Phantom limb pain is described as abnormal sensation (painful or non painful) from an amputated limb. Phantom limb pain is a very common condition in patients undergoing amputation regardless of the cause of amputation. The condition can be very disabling and therefore should be differentiated from non-painful phantom sensation, residual limb pain and stump pain secondary to bony overgrowths. There is overwhelming evidence regarding central nervous system changes in phantom limb pain, however the role of peripheral mechanisms and psychological factors are as important in the pathogenesis of phantom limb pain. The treatment of phantom limb pain is difficult and challenging. The evidence for the use of pharmacological approaches fro phantom limb pain is weak and non-pharmacological approaches do not work for most of the patients. Prolonged phantom limb pain interferes with the ongoing rehabilitation and prosthetic fitting leading to poor functional outcome. The prognosis of phantom pain varies and in some cases spontaneous resolution can occur following few years.
Sherman RA, Sherman CJ, Parker L. Chronic phantom and stump pain among American veterans: Results of a survey. Pain 1984; 18: 83–95.
Nikolajsen L, Jensen, TS. Phantom Limb Pain. Br J Anaesth 2001; 87(1): 107-16.
Davidson JH, Khor KE, Jones LE. A cross-sectional study of post-amputation pain in upper and lower limb amputees, experience of a tertiary referral amputee clinic. Disability and Rehabilitation 2010; 32 (22): 1855–86.
Hirsh AT, Dillworth TM, Ehde DM, Jensen MP. Sex differences in pain and psychological functioning in persons with limb loss. J Pain 2010; 11(1): 79– 86.
Wilkins KL, McGrath PJ, Finley GA, Katz J. Phantom limb sensations and phantom limb pain in child and adolescent amputees. Pain 1998; 78: 7-12.
Kooijman CM, Dijkstra PU, Geertzen JHB, Elizinga A. Sxhans CP. Phantom pain and phantom sensations in upper limb amputees: An epidemiological study. Pain 2000; 87: 33-41.
Montoya P, Larbig W, Grulke N, Flor H, Taub E, Birbaumer N. The relationship of phantom limb pain to other phantom limb phenomena in upper extremity amputees. Pain 1997; 72: 87-93.
Nikolajsen L, Ilkjaer S, Krøner K, Christensen JH, Jensen TS. The influence of preamputation pain on postamputation stump and phantom pain. Pain 1997; 72: 393-405.
Krane EJ, Heller LB. The prevalence of phantom sensation and pain in pediatric amputees. J Pain Sympt Manage 1995; 10: 21-29.
Rajbhandari SM, Jarett JA, Griffiths PD, Ward JD. Diabetic neuropathic pain in a leg amputated 44 years previously. Pain 1999; 83: 627-629.
Wartan SW, Hamann W, Wedley JR, McColl I. Phantom pain and sensations among British veteran amputees. Br J Anaesth 1997; 78: 652-9.
Katz J, Melzack R. Pain ‘memories’ in phantom limbs: review and clinical observations. Pain 1990;43:319-36.
Jensen TS, Kerbs B, Nielsen J, Rasmussen P. Immediate and long-term phantom limb pain in amputees: incidence, clinical characteristics and relationship to pre-amputation pain. Pain 1985; 21: 267-278.
Houghton AD, Nicholls G, Houghton AL, Saadah E, McColl L. Phantom Pain: natural history and association with rehabilitation. Ann R Coll Surg Engl 1994; 76: 22-25.
Hanley MA, Jensen PM, Smith DG, Ehde DM, Edwards WT, Robinson LR. Preamputation pain and acute pain predict chronic pain after lower extremity amputation. J Pain 2007; 8(2): 102–109.
Ephraim PL, Wegener ST, MacKenzie EJ, Dillingham TR, Pezzin LE. Phantom pain, residual limb pain, and back pain in amputees: Results of a national survey. Archives Physical Med Rehab 2005; 86(10): 1910–19.
Subedi B, Grossberg GT. Phantom Limb Pain: Mechanism and Treatment Approaches. Pain Res Treat; 2011: Article ID 864605, doi:10.1155/2011/864605.
Flor H, Nikolajsen L, Jensen TS. Phantom limb pain: a case of maladaptive CNS plasticity? Nature Reviews Neuroscience 2006; 7(11): 873-881.
Karanikolas M, Aretha D, Tsolakis I, Monantera G, Kiekkas P, Papadoulas S, et al. Optimized perioperative analgesia reduces chronic phantom limb pain intensity, prevalence, and frequency: a prospective, randomized, clinical trial,” Anesthesiology 2011; 114(5): 1144-54.
