Phantom Pain, Residual Limb Pain, and Back Pain in Amputees: Results of a National Survey


      Ephraim PL, Wegener ST, MacKenzie EJ, Dillingham TR, Pezzin LE. Phantom pain, residual limb pain, and back pain in amputees: results of a national survey.


      To describe the prevalence of amputation-related pain; to ascertain the intensity and affective quality of phantom pain, residual limb pain, back pain, and nonamputated limb pain; and to identify the role that demographics, amputation-related factors, and depressed mood may contribute to the experience of pain in the amputee.


      Cross-sectional survey.


      A sample of persons who contacted the Amputee Coalition of America from 1998 to 2000 were interviewed by telephone.


      A stratified sample by etiology of 914 persons with limb loss.


      Not applicable.

      Main Outcome Measures

      Prevalence, intensity, and bothersomeness of residual, phantom, and back pain, depressed mood as measured by the Center for Epidemiologic Study Depression Scale, characteristics of the amputation, prosthetic use, and sociodemographic characteristics of the amputee.


      Nearly all (95%) amputees surveyed reported experiencing 1 or more types of amputation-related pain in the previous 4 weeks. Phantom pain was reported most often (79.9%), with 67.7% reporting residual limb pain and 62.3% back pain. A large proportion of persons with phantom pain and stump pain reported experiencing severe pain (rating 7–10). Across all pain types, a quarter of those with pain reported their pain to be extremely bothersome. Identifiable risk factors for intensity and bothersomeness of amputation-related pain varied greatly by pain site. However, across all pain types, depressive symptoms were found to be a significant predictor of level of pain intensity and bothersomeness.


      Chronic pain is highly prevalent among persons with limb loss, regardless of time since amputation. A common predictor of an increased level of intensity and bothersomeness among all pain sites was the presence of depressive symptoms. Further studies are needed to elucidate the relationship between pain and depressive symptoms among amputees.

