Original research| Volume 98, ISSUE 1, P105-113, January 2017

Download started.


Cross-Sectional Assessment of Factors Related to Pain Intensity and Pain Interference in Lower Limb Prosthesis Users

Published:October 11, 2016DOI:



      To determine relationships between pain sites and pain intensity/interference in people with lower limb amputations (LLAs).


      Cross-sectional survey.




      Lower limb prosthesis users with unilateral or bilateral amputations (N=1296; mean time since amputation, 14.1y).


      Not applicable.

      Main Outcome Measures

      Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity (1 item to assess average pain), PROMIS pain interference (4-item short form to assess the consequences of pain in desired activities), and questions that asked participants to rate the extent to which each of the following were a problem: residual limb pain (RLP), phantom limb pain (PLP), knee pain on the nonamputated side, back pain, and shoulder pain.


      Nearly three quarters (72.1%) of participants reported problematic pain in 1 or more of the listed sites. Problematic PLP, back pain, and RLP were reported by 48.1%, 39.2%, and 35.1% of participants, respectively. Knee pain and shoulder pain were less commonly identified as problems (27.9% and 21.7%, respectively). Participants also reported significantly (P<.0001) higher pain interference (T-score ± SD, 54.7±9.0) than the normative sample based on the U.S. population (T-score ± SD, 50.0±10.0). Participants with LLAs rated their pain intensity on average ± SD at 3.3±2.4 on a 0-to-10 scale. Pain interference (ρ=.564, P<.0001) and intensity (ρ=.603, P<.0001) were positively and significantly correlated with number of pain sites reported.


      Problematic pain symptoms, especially RLP, PLP, and back pain, affect most prosthetic limb users and have the potential to greatly restrict participation in life activities.


      List of abbreviations:

      LLA (lower limb amputation), PLP (phantom limb pain), PROMIS (Patient-Reported Outcomes Measurement Information System), RLP (residual limb pain)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • 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
        • 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 Relat Res. 1999; : 29-38
        • Ephraim P.L.
        • Wegener S.T.
        • MacKenzie E.J.
        • Dillingham T.R.
        • Pezzin L.E.
        Phantom pain, residual limb pain, and back pain in amputees: results of a national survey.
        Arch Phys Med Rehabil. 2005; 86: 1910-1919
        • Uustal H.
        • Meier III, R.H.
        Pain issues and treatment of the person with an amputation.
        Phys Med Rehabil Clin N Am. 2014; 25: 45-52
        • Buchheit T.
        • Van de Ven T.
        • Hsia H.L.
        • et al.
        Pain phenotypes and associated clinical risk factors following traumatic amputation: results from Veterans Integrated Pain Evaluation Research (VIPER).
        Pain Med. 2016; 17: 149-161
        • 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
        • Norvell D.C.
        • Czerniecki J.M.
        • Reiber G.E.
        • Maynard C.
        • Pecoraro J.A.
        • Weiss N.S.
        The prevalence of knee pain and symptomatic knee osteoarthritis among veteran traumatic amputees and nonamputees.
        Arch Phys Med Rehabil. 2005; 86: 487-493
        • Gailey R.
        • Allen K.
        • Castles J.
        • Kucharik J.
        • Roeder M.
        Review of secondary physical conditions associated with lower-limb amputation and long-term prosthesis use.
        J Rehabil Res Dev. 2008; 45: 15-29
        • Gaffney B.M.
        • Murray A.M.
        • Christiansen C.L.
        • Davidson B.S.
        Identification of trunk and pelvis movement compensations in patients with transtibial amputation using angular momentum separation.
        Gait Posture. 2016; 45: 151-156
        • Hendershot B.D.
        • Wolf E.J.
        Persons with unilateral transfemoral amputation have altered lumbosacral kinetics during sitting and standing movements.
        Gait Posture. 2015; 42: 204-209
        • Morgenroth D.C.
        • Orendurff M.S.
        • Shakir A.
        • Segal A.
        • Shofer J.
        • Czerniecki J.M.
        The relationship between lumbar spine kinematics during gait and low-back pain in transfemoral amputees.
        Am J Phys Med Rehabil. 2010; 89: 635-643
        • Bosmans J.C.
        • Geertzen J.H.
        • Post W.J.
        • van der Schans C.P.
        • Dijkstra P.U.
        Factors associated with phantom limb pain: a 31/2-year prospective study.
        Clin Rehabil. 2010; 24: 444-453
        • Jensen M.P.
        • Smith D.G.
        • Ehde D.M.
        • Robinsin L.R.
        Pain site and the effects of amputation pain: further clarification of the meaning of mild, moderate, and severe pain.
        Pain. 2001; 91: 317-322
        • Desmond D.
        • Gallagher P.
        • Henderson-Slater D.
        • Chatfield R.
        Pain and psychosocial adjustment to lower limb amputation amongst prosthesis users.
        Prosthet Orthot Int. 2008; 32: 244-252
        • Littman A.J.
        • Boyko E.J.
        • Thompson M.L.
        • Haselkorn J.K.
        • Sangeorzan B.J.
        • Arterburn D.E.
        Physical activity barriers and enablers in older veterans with lower-limb amputation.
        J Rehabil Res Dev. 2014; 51: 895-906
        • 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
        • Amtmann D.
        • Abrahamson D.
        • Morgan S.
        • et al.
        The PLUS-M: item bank of mobility for prosthetic limb users.
        Qual Life Res. 2014; 23: 39-40
        • Gershon R.
        • Rothrock N.E.
        • Hanrahan R.T.
        • Jansky L.J.
        • Harniss M.
        • Riley W.
        The development of a clinical outcomes survey research application: Assessment Center.
        Qual Life Res. 2010; 19: 677-685
        • Paulsen A.
        • Overgaard S.
        • Lauritsen J.M.
        Quality of data entry using single entry, double entry and automated forms processing—an example based on a study of patient-reported outcomes.
        PLoS One. 2012; 7: e35087
        • Cella D.
        • Riley W.
        • Stone A.
        • et al.
        The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005-2008.
        J Clin Epidemiol. 2010; 63: 1179-1194
        • Amtmann D.
        • Cook K.F.
        • Jensen M.P.
        • et al.
        Development of a PROMIS item bank to measure pain interference.
        Pain. 2010; 150: 173-182
        • Bair M.J.
        • Robinson R.L.
        • Katon W.
        • Kroenke K.
        Depression and pain comorbidity: a literature review.
        Arch Intern Med. 2003; 163: 2433-2445
        • Kroenke K.
        • Outcalt S.
        • Krebs E.
        • et al.
        Association between anxiety, health-related quality of life and functional impairment in primary care patients with chronic pain.
        Gen Hosp Psychiatry. 2013; 35: 359-365
        • Cook R.D.
        Detection of influential observation in linear regression.
        Technometrics. 1977; 19: 15-18
        • Belsley D.A.
        • Kuh E.
        • Welsch R.E.
        Regression diagnostics: identifying influential data and sources of collinearity.
        John Wiley, New York1980
        • Chatterjee S.
        • Hadi A.S.
        Influential observations, high leverage points, and outliers in linear regression.
        Stat Sci. 1986; 1: 379-416
        • Borsje S.
        • Bosmans J.C.
        • van der Schans C.P.
        • Geertzen J.H.
        • Dijkstra P.U.
        Phantom pain: a sensitivity analysis.
        Disabil Rehabil. 2004; 26: 905-910
        • Lotze M.
        • Grodd W.
        • Birbaumer N.
        • Erb M.
        • Huse E.
        • Flor H.
        Does use of a myoelectric prosthesis prevent cortical reorganization and phantom limb pain?.
        Nat Neurosci. 1999; 2: 501-502
        • Farivar S.S.
        • Liu H.
        • Hays R.D.
        Half standard deviation estimate of the minimally important difference in HRQOL scores?.
        Expert Rev Pharmacoecon Outcomes Res. 2004; 4: 515-523
        • Ziegler-Graham K.
        • MacKenzie E.J.
        • Ephraim P.L.
        • Travison T.G.
        • Brookmeyer R.
        Estimating the prevalence of limb loss in the United States: 2005 to 2050.
        Arch Phys Med Rehabil. 2008; 89: 422-429
        • Morgan S.J.
        • Amtmann D.
        • Abrahamson D.C.
        • Kajlich A.J.
        • Hafner B.J.
        Use of cognitive interviews in the development of the PLUS-M item bank.
        Qual Life Res. 2014; 23: 1767-1775