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    Move Forward Guide

    Physical Therapist's Guide to Phantom Limb Pain

    When a limb (arm or leg) is amputated, a sensation that the amputated body part is still attached may persist. This phenomenon is called "phantom sensation." Phantom sensation may be painful, and therefore is most often referred to as “phantom limb pain.” Approximately 80% of people who undergo amputations experience phantom limb pain, and approximately 20% will experience pain for up to 2 years after the amputation.


     

    What is Phantom Limb Pain?

    Phantom limb pain is a painful or unpleasant sensation in a body part that has been surgically amputated or traumatically lost. The sensation may occur immediately following surgery or years later. Phantom pain is different from stump pain (or residual limb pain), which is localized in the remaining body part, or stump.

    At one time, phantom pain was thought to be a psychiatric illness. Now we understand that it occurs through complex biological mechanisms. These involve changes in your brain's perception of the affected body part, changes in how sensation is processed by your nervous system, and changes due to damage of the nerve at the amputation site. Phantom limb pain can be influenced by psychiatric stress and depression, but it does not result from these conditions.

    Factors associated with a higher risk of acquiring phantom limb pain include:

    • Pain prior to amputation
    • Pain prior to amputation of higher intensity and longer duration
    • Upper-limb amputation
    • Female gender
    • Older age
    • Residual pain in the nonamputated part of the limb

    Research is incomplete regarding who will or will not experience phantom limb pain. To date, there are no clear predictors of the condition.

     

    How Does it Feel?

    Phantom limb sensation, stump pain, and phantom limb pain are common experiences following an amputation. Up to 95% of people who undergo amputation will experience at least one of these conditions.

    Phantom limb sensation is a nonpainful feeling or sensation in the body part that was amputated. Phantom sensations are more commonly reported than stump pain or phantom limb pain. The sensations feel like the limb felt before the amputation, and are related to the same sense of awareness that helps people distinguish "myself" from others. The sensations occur from the interaction of current sensory inputs from your limb, and the internal "models" of the body in the brain.

    • Early on, the phantom limb resembles the limb shape prior to amputation. It may be perceived in a certain position, have feelings of warmth or cold, itching, or tingling.
    • Following amputation, it is common to "forget" the limb is absent and to attempt to use it—a sensation that can result in a fall.
    • It is also common for people who experienced amputation to feel as though the upper portion of the limb is missing, or has shrunk. This phenomenon, called telescoping, is caused by a change in the internal model of the body in the brain. It also can cause the sensation that the amputated part of the limb is floating, or has even moved up inside the stump.

    Stump pain is common in the postoperative period. It is felt only in the remaining body part, or stump. Stump pain may be felt at the incision or deeper into the residual limb. This pain is often described as sharp, burning, stabbing, or "electric." Stump pain, which normally fades as the surgical scar heals, can coexist with phantom limb pain.

    Phantom limb pain is a painful or unpleasant sensation in the lost body part. Sensations can include:

    • Tingling, burning, and cramping (the most common pain felt from amputation)
    • Shooting, stabbing, boring, squeezing, or throbbing pain
    • Pain just like that experienced at the time of the accident or serious injury
    • A feeling like the phantom limb is in a forced and uncomfortable position

    Since phantom pain is related to the brain and nervous system, it can also be experienced in the nonamputated part of the limb, in the opposite nonamputated limb, or even in the neck or back.

    Phantom limb pain usually affects the part of the limb farthest from the body. For example, lower-limb phantom pain will usually be experienced in the toes, heel, instep, or top of the foot. The pain may be continuous, or it may come and go during the day. In many cases it occurs randomly.

    Phantom pain may be triggered by:

    • Pressure on the remaining part of the limb from objects such as clothing
    • Emotional stress
    • Forgetting the limb’s absence and attempting to use it
    • A poorly fitting artificial limb
    • Stump pain
     

    How Is It Diagnosed?

