbing, massaging and stimulating the stump can help to desensitise the nerves and alleviate pain. A lack of blood to the stump is also considered to be one of the probable causes of phantom pain, so frequent exercise, including flexing and relaxing the muscles of the residual limb, can help to combat phantom pain. • Acupuncture (see Body Stimulation). • Transcutaneous Electrical Nerve Stimulation (TENS) - Electrical treatment using a current of electricity at a low frequency. This treatment provides pain relief through nerve stimulation. • Microcurrent Electrical Therapy (MET) – An alternative treatment using electricity at a low frequency. This treatment also provides pain relief through nerve stimulation. • Spinal Cord Stimulation (see Body Stimulation). Cognitive / Psychotherapy • Mirror Visual Feedback – A mirror is placed to reflect the opposite limb so it looks as if the phantom limb has returned. Using exercises and movement of the opposite limb it can help to relieve the feelings of the phantom limb and therefore the pain. • Hypnotherapy - A sleep-like state in which subjects act upon external suggestion. Much of our bodily movements are controlled by the subconscious mind. The subconscious mind is conditioned to expect/experience certain sensations from the limbs. Although the limbs don’t exist, the subconscious mind continues to experience the previously learned sensations and expect certain responses. The Hypnotherapist re-trains the subconscious mind. Visualisation is an important tool in changing the blueprint (Mind Map) of the body. • Biofeedback - A training program in which a person is given information about physiological processes (e.g. blood pressure), which is not normally available to them. The goal is to gain conscious control of the mind & body. It is thought that the hyperactivity of muscles and nerves caused by pre-existing conditions, or amputation, cause over stimulation / activity. This causes irritation in nerve endings of the residual limb. One example of how this works is to attach electrodes to the residual limb detecting when the muscles are tense. A signal is passed back to a monitor, which provides feedback and can be used to control the tension and reduce the stimuli. • Farabloc – This is a patented weave of nylon and ultra-thin stainless steel fibres. Farabloc's protective shield helps to filter out harmful high-frequency electromagnetic waves, thought to aggravate nerve-endings. They also help to stimulate circulation and produce a sensation of warmth. • Stump Socks and Shrinker Socks - Bandages and shrinker socks apply even-pressure to the residual limb, which may alleviate pain and offer an alternative sensation. A German company called Medipro® created the first liner designed to reduce phantom pain. Their research team found that electromagnetic waves could cause a static-electric charge in the socket of a prosthesis, stimulating the nerve endings of the residual limb. Based upon this they developed a new cover material called Umbrellan®, which shields the residual limb and blocks transmission of pain to the brain. The cover is designed specifically for the needs of people with sensitive skin, including diabetics. • Wearing an Artificial Limb - It is believed that wearing an artificial limb may reduce pain sensations for a number of reasons. Firstly the artificial limb is stimulating the nerves on the residual limb, offering an alternative sensation and wearing a prosthesis can increase circulation and blood flow alleviating some symptoms. The artificial limb may also have an impact on the Bodies Mind Map. • Heat - Applying heat to the residual limb can help to relieve the symptoms of phantom pain. Examples include taking a warm bath, applying a heat pack or wrapping the stump in a warm towel or blanket. You can also apply a heat rub such as Deep-Heat or Tiger Balm. All these methods increase the circulation in the residual limb. • Cold - Applying cold to the residual limb is also believed to help alleviate discomfort from muscle spasms. Cold can be administered through cold compression, ice packs or cool baths. Cooling creams can also offer relief from muscular aches and pains.


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Pii: s0014-5793(98)01258-7

The role and source of 5P-deoxyadenosyl radical in a carbon skeletonrearrangement catalyzed by a plant enzymeSandrine Ollagnier, Eric Kervio, Jaènos Reètey*Lehrstuhl fuër Biochemie, Institut fuër Organische Chemie, Universitaët Karlsruhe, Kaiserstr. 12, D-76128 Karlsruhe, GermanyReceived 15 August 1998; received in revised form 24 September 1998Abstract The last step in the biosynthesi

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