Overview

Phantom pain is pain that feels like it's coming from a body part that's no longer there. Doctors once believed this post-amputation phenomenon was a psychological problem, but experts now recognize that these real sensations originate in the spinal cord and brain.

Most people who've had a limb removed report that it sometimes feels as if the amputated limb is still there. This painless phenomenon, known as phantom limb sensation, isn't the same as phantom pain.

For some people, phantom pain gets better over time without treatment. For others, managing phantom pain can be challenging. You and your doctor can work together to treat phantom pain effectively with medication or other therapies.

Symptoms

Characteristics of phantom pain include:

  • Onset within the first week after amputation, though it can be delayed by months or longer
  • Pain that comes and goes or is continuous
  • Symptoms affecting the part of the limb farthest from the body, such as the foot of an amputated leg
  • Pain that may be described as shooting, stabbing, cramping, pins and needles, crushing, throbbing, or burning

Causes

The exact cause of phantom pain is unclear, but it appears to come from the spinal cord and brain. During imaging scans — such as magnetic resonance imaging (MRI) or positron emission tomography (PET) — portions of the brain that had been neurologically connected to the nerves of the amputated limb show activity when the person feels phantom pain.

Many experts believe phantom pain may be at least partially explained as a response to mixed signals from the brain. After an amputation, areas of the spinal cord and brain lose input from the missing limb and adjust to this detachment in unpredictable ways. The result can trigger the body's most basic message that something is not right: pain.

Studies also show that after an amputation the brain may remap that part of the body's sensory circuitry to another part of the body. In other words, because the amputated area is no longer able to receive sensory information, the information is referred elsewhere — from a missing hand to a still-present cheek, for example.

So when the cheek is touched, it's as though the missing hand is also being touched. Because this is yet another version of tangled sensory wires, the result can be pain.

A number of other factors are believed to contribute to phantom pain, including damaged nerve endings, scar tissue at the site of the amputation and the physical memory of pre-amputation pain in the affected area.

Risk factors

Not everyone who has an amputation develops phantom pain. Some factors that may increase your risk of phantom pain include:

  • Pain before amputation. Some researchers have found that people who had pain in a limb before amputation are likely to have it afterward. This may be because the brain holds on to the memory of the pain and keeps sending pain signals, even after the limb is removed.
  • Residual limb pain. People who have persistent pain in the remaining part of the limb usually have phantom pain, too. Residual limb pain can be caused by an abnormal growth on damaged nerve endings (neuroma) that often results in painful nerve activity.

Prevention

Because the risk of developing phantom pain is higher for people who have experienced pain in the limb before amputation, some doctors recommend regional anesthesia (spinal or epidural) in the hours or days leading up to amputation. This may reduce pain immediately following surgery and reduce the risk of lasting phantom limb pain.

Oct. 30, 2018
References
  1. Benzon HT, et al., eds. Phantom limb pain. In: Practical Management of Pain. 5th ed. Philadelphia, Pa.: Mosby Elsevier; 2014. https://www.clinicalkey.com. Accessed Sept. 7, 2018.
  2. Pain: Hope through research. National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Hope-Through-Research/Pain-Hope-Through-Research. Accessed Sept. 1, 2018.
  3. Kalapatapu V. Lower extremity amputation. https://www.uptodate.com/contents/search. Accessed Sept. 7, 2018.
  4. Fuchs X, et al. Psychological factors associated with phantom limb pain: A review of recent findings. Pain and Research Management. https://www.hindawi.com/journals/prm/2018/5080123/. Accessed Sept. 7, 2018.
  5. Vaso A, et al. Peripheral nervous system origin of phantom limb pain. Pain. 2014;155:1384.
  6. Pain in the residual limb. Merck Manual Professional Version. https://www.merckmanuals.com/professional/special-subjects/limb-prosthetics/pain-in-the-residual-limb#v21361465. Accessed Sept. 7, 2018.
  7. Ambron E, et al. Immersive low-cost virtual reality treatment for phantom limb pain: Evidence from two cases. Frontiers in Neuroscience. 2018;9:1.
  8. Alviar MJM, et al. Pharmacologic interventions for treating phantom limb pain. Cochrane Database of Systematic Reviews. http://www.thecochranelibrary.com. Accessed Sept. 7, 2018.
  9. Raffin E, et al. Primary motor cortex changes after amputation correlate with phantom limb pain and the ability to move the phantom limb. NeuroImage. 2016;130:134.
  10. Managing phantom pain. Amputee Coalition. https://www.amputee-coalition.org/limb-loss-resource-center/resources-for-pain-management/managing-phantom-pain/. Accessed Sept. 7, 2018.
  11. Rosenquist EWK. Overview of the treatment of chronic non-cancer pain. https://www.uptodate.com/contents/search. Accessed Sept. 7, 2018.
  12. Thieme H, et al. The efficacy of movement representation techniques for treatment of limb pain — A systematic review and meta-analysis. The Journal of Pain. 2016;17:167.
  13. Barbin J, et al. The effects of mirror therapy on pain and motor control of phantom limb in amputees: A systematic review. Annals of Physical and Rehabilitation Medicine. 2016;59:270.
  14. Ortiz-Catalan M, et al. Phantom motor execution facilitated by machine learning and augmented reality as treatment for phantom limb pain: A single group, clinical trial in patients with chronic intractable phantom limb pain. The Lancet. 2016;388:2885.
  15. Brain stimulation therapies. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml. Accessed Oct. 9, 2018.
  16. Malavera A, et al. Repetitive transcranial magnetic stimulation. Journal of Pain. 2016;17:911.
  17. Sandroni P (expert opinion). Mayo Clinic, Rochester, Minn. Sept. 24, 2018.