Phantom Limb

Phantom Limb Pain

By Saeha Shin, BHSc Level III, McMaster University

Introduction

Phantom limb pain is the medical condition that results in painful sensations, which arise when a body part has been removed. Many individuals with this condition experience sensations in the limb as if it were still attached to the body, even though it is not. This is why it is known as phantom limb. Phantom limb pain ranges from the sensation of mild electric shocks to the feeling that the limb is being cramped, twisted, burned, or crushed. In many cases, the pain felt by the phantom limb is identical to the pain felt prior to the amputation.

Phantom limb pain is poorly understood and difficult to treat. However, it is a prevalent problem after amputation, with about 74% of patients with an amputated limb experiencing some phantom pain. The condition does not seem to be affected by gender, side or level of amputation, but is less common in young children and in congenital amputees. Congenital amputation means being born without one or more limbs or parts of a limb.

Signs and symptoms

Some of the non-painful sensations from the phantom limb include:

  • pleasure
  • movement of the phantom limb
  • warmth and cold
  • itching, tingling, or electric sensations

For those experiencing phantom limb pain, sensations are much more severe and like neuropathic pain, and include:

  • shooting, stabbing, piercing, or burning pain
  • twisting, burning, or crushing sensation of the phantom limb
  • numbness
  • cramping

The intensity and frequency of phantom limb pain is different for everyone. Painful episodes may occur periodically, daily, weekly, or constantly. The sensation of phantom limb appears to fade with time, but for some, it remains a troubling part of daily life.

Causes

The exact cause of phantom pain remains unclear. There are a few possible explanations, including the rewiring of the nervous system. After an amputation, the brain and spinal cord experience changes that cause pain to be interpreted differently. Also, some researchers believe that phantom limb pain arises from the memory of limb pain: when patients with limb damage suffer from pain, the brain is used to such sensations after the body part has been removed and the brain feels the same kind of pain, even after the limb has been removed.

Risk factors

Some of the risk factors that may increase the chance of developing phantom limb pain are:

  • pre-amputation infection
  • pre-amputation pain
  • blood clot in the amputated limb
  • traumatic amputation (injury caused by an accident)

Diagnostic Tests

Unfortunately, there are no current medical tests to diagnose phantom limb pain. Diagnoses are made based on the symptoms of any sensations that may arise from the amputated body part. After reviewing your medical history, the doctor will perform a physical examination.

Treatment approaches

Most patients suffer from phantom limb pain for a short period of time. But for those suffering from persistent pain, treatments may be necessary. Some of the commonly used treatments for phantom limb pain are as follows.

Medicines

Patients with phantom limb pain are often treated and managed with drug treatments used for neuropathic pain. Effective treatment often involves a combination of medications, such as:

  • Antidepressants: tricyclic antidepressants (TCAs; ex. amitriptyline), serotonin-norepinephrine reuptake inhibitors (SNRIs; ex. duloxetine, venlafaxine), tetracyclic antidepressant (ex. mirtazapine)
  • Anticonvulsants: gabapentin, pregabalin and carbamazepine
  • Opioids: methadone, levorphanol, oxycodone, tramadol
  • Anesthetics: intravenous lidocaine, oral anesthetic analogues (ex. mexiletine)
  • NMDA receptor antagonist: ketamine
  • Other pharmacologic drugs: propranolol, nifedipine, calcitonin

Non-Drug Therapies

Various non-drug options exist for phantom limb pain. Some of these treatments include: 

  • Surgery on the stump and other surgical procedures
  • Psychological: electromyographic biofeedback, temperature biofeedback, congnitive-behavioural pain management, sensory discrimination training, hypnosis
  • Other: transcutaneous nerve stimulation, acupuncture, physiotherapy, ultrasound, manipulation, massage, exercise

References

Weiner IB, Craighead WE. The Corsini Encyclopedia of Psychology. 2010. Washington D.C. John Wiley & Sons.

Nikolajsen L, Jensen TS. Phantom limb pain. Current Review of Pain. 2000;4(2):166–70.

Flor H. Phantom-limb pain: Characteristics, causes, and treatment. The Lancet Neurology. 2002;1(3):182–9.

Black LM, Persons RK, Jamieson B. What is the best way to manage phantom limb pain? J Fam Pract. 2009;58:155-158.