Borghi B, D’Addabbo M, White PF, Gallerani P, Toccaceli L, Raffaeli W, et al. The use of prolonged peripheral neural blockade after lower extremity amputation: the effect on symptoms associated with phantom limb syndrome. Anesthes Analges 2010; 111(5): 1308-15.
Kajander KC, Wakisaka S, Bennett GJ. Spontaneous discharge originates in the dorsal root ganglion at the onset of a painful peripheral neuropathy in the rat. Neurosci Latt 1992; 138: 225-8.
Devor M, Hainf W, Michaelis M. Modulation of activity in dorsal root ganglion neurons by sympathetic activation in nerve-injured rats. J Neurophysiol 1994; 7: 28-47.
Torebjork E, Wahren L, Wallin G, Koltzenburg M. Noradrenaline-evoked pain in neuralgia. Pain 1995; 49:439-41.
Chabal C, Jacobson L, Russell L, Burchiel KL. Pain responses to perineuromal injection of normal saline, epinephrine and lidocaine in humans. Pain 1992; 49: 9-12.
Baron R. Mechanisms of disease: neuropathic pain—a clinical Perspective. Nature Clinical Practice Neurology 2006; 2(2): 95-106.
Baron R, Binder A, Wasner G. Neuropathic pain: diagnosis, pathophysiological mechanisms, and treatment. The Lancet Neurology 2010; 9(8): 807-19.
Ramachandran VS, Brang D, McGeoch PD. Dynamic reorganization of referred sensations by movements of phantom limbs. Neuro Report 2010; 21(10): 727-30.
MacIver K, Lloyd DM, Kelly S, Roberts N, Nurmikko T. Phantom limb pain, cortical reorganization and the therapeutic effect of mental imagery. Brain 2008; 131 (8): 2181-91.
Spring J. Neural plasticity and the progress of phantom pain research mind matters. Wesleyan J Psychol 2010; 5:13-26.
Roux FE, Ibarrola D, Lazorthes Y, Berry I. Chronic motor cortex stimulation for phantom limb pain: a functional magnetic resonance imaging study: technical case report. Neurosurgery 2008; 62(6 Suppl 3):978-85.
Head H, Holmes G. Sensory disturbances from cerebral lesions. The Lancet 1912; 179(4612): 144-52.
Giummarra MJ. Gibson SJ. Georgiou-Karistianis N, Bradshaw JL. Central mechanisms in phantom limb perception: the past, present and future. Brain Research Reviews 2007; 54(1): 219-32.
Melzack R. Evolution of the neuromatrix theory of pain. The Prithvi Raj Lecture. Presented at the Third World Congress of World Institute of Pain, Barcelona 2004,” Pain Practice 2005: 5(2): 85-94.
Iannetti DG, Mouraux A. From the neuromatrix to the pain matrix (and back),” Experimental Brain Research 2010; 205(1): 1-12.
Berger H, Bacon DR Historical notes on amputation and phantom limb pain: “All Quiet on the Western Front? Gundersen Lutheran Med J 2009; 6(1): 26-9.
Richardson C, Glenn S, Horgan M, Nurmikko T. A prospective study of factors associated with the presence of phantom limb pain six months after major lower limb amputation in patients with peripheral vascular disease. J Pain 2007; 8(10): 793–801.
Reuben SS, Buvanendran A. Preventing the development of chronic pain after orthopaedic surgery with preventive multimodal analgesic techniques. J Bone Joint Surg 2007; 89(6): 1343-58.
Hayes C, Armstrong-Brown A, Burstal R. Perioperative intravenous ketamine infusion for the prevention of persistent post-amputation pain: A randomized, controlled trial. Anaesthes Intensive Care 2004; 32(3): 330–8.
Hanley MA, Ehde DM, Campbell KM, Osborn B, Smith DG. Self-reported treatments used for lower-limb phantom pain: descriptive findings. Archives Physical Med Rehab 2006; 87 (2): 270-7.
Verdu B, Decosterd I, Buclin T, Stiefel F, Berney A. Antidepressants for the treatment of chronic pain. Drugs 2008; 68(18): 2611–32.
Wilder-Smith CH, Hill LT, Laurent S. Postamputation pain and sensory changes in treatment-naive patients: characteristics and responses to treatment with tramadol, amitriptyline, and placebo. Anesthesiol 2005; 103(3):619–628.
Robinson LR, Czerniecki JM, Ehde DM, Edwards WT, Judish DA, Goldberg ML, et al. Trial of amitriptyline for relief of pain in amputees: results of a randomized controlled study, Archives Physical Med Rehab 2004; 85(1): 1–6.
Jefferies K. Treatment of neuropathic pain. Seminars in Neurology 2010; 30(4): 425–32.