      Key Words

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        • Adams P.
        • Hendershot G.
        • Marano M.
        Current estimates from the National Health Interview Survey, 1996. National Center for Health Statistics, Bethesda1999
        • Smith D.G.
        • Ehde D.M.
        • Legro M.W.
        • Reiber G.E.
        • del Aguila M.
        • Boone D.A.
        Phantom limb, residual limb, and back pain after lower extremity amputations.
        Clin Orthop. 1999; (Apr): 29-38
        • Carlen P.L.
        • Wall P.D.
        • Nadvorna H.
        Phantom limbs and related phenomenon in recent traumatic amputations.
        Neurology. 1978; 28: 211-217
        • Shukla G.D.
        • Sahu S.C.
        • Tripathi R.P.
        • Gupta D.K.
        Phantom limb.
        Br J Psychiatry. 1982; 141: 54-58
        • Steinbach T.V.
        • Nadvorna H.
        • Arazi D.
        A five year follow-up study of phantom limb pain in post traumatic amputees.
        Scand J Rehabil Med. 1982; 14: 203-207
        • Sherman R.A.
        • Sherman C.J.
        Prevalence and characteristics of chronic phantom limb pain among American veterans. Results of a trial survey.
        Am J Phys Med. 1983; 62: 227-238
        • Sherman R.A.
        • Sherman C.J.
        • Parker L.
        Chronic phantom and stump pain among American veterans.
        Pain. 1984; 18: 83-95
        • Jensen T.S.
        • Krebs B.
        • Nielsen J.
        • Rasmussen P.
        Phantom limb, phantom pain and stump pain in amputees during the first 6 months following limb amputation.
        Pain. 1983; 17: 243-256
        • Jensen T.S.
        • Krebs B.
        • Nielsen J.
        • Rasmussen P.
        Non-painful phantom limb phenomena in amputees.
        Acta Neurol Scand. 1984; 70: 407-414
        • Jensen T.S.
        • Krebs B.
        • Nielsen J.
        • Rasmussen P.
        Immediate and long-term phantom limb pain in amputees.
        Pain. 1985; 21: 267-278
        • Wall R.
        • Novotny-Joseph P.
        • Macnamara T.E.
        Does preamputation pain influence phantom limb pain in cancer patients?.
        South Med J. 1985; 78: 34-36
        • Houghton A.D.
        • Nicholls G.
        • Houghton A.L.
        • Saadah E.
        • McColl L.
        Phantom pain.
        Ann R Coll Surg Engl. 1994; 76: 22-25
        • Wartan S.W.
        • Hamann W.
        • Wedley J.R.
        • McColl I.
        Phantom pain and sensation among British veteran amputees.
        Br J Anaesth. 1997; 78: 652-659
        • Kooijman C.M.
        • Dijkstra P.U.
        • Geertzen J.H.
        • Elzinga A.
        • van der Schans C.P.
        Phantom pain and phantom sensations in upper limb amputees.
        Pain. 2000; 87: 33-41
        • Ehde D.M.
        • Czerniecki J.M.
        • Smith D.G.
        • et al.
        Chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after lower limb amputation.
        Arch Phys Med Rehabil. 2000; 81: 1039-1044
        • Gallagher P.
        • Allen D.
        • Maclachlan M.
        Phantom limb pain and residual limb pain following lower limb amputation.
        Disabil Rehabil. 2001; 23: 522-530
        • Parkes C.
        Factors determining the persistence of phantom limb pain in the amputee.
        J Psychosom Res. 1973; 17: 97-108
        • Hoaglund F.T.
        • Jergesen H.E.
        • Wilson L.
        • Lamoreux L.W.
        • Roberts R.
        Evaluation of problems and needs of veteran lower-limb amputees in the San Francisco Bay Area during the period 1977–1980.
        J Rehabil Res Dev. 1983; 20: 57-71
        • Ehde D.M.
        • Smith D.G.
        • Czerniecki J.M.
        • Campbell K.M.
        • Malchow D.M.
        • Robinson L.R.
        Back pain as a secondary disability in persons with lower limb amputations.
        Arch Phys Med Rehabil. 2001; 82: 731-734
        • Loeser J.
        Pain after amputation.
        in: Loeser J. Butler S. Chapman C. Bonica’s management of pain. Lippincott Williams & Wilkins, Philadelphia2001: 412-423
        • Appenzeller O.
        • Bicknell J.
        Effects of nervous system lesions on phantom experience in amputees.
        Neurology. 1969; 19: 141-146
        • Nikolajsen L.
        • Ilkjaer S.
        • Kroner K.
        The influence of preamputation pain on postamputation stump and phantom pain.
        Pain. 1997; 72: 393-405
        • Marshall H.M.
        • Jensen M.P.
        • Ehde D.M.
        • Campbell K.M.
        Pain site and impairment in individuals with amputation pain.
        Arch Phys Med Rehabil. 2002; 83: 1116-1119
        • Rudy T.
        • Lieber S.
        • Boston J.
        • Gourley L.
        • Baysal E.
        Psychosocial predictors of physical performance in disabled individuals with chronic pain.
        Clin J Pain. 2003; 19: 18-30
        • Schoppen T.
        • Boonstra A.
        • Groothoff J.W.
        • van Sonderen E.
        • Goeken L.N.
        • Eisma W.H.
        Factors related to successful job reintegration of people with a lower limb amputation.
        Arch Phys Med Rehabil. 2001; 82: 1425-1431
        • Whyte A.S.
        • Carroll L.J.
        A preliminary examination of the relationship between employment, pain and disability in an amputee population.
        Disabil Rehabil. 2002; 24: 462-470
        • Millstein S.
        • Bain D.
        • Hunter G.A.
        A review of employment patterns of industrial amputees—factors influencing rehabilitation.
        Prosthet Orthot Int. 1985; 9: 69-78
        • Marshall M.
        • Helmes E.
        • Deathe A.B.
        A comparison of psychosocial functioning and personality in amputee and chronic pain populations.
        Clin J Pain. 1992; 8: 351-357
        • Kashani J.
        • Frank R.
        • Kashina S.
        • Wonderlich S.
        • Reid J.
        Depression among amputees.
        J Clin Psychiatry. 1983; 44: 256-258
        • Cansever A.
        • Uzun O.
        • Yildiz C.
        • Ates A.
        • Atesalp A.
        Depression in men with traumatic lower part amputation.
        Mil Med. 2003; 168: 106-109
        • Eaton W.
        Epidemiologic evidence on the comorbidity of depression and diabetes.
        J Psychosom Res. 2002; 53: 903-906
        • Blazer D.
        • Kessler R.
        • McGonagle K.
        • Swartz M.
        The prevalence and distribution of major depression in a national community sample.
        Am J Psychiatry. 1994; 151: 979-986
        • Frank R.
        • Kashani J.
        • Kashani S.
        • Wonderlich S.
        • Umlauf R.
        • Ashkanazi G.
        Psychological response to amputation as a function of age and time since amputation.
        Br J Psychiatry. 1984; 144: 493-497
        • Livney H.
        • Antonak R.
        • Gerhardt J.
        Psychosocial adaptation to amputation.
        Int J Rehabil Res. 1999; 22: 21-31
        • Williamson G.
        The central role of restricted normal activities in adjustment to illness and disability.
        Rehabil Psychol. 1998; 43: 327-347
        • Jensen M.P.
        • Smith D.G.
        • Ehde D.M.
        • Robinson L.R.
        Pain site and the effects of amputation pain.
        Pain. 2001; 91: 317-322
        • Kohout F.J.
        • Berkman L.F.
        • Evans D.A.
        • Cornoni-Huntley J.
        Two shorter forms of the CES-D (Center for Epidemiological Studies Depression) depression symptoms index.
        J Aging Health. 1993; 5: 179-193
        • Shrout P.E.
        • Yager T.J.
        Reliability and validity of screening scales.
        J Clin Epidemiol. 1989; 42: 69-78
        • US Census Bureau
        Poverty 2000. Census Bureau, Washington (DC)2004
        • Jones L.E.
        • Davidson J.H.
        The long-term outcome of upper limb amputees treated at a rehabilitation centre in Sydney, Australia.
        Disabil Rehabil. 1995; 17: 437-442
        • Geraghty T.
        • Jones L.
        Painful neuromata following upper limb amputation.
        Prosthet Orthot Int. 1996; 20: 176-181
        • Montoya P.
        • Larbig W.
        • Grulke N.
        • Flor H.
        • Taub E.
        • Birbaumer N.
        The relationship of phantom limb pain to other phantom limb phenomena in upper extremity amputees.
        Pain. 1997; 72: 87-93
        • Pleis J.
        • Coles R.
        Summary health statistics for U.S. adults.
        Vital Health Stat 10. 2002; : 1-113