Keywords: Phantom limb pain/Pain

assessment/Neuropathic pain/
Amputation
This article has been double-blind
peer reviewed

Nursing Practice
Practice review
Pain management

Nurses must conduct holistic assessments to manage this condition appropriately

Dealing with phantom limb

pain after amputation
In this article...

associated with the physiological mechanisms of neuropathic pain (Flor, 2002).

Neuropathic pain is associated with a primary lesion or dysfunctions in the nervous
system (IASP, 2010). Box 2 outlines possible
causes of PLP.

The mechanism of phantom limb pain

The barriers to accurate pain assessment
Why patients may not report pain
What pain assessment tools are available
Authors Dawn Fieldsen is staff nurse
orthopaedics and trauma, Huddersfield
Royal Infirmary; Sharon Wood is lecturer
in nursing at University of Leeds.

What is pain?

Assessment of phantom limb pain

Pain is an individual experience, which is

not caused solely by a painful stimulus
(Mann et al, 2009). The perception of pain
can be affected by numerous factors, inAbstract Fieldsen D, Wood S (2011)
cluding memory of previous pain, the
Dealing with phantom limb pain after
cause of the pain, the type and intensity of
amputation. Nursing Times; 107, 1: 21-23.
preoperative pain and cultural perspecPatients usually experience phantom limb
tives of pain (Mann et al, 2009).
pain after amputation but it may also occur
The International Association for the
following resection of other parts of the
Study of Pain (2010) defines pain as an unbody, such as the breast and internal
pleasant sensory and emotional experiorgans like the rectum. The causes are
ence associated with actual or potential
complex and patients require careful
tissue damage, or described in terms of
assessment to ensure they receive
such damage. This suggests pain is not
appropriate care. This article describes the
only a physiological process, but an expecauses of phantom limb pain and discusses rience that people interpret individually,
assessment strategies.
regardless of whether there is actual injury
to the body. This may help to explain why
hantom limb pain (PLP) is report- patients experience PLP.
ed in 6080% of patients after a
limb amputation, with up to 10% The pain response
reporting severe pain (Nikolajsen A response to noxious stimuli occurs after
et al, 2006). It is defined as a painful phe- amputation surgery, resulting in patients
nomenon at the site of limb amputation, experiencing nociceptive pain. The nociwhich gives the sensation that the limb ceptive pain pathway includes transducmay still be there (Australian and New Zea- tion, transmission, perception and moduland College of Anaesthetists, 2010; Niko- lation (McCaffrey et al, 1999). These are
lajsen et al, 2006). Table 1 lists descriptions outlined in Box 1.
Normal nociceptive pain will be experiof phantom pain after amputation.
Phantom pain has also been reported af- enced after surgery, but the exact physiolter amputation and removal of other body ogy of PLP is unknown (Houser, 2002). It
parts, including the breast, rectum, tongue may be experienced in missing limbs and
and/or teeth and genitalia. Reasons for am- stumps, and a range of symptoms that are
putation include vascular disease (includ- different to those associated with nociceping neuropathy caused by diabetes), trau- tive pain will be present (see Table 1).
There may be no physical reason for
ma, infection and abnormal tissue growth
PLP (McCaffrey et al, 1999) but it can be
(Limb Loss Information Centre, 2010).

Nurses have an important role in managing pain control because they have more
contact with patients who are experiencing pain than any other healthcare professional (Mann et al, 2009). Using pain
assessment tools improves communication and makes it easier to select the appropriate treatment (Mann et al, 2009).
The Department of Health (2010)
suggests assessment should include an
evidence based tool that is appropriate to
the individual's needs and health problem.
Assessment should consider the physical,
psychological, social and spiritual aspects
of the pain experience (DH, 2010). The Clinical Resource Efficiency Support Team
(2008) and the National Institute for Health
and Clinical Excellence (2010) offer guidance on the pharmacological management
and treatment of neuropathic pain. This
type of pain is often an element of PLP but
guidance does not specifically mention it.

