• Phantom Limb Pain. Described as stabbing, throbbing, burning, cramping, shocking, or shooting pain (59,79).
• Allodynia (pain with typically non-painful stimulus)
• Residual Limb Pain (also called stump pain).

• Older age at time of amputation (14,23,96,97).
• Lower limb amputation (vs. upper limb) (14).
• Bilateral amputation (vs. unilateral) (14).
• Multiple studies show a correlation between the presence of stump pain and phantom limb pain (14,23,59,99).
• Catastrophizing (18,23,97).
• Stress and/or anxiety (23,59,79,89).
• Etiology of electrical burn (vs. flame burn) in children (85).
• Etiology of sudden blood clot in adults (14).
• Surgical amputation (vs. congenital) in children (85).
• Unemployment may increase intensity of PLP but no other type of pain associated with limb loss (96).
• Presence of chronic pain before amputation (23).

For RLP

• Presence of scar tissue or neuroma on stump, bony spurs, infection, ischemia, necrosis, adhesions, muscle spasm, a poorly fashioned stump, or poorly fitting prosthesis (59).

Neuropathic pain is difficult to treat. No single treatment has provided consistent relief in all cases. Trial and error may be necessary. A multidisciplinary / multimodal approach may be best (23,59,79,85).

Pharmacological
For phantom limb pain (PLP):

• Preemptive analgesia before and during surgery (mixed results reported) (23,59,103).
• Aggressive postoperative pain management such as epidural infusion, patient-controlled intravenous analgesia, intrathecal opioids or nerve blocks along the adjuvant analgesics such as NSAIDs and paracetamol (59,79).
• Sympathetic or regional nerve blocks (59).
• Local anesthetic injections in neuromas (79).
• Low doses of anticonvulsant and antidepressant drugs (in lower doses than used to treat epilepsy or depression) (23,59,79).
• NMDA-receptor antagonists (memantine or ketamine) are thought to be especially helpful with allodynia (mixed results - a recent randomized, double-blinded, placebo-controlled trial of memantine showed it ineffective; another recent study of memantine of the same design showed it effective in reducing PLP when used during amputation surgery. It may be of more value in preventing pain than treating it (23,53,59).
• Opioids (23).
• Oral methadone found effective in small case report study (n=4). Further study needed (4).

• Botulinum toxin type B injections offered relief of residual limb pain for 10 to 14 weeks in small case report study (n=4) (48).
• NSAIDs are especially helpful in treating stump pain (59).
• Local anesthetic injections of neuromas (23,79).
• Opioids (18,59).
• Trigger point injections (59)

Non-Pharmacologial

• Adaptive coping skills (23,97).
• Increasing activity levels.
• Support system (23).
• Time passage since amputation (14).
• Transcutaneous electric nerve stimulation (TENS) (conflicting results) - may involve a bit of trial and error regarding current used and amount and position of electrodes (18,23,59,79).
• Spinal cord stimulation (46).
• Deep brain stimulation of the thalamic nucleus vertralis caudalis (46).
• Motor cortex stimulation. Requires skill in placement of electrode - computer imaging can help with accuracy (46,81).
• Psychological therapies to reduce stress, anxiety, and catastrophizing may help since they seem to go hand-in-hand with pain intensity.
• Use of prosthetic limb in lower limb amputation can reduce pain, but excess use can aggravate - more study needed (96).
• Early fitting of prosthesis may significantly reduce incidence of phantom limb pain (59).
• Refitting and/or adjusting of prosthetic lower limb to ensure fit with changes that occur in stump after initial fitting.

• Surgical or chemical sympathectomy may be useful in people who describe pain as burning, but can have undesirable complications such as increased pain, new pain, and abnormal sweating - more study needed (54,79).
• Surgical interventions such as cordotomies and neuroablation can cause more harm than good and should be tried as last resort. Scar tissue or neuroma removal and stump refashioning are less drastic and may be more helpful surgical options (59).
• Surgical removal of neuromas (79).

Musculoskeletal Pain

• Back pain, especially with lower limb amputations.
• Arthritic pain mainly from prosthetic limb use (96).

Back, non-amputated leg or foot, buttocks/hips, neck/shoulders (18).

NOTE: Back pain in some studies and residual limb pain in others is reported as significantly more troublesome and interfering with activities than phantom limb pain (18,56).

• Stress
• Excessive use or too little use of lower limb prosthesis - mixed results; more research needed to determine what level of prosthesis use is most beneficial (96).
• Advancing age.

See section on Osteoarthritis for exercise guidelines to manage arthritic pain.