Clinical Inquiries

What is the best way to manage phantom limb pain?

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No single best therapy for phantom limb pain (PLP) exists. Treatment requires a coordinated application of conservative, pharmacologic, and adjuvant therapies.

Evaluative management (including prosthesis adjustment, treatment of referred pain, and residual limb care) should be tried initially (strength of recommendation [SOR]: C, expert opinion). Other first-line treatments such as transcutaneous electrical nerve stimulation (TENS) (SOR: A, multiple high-quality randomized, control trials [RCTs]), and biofeedback (SOR: B, numerous case studies) can reduce PLP. Pharmacotherapy, including opioids, anticonvulsants (gabapentin), and nonsteroidal anti-inflammatory drugs (NSAIDs), can also relieve pain (SOR: B, initial RCTs and inconsistent findings).

Adjuvant therapies (mirror box therapy, acupuncture, calcitonin, and N-methyl d-aspartate receptor antagonists) haven’t been rigorously investigated for alleviating PLP, but can be considered for patients who have failed other treatments.

Evidence summary

An estimated 1.7 million people in the United States are living with limb loss. The number is expected to increase because of ongoing military conflicts.1 The incidence of PLP is 60% to 80% among amputees.1

A multidisciplinary approach

A lack of comparative clinical trials of therapies for PLP has led health-care providers to adopt a multidisciplinary approach that combines evaluative management, desensitization, psychotherapy, and pharmacotherapy (FIGURE).

Evaluative management, based largely on expert opinion, includes assessing the fit of the prosthesis, treating referred pain, and assessing aggravating factors. Because residual limb pain can exacerbate PLP, adjusting a poorly fitting prosthesis or providing the patient with NSAIDs when there is evidence of stump inflammation may adequately control pain.2,3 Anatomically distant pain syndromes, such as hip or lower back pain, can also aggravate PLP and should be managed to provide optimal pain relief.2

Desensitization, using TENS, has reduced PLP in multiple placebo-controlled trials and epidemiologic surveys.2-5 TENS is an easy-to-use, low-cost, noninvasive, first-line therapy.5 Its long-term effectiveness in alleviating PLP remains unknown.2 Some experts suggest that pain reductions after 1 year of treatment are comparable to placebo.2 Other forms of desensitization (percussion and massage) are supported only by anecdotal reports.

Psychotherapy, including biofeedback, has been found in several case studies to effectively treat chronic PLP.2,5 Psychotherapy can reportedly reveal the underlying mechanisms (muscle spasm, vascular insufficiency) and therefore direct therapeutic interventions by biofeedback or other focus techniques.2

FIGURE Management of phantom limb pain1-10

HO, heterotopic ossification; NSAIDs, nonsteroidal anti-inflammatory drugs; OT, occupational therapy; PT, physical therapy; TCAs, tricyclic antidepressants; TENS, transcutaneous electrical nerve stimulation.
*Expert opinion.
†Case studies.
‡Randomized controlled trials or cohort studies.


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