Residual Limb Pain
(Phantom Pain; Phantom Sensation)
After an amputation, over 70% of people have pain in the residual limb (stump), which can severely limit function, impair quality of life, and significantly impede rehabilitation. Residual-limb pain should be evaluated and treated aggressively because some causes can be dangerous. Phantom-limb sensation is a desirable, nonpainful sensation that can improve a person's sense of where the limb is and is distinct from phantom pain. (See also Overview of Limb Prosthetics.)
Causes of residual-limb pain include
A person with residual limb pain should first check for signs of infection and skin breakdown. If infection looks likely, the doctor should be consulted. Even if there is no obvious signs of infection, the doctor should be consulted if pain is severe and sudden or if there is fever; these symptoms may indicate an infection. The area may be cleaned or flushed out with a solution. Dead skin may be removed, and a bandage applied. Antibiotics and sometimes surgery may be needed.
Surgical wound pain typically resolves as tissues heal, usually over 3 to 6 months. Pain continuing beyond that time has numerous causes, including infection and a poorly fitting preparatory prosthesis. Treatments are directed at the cause and may also include modifying the prosthesis, not wearing the prosthesis until the wound heals, and taking painkillers.
Pain due to nerve damage (neuropathic pain) is common. Usually described as a shooting or burning pain, neuropathic pain typically develops within 7 days of amputation. It can go away on its own but is often long-lasting. It can be unrelenting and severe, or intermittent. Nerves may have been damaged from an injury or when they were severed during the amputation. Treatment of neuropathic pain includes psychologic treatments, physical methods, antidepressants, and antiseizure drugs.
Painful neuromas (noncancerous overgrowths of nerve tissue) can occur in any severed nerve (from surgery or trauma) and may cause pain that feels electrical, shooting, tingling, sharp and stabbing, or prickly. The pain typically does not involve the phantom limb but can. Other symptoms of neuroma include unusual and unpleasant sensations that occur without stimulation or upon contraction of residual-limb muscles and a disagreeable sensation (dysesthesia) that occurs with light palpation of skin. The longer the neuroma is irritated, either from wearing the prosthesis or from muscle contractions, the longer it takes to go away. Doctors sometimes do MRI and/or ultrasound to confirm the diagnosis of neuroma. A severe neuroma may require surgery.
Patients whose amputation was necessitated by poor circulation (peripheral arterial disease) may have poor circulation in their stump, which can be difficult to diagnose.
If there is no medical disorder causing the pain, massaging and light tapping combined with elevating the residual limb may help relieve the pain. If this is ineffective, mild painkillers (such as ibuprofen or acetaminophen) can be used. If pain persists, a pain management specialist may be helpful.
Sometimes pain is felt in other limbs or in the hips, spine, shoulders, or neck. This pain may occur because wearing a prosthesis makes people change the way they walk or hold their body (body alignment) or causes them to repeat movements. Regularly doing specific stretching exercises and exercises to strengthen muscles may help prevent or relieve this type of pain. A physical therapist can help design an appropriate exercise program.
Most people experience pain that feels as though it were occurring in the amputated limb (phantom pain) at some time. The phantom aspect is not the pain, which is real, but the location of the pain—in a limb that has been amputated. Phantom pain usually begins within days following amputation but could be delayed months to years. Phantom pain may feel like tingling, shooting, stabbing, throbbing, burning, aching, pinching, clamping, and vise-like squeezing pain.
Phantom pain is often worse soon after the amputation, then decreases over time. For many people, phantom pain is more common when the prosthesis is not being worn, for example, at night. The risk of having this pain is reduced if both a spinal anesthetic and a general anesthetic are used during surgery.
Transcutaneous electrical nerve stimulation (TENS), acupuncture, and spinal cord stimulation may relieve the pain.
Most people experience phantom sensation, which is the feeling that the amputated part is still present. Phantom sensation is different from phantom pain. Phantom sensation can be a particular problem with lower limb amputees during nighttime trips to the bathroom. They believe their limb is still there and take a step and fall or injure their residual limb. A protective device can be worn while sleeping to prevent injury.
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