Phantom Limb Pain

Brief Overview: According to Columbia Doctors, “Phantom limb pain is pain that feels like it is coming from an arm or leg that has been amputated. Although the limb is gone, the nerve endings at the site of the amputation continue to send pain signals to the brain that make the brain think the limb is still there. Phantom limb pain can be mild to agonizing and even disabling for some. And it may lead to a lifelong battle with chronic pain.”

Etiology: According to Cleveland Clinic, “Phantom limb sensation (feelings of touch without pain) happens because your brain is trying to rearrange sensory signals after an amputation. Your body naturally sends signals to your limbs throughout your entire life. If there’s an amputation, your brain needs to relearn where to send signals to adapt to the change. It takes time to learn something new. In the same way, your body needs time to adjust, which is why you feel phantom sensations.”

Risk Factors: According to Cleveland Clinic, “Anyone who has an amputation can develop phantom pain. It’s more common in upper extremity amputations (arms and fingers) but it can affect any part of your body. If you regularly wear a prosthetic device, you might find the pain is worse when you aren’t wearing a prosthetic.”

Commonly Associated Conditions:

Residual limb (stump) pain
Neuromas
Chronic pain syndromes (CRPS, back pain)
Depression, anxiety, PTSD
Sleep disturbance
Mobility limitations, prosthetic use issues

Common Medications:

(No single universally effective drug—multimodal management is key)

Neuropathic pain agents: gabapentin, pregabalin, duloxetine, amitriptyline, nortriptyline
NSAIDs, acetaminophen
Opioids: may provide relief in select refractory cases, but generally avoided long-term
NMDA receptor antagonists: ketamine (IV, limited use)
Topical agents: lidocaine patches, capsaicin (applied to residual limb)
Others: tramadol, clonidine, propranolol, nifedipine, calcitonin (experimental/limited use), Botox injections

Common Labs, Imaging, and Tests:

Diagnosis typically made from history and physical. No further testing is generally required.

Common Symptoms:

Pain in absent limb: burning, stabbing, shooting, cramping, electric shock-like
Pain often intermittent, triggered by stress, weather changes, or prosthetic use
Non-painful phantom sensations may coexist (itching, tingling, movement sensation)
Sleep disturbance, anxiety, mood changes

Common Treatments:

Mirror therapy
Nerve stimulation, spinal cord stimulation
Acupuncture
CBT
Epidural, nerve blocks

Physical Findings:

Surgical amputation site (healed or with residual limb issues)
Normal physical exam otherwise, since phantom pain is perceived in absent limb

Potential Complications and Contraindications:

Complications:
- Chronic pain and disability
- Depression, anxiety, PTSD
- Sleep disturbance and fatigue
- Reduced prosthetic tolerance/use → mobility limitations
- Medication dependence/misuse if poorly managed
Contraindications:
- Long-term opioid monotherapy (not effective, high risk)
- TCAs in elderly or patients with cardiac arrhythmia, glaucoma, urinary retention
- Ketamine use contraindicated in psychosis or uncontrolled hypertension

General Health and Lifestyle Guidance:

Encourage consistent prosthetic use and regular fit checks to reduce stump irritation
Daily residual limb care to prevent infection and skin breakdown
Exercise and PT to maintain mobility, balance, and strength. Discuss with your healthcare provider what exercises are recommended for you.
Stress management (yoga, meditation, counseling)
Good sleep hygiene
Avoid alcohol, tobacco, and recreational drugs (worsen pain control and healing)
Support groups for amputees can reduce isolation and improve coping

Suggested Questions to Ask Patients:

When did your pain start after amputation?
How would you describe your pain (burning, stabbing, electric, cramping)?
How often does it occur, and what triggers or relieves it?
Do you also have pain in the residual limb (stump)?
How does pain affect your sleep, mood, and daily activities?
Are you currently using a prosthesis, and does it worsen or relieve pain?
What medications or therapies have you tried, and how effective were they?

Suggested Talking Points:

Phantom limb pain is common after amputation and happens because the brain and nerves still “remember” the missing limb.
The pain is real, not imagined, and can be managed with multiple strategies.
A combination of medications, therapy (like mirror therapy), and lifestyle measures typically works best.
Good residual limb care and prosthetic fit are important.
Stress and poor sleep can make pain worse; addressing these helps reduce symptoms.
Make sure to follow up regularly with your healthcare provider, as directed. Always report any new, worse, or persistent symptoms to your healthcare provider.

Sources:

This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.