What is phantom limb pain, and how is it treated?

What does phantom limb pain feel like?

Phantom limb pain can feel like burning, stabbing, cramping, shooting or crushing pain in the missing limb, for example in a foot or hand that is no longer there. It may come and go or be constant, and it often begins in the days or weeks after amputation.

Phantom sensations, such as tingling, itching or feeling that the limb is still present, are different from phantom pain and are very common. Residual limb pain, felt in the remaining part of the limb, is also different and may have other causes.

How common is phantom limb pain?

A systematic review and meta-analysis estimated that 64 per cent of people with amputations report phantom limb pain. The prevalence was 66.55 per cent in developed countries and 53.98 per cent in developing countries 1.

The review identified persistent pain before the amputation, a higher level of amputation, residual limb pain, lower limb amputation and phantom sensations as risk factors 1.

Why does phantom pain happen?

After amputation, damaged nerves in the residual limb can send abnormal signals. The spinal cord and brain also reorganise, because the area of the brain that previously received signals from the missing limb is no longer receiving normal input. These changes can produce pain perceived in the missing limb.

Stress, fatigue, changes in weather, poorly fitting prostheses and problems with the residual limb can trigger or worsen episodes.

What treatments help?

Rehabilitation guidelines for lower limb amputation emphasise a coordinated, interdisciplinary approach that includes pain management alongside physical rehabilitation and prosthetic care 3. Medicines used for nerve pain, such as certain antidepressants and anticonvulsants, may be tried, and pain before and around the time of surgery is managed carefully.

Non-drug approaches include desensitisation of the residual limb, massage, TENS, graded motor imagery, relaxation and psychological therapies. Wearing a well-fitting prosthesis and staying active can also reduce phantom pain for some people.

What is mirror therapy?

In mirror therapy, a mirror is placed so that the reflection of the intact limb appears in the position of the missing limb. Moving the intact limb while watching the reflection gives the brain visual feedback that the missing limb is moving without pain.

A small randomised study of people with leg amputations reported reduced phantom pain after four weeks of mirror therapy compared with using a covered mirror or mental visualisation 2. Larger studies are needed, but the technique is low-risk and often included in rehabilitation.

Does phantom pain go away?

For many people, phantom pain becomes less frequent and less intense over months to years. Some people continue to have episodes long term and benefit from a pain management plan.

Keeping a diary of triggers and effective strategies can help people manage episodes and communicate with their care team.

What is graded motor imagery?

Graded motor imagery is a stepwise programme that aims to retrain the brain's processing of movement and pain. It usually starts with recognising whether pictures show a left or right limb, moves on to imagining movements of the missing limb, and then progresses to mirror therapy.

Each stage is practised regularly over several weeks. It is usually taught and supervised by a physiotherapist or occupational therapist, and it is often combined with other treatments for phantom pain.

When should pain be reviewed?

Seek assessment for pain that is severe, worsening or interfering with sleep, mood or prosthesis use. New pain in the residual limb, especially with redness, swelling, wound breakdown or fever, may indicate infection or another problem.

Low mood or thoughts of self-harm are important to discuss with a healthcare professional. Help is available.

Frequently asked questions