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Controlling phantom limb pain in Sierra Leone

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The question posed in the pain clinic was in the modified English, Krio, the widely used language in Sierra Leone. " De hand wae nar dae, you kin geh pain insaie?" Kulfar Dabor looked at his stump and nodded. With his remaining hand he touched the finger joints and knuckles of the nurse who had asked the question. "Yes, a kin geh pain nar me fingers", he replied. Phantom pain is one of the cruelest reminders for an amputee of the part of the body lost in Sierra Leone's war of mutilation.

The pain clinic, established by the non-governmental organisation Médecins Sans Frontières (MSF), is an attempt to help ease some of the continued suffering. The clinic has been taking place in Murraytown Amputees Camp in Freetown, the capital of Sierra Leone, as part of a project in pain management. The kind of chronic, long-term pain that the amputees are suffering from has always been difficult to deal with, even in the most privileged western setting.

But there have been advances and the MSF project is an attempt to find ways of adapting and implementing them in the field. The project is also working on improved procedures for acute pain relief in hospital surgery work, where reducing postoperative pain might lead to less chronic, long-term pain. Phil Lacoux is the anaesthetist running the project, and he stresses the importance of effective pain management.

"From a humanitarian point of view of course, pain should always be reduced but it's also very good for getting people out of hospital beds and generally fit again. If people are in pain after an operation they will often get complications, high blood pressure, chest infections, bed sores and blood clots because they are still in bed with the pain." Back in the amputees camp, Dabor is being prescribed amitriptylene, and carbemazepine, which can have a powerful effect on the chronic pain left by amputation. Dabor's hand was chopped off with a machete five years ago, a fate suffered by many people in his village, as part of the military's policy of terror.

He told his story during the detailed investigation of each patient in the pain clinic. To be sure of the treatment and its results, patients are asked about their physical symptoms, mobility, practical skills and emotional state. "Does the pain stop you doing what you want to do?" "Do you get sudden feelings of panic?" "Can you still laugh and see the funny side of things?" Dabor says the injury has reduced him to the state of a child and for a long time all he wanted to do was to die. But on his second visit to the clinic he is getting much more positive about how the drugs might help.

The project in Freetown developed from a preliminary survey of 40 amputees, which showed that chronic pain was widespread. All of them had significant pain in the stumps of their arms or legs many months or years after the injury. 25% experienced phantom pain. These are both parts of what Phil Lacoux calls "useless pain". Acute pain at least has the beneficial function of warning against further stress or damage to the tissues.

But chronic pain is still very real and health carers are trying to refine the ways in which patients are identified for treatment. One way forward might be to improve the questionnaires and perhaps better adapt them to the African setting and culture. In the second part of the project, run within a surgical programme in Connaught Hospital in Freetown, the plan is for a more rigorous use of combination drug treatments such as ibuprofen, paracetamol, and tramadol to give patients the most effective pain relief.

The overall philosophy in both parts of the project is to increase patients' feeling of control over their pain which, because there is a major psychological component to phantom pain, can help reduce the patients' pain. The physiological and chemical origins are connected and modified by emotional states and even behaviour. There is a controversial example of this in a therapy that is being tested in the Murraytown clinic.

It involves setting up a mirror in such a way that patients who have lost one arm can put the stump behind the glass and watch the reflection of the good arm re-create the missing limb. Experience in the West has shown that this can help amputees to "imagine" the movement of a hand or fingers and relieve some of the phantom pain. Phil Lacoux says that when he first tried it in Murraytown, the results were disturbing.

Despite his care in explaining what it was for, three of his patients got confused and upset by the method. The poor results highlighted the need to sometimes adapt therapies to different cultures. The combination drug treatments are producing better results. 120 patients have been put on the daily regimen and are returning each week to be checked for side-effects and to renew prescriptions. So far, most patients seem to be pleased with the pain relief. Together, doctors and patients are working towards achieving lower levels of pain that might, for example, allow a patient to walk longer distances using an artificial leg.

A full assessment of the efficacy of the treatment will not happen until October, because one of the critical measures is sustainability. Many patients are expected to be phasing down their treatments by then and to have achieved long-term reduction in pain.

For some of the patients though, their lives have already been changed. "Part of the good that can come from this ", says Phil Lacoux, "is that we show these people we believe them about their pain. They are not making it up; they are not going mad. And they will be less frightened by it, because we have given them - for the first time - some feeling of control over their own pain. They have regained part of their lives."