    There are no medical tests to diagnose phantom limb pain. Diagnosis is made based on your symptoms and the history of what occurred before the pain started. For example, was there illness, trauma, or surgery before the amputation? Reporting clearly and precisely what seems to trigger the phantom pain will help your physical therapist diagnose the problem. The physical therapist may have you complete questionnaires about your symptoms and functional difficulties to help clarify details of your problem and how it is affecting your daily life and activities. All other possible sources of your pain symptoms must be ruled out.

    Your physical therapist will:

    • Perform a careful examination of the bone and soft tissues of your stump to identify possible skin breakdown, infection, or abnormal pressure on weight-bearing contact points.
    • Gently tap on the stump to identify possible nerve injury or a neuroma (an overgrowth of nerves in the stump).
    • Check the fit of your prosthetic limb. (It is common for the shape of your stump to change over time, affecting the prosthetic's fit and comfort.)
    • Check to make sure that you are using the correct stump socks, and that you are putting your prosthetic on properly.
    • Explain how any of the above changes can cause skin breakdown and provoke pain problems.

    Your physical therapist will work with your physician to determine the need for additional tests to rule out other conditions, such as poor circulation, and may refer you for X-rays to identify bone spurs or other abnormal bone formations.

     

    How Can a Physical Therapist Help?

    Phantom limb pain needs to be managed to prevent symptom flare-ups, or to resolve the problem. Pain management includes treating the biological and complex mechanisms of the problem with different strategies. A symptom-specific approach may include—in addition to physical therapy—the use of medication prescribed by the physician, psychological and behavioral therapies, and, if needed, surgical intervention.

    Your physical therapist may provide hands-on treatment and other interventions and exercises. Your treatment plan may include:

    Electrical stimulation

    • TENS (transcutaneous electrical nerve stimulation)
    • Electromyofeedback
    • EMG biofeedback

    Manual therapy

    • Massage
    • Manipulation (gentle limb movements performed by the physical therapist)

    Stump management

    • Skin care
    • Stump sock use
    • Stump shrinker (an elastic sock to prevent swelling) use

    Prosthetic fittings and proper use training

    Your physical therapist may perform and/or refer you for proper prosthetic device fittings, and help train you in the safe usage of your prosthetic device.

    Technology

    • Mobile applications, such as the RecogniseTM app, can help “retrain” and “remap” how the brain sends pain to a body region. Your physical therapist will recommend the use of any technology that may apply to your specific condition.

    Nervous system treatments

    Treatment that focuses on improving how the nervous system is processing sensations from the amputated limb can help change the brain’s representation or body image of the affected part and improve nervous system function. Your physical therapist may prescribe the following treatments/exercises:

    • Desensitization. This treatment helps modify how sensitive an area is to factors like clothing pressure or touch.
    • Graded motor imagery/movement imagery training. These imagery exercises help your brain process information about your amputated limb more accurately, which can help you form a clearer image of the affected limb to improve or resolve phantom pain.
    • Mirror visual feedback/mirror box therapy. This treatment uses a mirror or mirror box to "trick" your brain into believing the reflection of your nonamputated limb is actually your opposite limb. The brain adapts how it processes perception and sensation of the amputated limb, which can help reduce phantom sensations.

    The above exercises should only be performed under the guidance of a trained physical therapist. For more detailed information on what these treatments involve, see the references below.

     

    Can this Injury or Condition be Prevented?

    There is no clear evidence that phantom limb pain can be prevented. Pain management that eliminates symptoms before and after amputation may help limit the onset of pain and even prevent it. However, some people will still get phantom limb pain even with excellent pain management.

     

    Real Life Experiences

    Bill is a 67-year-old retired school teacher who recently underwent an amputation of his right lower leg due to severe circulatory problems and infection. Bill experienced a lot of pain and discomfort with this illness and was unable to walk because of it. He was treated for pain prior to his amputation and felt some improvement. However, following his surgery, Bill complained of pain and burning in his stump. His surgeon referred him to physical therapy.