Pain assessment tools

Common pain assessment tools include:

The four-point verbal rating scale (VRS),
which is used to describe increasing
pain intensity: 0 (no pain); 1 (mild pain);
3 (moderate pain); 4 (severe pain);
The 10-point numerical rating scale
(NRS), which is represented as a line
with numbers: 0 (no pain) to 10 (most
pain possible) on which patients
indicate their level of pain.
Measuring pain intensity is an important
part of assessment (Turk et al, 2001) and
benefits of these tools include ease of use
(Jensen et al, 2001).
Research has demonstrated that the VRS

www.nursingtimes.net / Vol 107 No 1 / Nursing Times 11.01.11 21

Nursing Practice
Practice review
learning
pointS

Nociceptive pain may be experienced in missing limbs and stumps

5 key
facts

Phantom limb
pain (PLP) is
reported in
6080% of patients
following a limb
amputation
(Nikolajsen et al,
2006)
There may be
no physical
reason for PLP
(McCaffrey et al,
1999)
Pain assessment should
consider the
physical, psychological, social and
spiritual aspects of
the pain experience (DH, 2010)
There is a lack
of guidance on
assessing and
managing PLP
Other aspects
of pain may
include reduced
quality of sleep
and depression

2
3

Alamy

Reflect on an occasion when

you assessed a patient who
was reporting pain after an
amputation:
What pain assessment tool
did you use?
Was this effective in
assessing the patient's pain?
Did you reassess the pain
to establish whether the
analgesia you administered
was effective in reducing the
levels of pain?
What could you have done
to improve pain management for this patient?

Table 1. Types of phantom limb pain

Type of pain
Symptoms
Phantom pain
Burning, tingling, stinging, cramping, shooting,

twisting. Often stronger versions of phantom

sensations
Phantom sensations Sense of position, temperature, itching, discomfort
Stump pain Localised pain in the area of amputation, often

acute postoperative pain
Adapted from Australian and New Zealand College of Anaesthetists (2005)

Box 1.
Nociceptive
pain pathwayS
Transduction: Initial
stimulation of the primary
afferent neurons occurs as a
result of thermal, mechanical
or chemical stimuli from
amputation surgery and the
inflammatory response
(Caterina et al, 2005). This
causes the release of
excitatory neurotransmitters
including prostaglandins,
substance P and histamine.
Transmission: Impulses are
generated along the afferent
neurons to the dorsal horn of
the spinal cord. Through
excitatory neurotransmitters,
the impulse can continue
across the synaptic cleft, up
the spinal cord, through the
ascending pathways to the
brain stem and thalamus
(Wood, 2008; McCaffrey et
al, 1999).

Perception: This does not

originate from one distinct
area of the brain, which has
led to the neuromatrix theory
(Brooks et al, 2005). Melzack
(1989) proposed this theory
to describe the mechanism of
phantom limb pain, suggesting a network of neurons
continuously communicated
information about pain
sensation through various
circuits in the brain.
Modulation: This describes
regulating the response to the
perceived pain (Jagger, 2005).
Melzack and Wall (1965)
suggested inhibitory neurons
in the dorsal horn can control
incoming sensory information
before transmission to the
brain. Stimulation by massage
and touch can release
inhibitory neurotransmitters,
including endogenous opioids
and serotonin aiding pain relief
(Mann et al, 2009; Mitchinson
et al, 2007; McCaffrey et al,
1999).