Spiegel DR, Lappinen E, Gottlieb M. A presumed case of phantom limb pain treated successfully with duloxetine and pregabalin. General Hospital Psychiatry 2010; 322:46.
Kuiken TA, Schechtman L, Harden RN. Phantom limb pain treatment with mirtazapine: a case series. Pain Practice 2005; 5(4): 356–60.
Wiffen PJ, McQuay HJ, Edwards JE, Moore RA. Gabapentin for acute and chronic pain. Cochrane Database of Systematic Reviews 2005;3. Article ID CD005452.
Smith DG, Ehde DM, M. Hanley A, Campbell KM, Jensen MP, Hoffman AJ, et al. Efficacy of gabapentin in treating chronic phantom limb and residual limb pain. J Rehabil Res Dev 2005; 42(5): 645-654.
Nikolajsen L, Finnerup NB, Kramp S, A. Vimtrup S, Keller J, Jensen TS. A randomized study of the effects of gabapentin on postamputation pain. Anesthesiology 2006; 105(5): 1008–15.
Casale R, Alaa L, Mallick M, Ring H. Phantom limb related phenomena and their rehabilitation after lower limb amputation. Eur J Physical Rehab J2009; 45(4): 559-566.
Weeks SR, Anderson-Barnes VC, Tsao JW. Phantom limb pain: theories and therapies. Neurologist 2010; 16(5): 277–86.
O’Connor AB, Dworkin RH. Treatment of neuropathic pain: an overview of recent guidelines. Am J Med 2009; 122(10): S22-S23.
Eichenberger U, Neff F, Sveticic G, Björgo S, Petersen-Felix S, Arendt-Nielsen L, et al. Chronic phantom limb pain: the effects of calcitonin, ketamine, and their combination on pain and sensory thresholds. Anesthes Analges 2008; 106(4): 1265-73.
Hackworth RJ, Tokarz KA, Fowler MI, Wallace SC, Stedje-Larsen ET. Profound pain reduction after induction of memantine treatment in two patients with severe phantom limb pain. Anesthes Analges 2008; 107(4): 1377-9.
Giuffrida O, Simpson L, Halligan PW. Contralateral stimulation, using tens, of phantom limb pain: two confirmatory cases. Pain Medicine 2010; 11(1): 133-41.
Ramachandran VS, Rogers-Ramachandran D. Synaesthesia in phantom limbs induced with mirrors. Proceedings of the Royal Society B: Biological Sciences 1996; 263:377-86.
Feinberg TE. Brain and self: bridging the Gap. Conscious Cogn 2011; 20(1): 2-3.
Diers, M, Christmann, C, Koeppe, C, Ruf, M, Flor, H. Mirrored, imagined, and executed movements differentially activate sensorimotor cortex in amputees with and without phantom limb pain. Pain 2010; 149(2): 296-304
Harden RN, Houle TT, Green S, Remble TA, Weinland SR, Colio S, et al. Biofeedback in the treatment of phantom limb pain: a time-series analysis. Applied Psychophysiology Biofeedback 2005; 30(1): 83-9.
Ramachandran VS, Brang D, McGeoch PD. Size reduction using mirror visual feedback (MVF) reduces phantom pain. Neurocase 2009; 15(5): 357–60.
Cassileth BR, Keefe FJ. Integrative and behavioral approaches to the treatment of cancer-related neuropathic pain. Oncologist 2010;15:19–23.
Bradbrook D. Acupuncture treatment of phantom limb pain and phantom limb sensation in amputees. Acupuncture Med 2004; 22(2):93–7.
Wetering EJVD, Lemmens KMM, Nieboer AP, Huijsman R. Cognitive and behavioral interventions for the management of chronic neuropathic pain in adults—a systematic review. Eur J Pain 2010; 14(7): 670-81.
Viswanathan A, Phan PC, Burton AW. Use of spinal cord stimulation in the treatment of phantom limb pain: case series and review of the literature. Pain Practice 2010; 10(5): 479–84.
Bittar RG, Otero S, Carter H, Aziz TZ. Deep brain stimulation for phantom limb pain. J Clin Neurosci 2005; 12(4): 399-404.
Fagundes-Pereyra JW, Teixeira MJ, Reyns N, Touzet G, Laureau E, Blond S. Motor cortex electric stimulation for the treatment of neuropathic pain,” Arquivos deNeuropsiquiatria 2010; 68(6):923-9.
Rasmussen KG, Rummans TA. Electroconvulsive therapy for phantom limb pain. Pain 2000; 85(1-2): 297-9.
Work published in KMUJ is licensed under a
Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.