    Bill’s physical therapist performed a careful examination of the bone and soft tissues in his stump to identify possible skin breakdown, infection, or abnormal pressure points. She applied appropriate stump shrinkers for compression, to help reduce swelling. During his first treatment, she gently massaged the stump, and applied electrical stimulation to it. She also taught Bill some gentle exercises to improve his symptoms.

    Although his physical therapy treatments greatly reduced his stump pain, Bill then started noticing that it felt like his amputated leg was still there. He felt his foot itching at times, and even forgot his leg was amputated and tried to stand up on it after a nap in his chair, almost falling.

    Bill's physical therapist explained that he was experiencing phantom limb sensation. She assured him that this sensation is very common after amputation and can improve over time. She added several functional exercises as well as use of the mobile app RecogniseTM to help him learn how to move and walk safely in spite of the new phantom limb sensation. She also introduced mirror box therapy to help the brain adapt to the missing limb.

    A few weeks later, Bill told his physical therapist that he was experiencing intermittent burning and tingling sensations in his amputated limb. He thought the pressure of his pants leg could be causing the pain. His physical therapist taught him about phantom limb pain. She prescribed exercises to help improve his perception of his right leg and the brain’s representation, or “body image,” of the affected part.

    Bill learned and practiced desensitization of the stump, mirror visual feedback/mirror box exercises, and movement imagery training over the next several weeks. He began to notice his symptoms were not as easily triggered and were not occurring as much. He also started using his prosthetic leg more, and increased his daily activity.

    Now that he is becoming more active again, Bill’s physical therapist works with his prosthetist to ensure the prosthesis continues to fit well. She also continues to train Bill on the proper use of the prosthetic leg, and is helping him increase the amount of time he wears it daily. Bill continues his program daily with less phantom pain—and with improved strength, walking ability, and well-being!

    This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

     

    What Kind of Physical Therapist Do I Need?

    All physical therapists are prepared through education and experience to treat limb amputation conditions. However, you may want to consider:

    • A physical therapist who is experienced in treating people with limb amputation conditions. Some physical therapists have a practice with a rehabilitation focus, including expertise in prescription of limb prosthetics and prosthetic training.
    • A physical therapist who is experienced in treating chronic pain conditions.
    • A physical therapist who is a board-certified clinical specialist, or who completed a residency or fellowship in orthopedics or geriatrics with a rehabilitation physical therapy clinic. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.

    You can find physical therapists with these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

    General tips when you're looking for a physical therapist (or any other health care provider):

    • Get recommendations from family and friends or from other health care providers.
    • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have a limb amputation.
    • During your first visit with the physical therapist, be prepared to describe your symptoms and functional difficulties in as much detail as possible, and what makes your problem worse. 
     

    Further Reading

    The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for a visit with their health care provider.

    The following articles provide some of the best scientific evidence related to physical therapy treatment of phantom limb pain. The articles report the most recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

    Amputee Coalition. Amputee Coalition website. Accessed August 1, 2018.

    Hsu E, Cohen SP. Postamputation pain: epidemiology, mechanisms, and treatment. J Pain Res. 2013;6:121–136. Free Article.

    Subedi B, Grossberg GT. Phantom limb pain: mechanisms and treatment approaches. Pain Res Treat. 2011;2011:864605. Free Article.

    Giummarra MJ, Mosely LG. Phantom limb pain and bodily awareness: current concepts and future directions. Curr Opin Anaesthesiol. 2011;24:524–531. Article Summary on PubMed.

    Ülger O, Topuz S, Bayramlar K, et al. Effectiveness of phantom limb pain: a pilot study. J Rehabil Med. 2009;41:582–584. Free Article.

    * PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

    Revised by David Morrisette, PT, PhD. Authored by Mary Kay Zane, PT. She is a board-certified clinical specialist in orthopaedic physical therapy. Reviewed by the MoveForwardPT.com editorial board.

     

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