22 Nursing Times 11.01.11 / Vol 107 No 1 / www.nursingtimes.net

does not provide sensitive data (Williamson

et al, 2005) and its reliability may be affected by the intervals between the predetermined levels of pain (Jensen et al, 2001). The
more levels a tool has to gauge pain, the easier it is to identify a change in intensity
(Williamson et al, 2005). The 10 point NRS
could be considered more responsive to the
change in pain intensity than the four-point
VRS, but the advantage of the VRS is that it
uses words to describe pain intensity.
Using the VRS or NRS may enhance a
systematic and effective assessment of the
pain and evaluation of the effectiveness of
treatments for PLP. However, assessing
PLP intensity may fail to identify other factors such as reduced quality of sleep and
function, and depression (Turk et al, 2001).
Pain should be individually assessed
and tools appropriate to the patient should
include dimensions such as intensity, sensation, mood and function.
Multidimensional assessment tools
Some multidimensional pain assessment
tools are specifically designed to diagnose
neuropathic pain. As PLP appears to be
considered within the umbrella term of
neuropathic pain, CREST (2008) suggests
using The Leeds Assessment of Neuropathic Symptoms and Signs Self-report
tool (S-LANSS).
This tool has encouraged accurate diagnoses of neuropathic-related pain including PLP in 75% of people studied and
demonstrates high levels of sensitivity
(Bennett et al, 2005). This suggests the SLANSS provides a more accurate and sensitive assessment of PLP when compared
with the unidimensional VRS and NRS.
Dworkin et al (2001) argued the assessment of neuropathic-related pain, such as
PLP should include more than one tool in
order to consider wider aspects of the pain
experience. The S-LANSS tool diagnoses
the presence and type of pain and, combined with an intensity score for example, from the VRS or NRS may help nurses
provide the most appropriate treatment or
early referral to specialist services. It may
also be necessary to use additional tools
that assess the different aspects of the
effect of PLP on the patient, for example,
mood, behaviour and functions. Further
research is required to identify a tool that
will facilitate a holistic assessment of PLP.
The DH (2010) describes pain as the fifth
vital sign and confirms that assessment of
it and management strategies should be
ongoing and regularly observed along with
other vital physiological measurements.
This can be done with a unidimensional
VRS or NRS but may be more problematic

Nursing
Times.net

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on neuropathic pain, go to
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with a tool like the S-LANSS as the data

obtained is more difficult to represent on
vital sign documents. Adapting documentation to include a multidimensional and
pain intensity assessment tool for people
with PLP would make it more likely that
pain would be treated as the fifth vital.

Assessment barriers

Difficulties are often encountered in clinical practice when assessing PLP. The commonly reported symptoms outlined in
Table 1 are difficult to understand as the
source of the pain has been amputated, the
assessment must rely purely on the
patients description of it. McCaffrey et al
(1999) acknowledged that healthcare
professionals are more likely to treat pain
when the cause is clear.
It is vital that nurses remain non-judgemental and administer analgesia according to the pain being expressed. Pain
assessment can be affected by healthcare
professionals' beliefs that people who
report PLP construct it in their minds
(Flor, 2002). This can lead to inaccurate
assessment by nurses and non-reporting
of pain by patients.
Other barriers to the overall assessment
of pain that are commonly experienced in
clinical practice can include heavy workload, constant interruptions and problems
with prescriptions. Barriers to effective
pain management may also include staff
shortages, nurses not asking patients what
levels of pain they are experiencing and
relying on non-verbal behaviour to assess
pain (Mann et al, 2009; Schafheutle et al,
2000). Patients may also be reluctant to
express their pain experience to nurses
due to psychological barriers, such as fear
of the meaning of the pain, of injections,
of becoming addicted to pain killers, of
becoming an unpopular patient or being
disbelieved, or resignation to the pain.
This demonstrates why pain assessment
undertaken by nurses may be seen as inadequate (Sloman et al, 2005).

Treatment of neuropathic and

phantom limb pain

Recommendations for the treatment of

neuropathic pain and PLP suggest that
opioids, such as morphine, and the tricyclic antidepressant, amitriptyline, should
be used (NICE, 2010; CREST, 2008). Gabapentin and other anticonvulsant drugs are
often used to treat PLP but the evidence
base on their efficacy is small (Smith et al,
2005). These are commonly used in clinical
practice, but they are not effective for all
people experiencing symptoms of PLP.
Dworkin et al (2007) suggested that

pharmacological treatment should be tailored to the individual patient by identifying the medication that delivers the greatest pain relief with the least number of side
effects. This is why individualised pain
assessment is important. CREST (2008)
and NICE (2010) have recommended
prompt referral to specialist pain services.

Conclusion

Nurses should be aware of PLP and how it

can differ from other types of pain to ensure
patients receive holistic care. Nurses should
obtain information about pain from the patient as part of their care plan and use the
tools available in their clinical area. It may
also be possible for nurses to access the
specialist knowledge of pain nurses, who
are there to support both nurses and patients through the management of pain. NT

Box 2. Causes
of phantom
limb pain
Allodynia: Pain evoked by
stimuli that would not usually
be considered painful (Jensen
et al, 2001). Nerve fibres may
lose their ability to desensitise
the pain sensation and instead
evoke pain impulses (Mann et
al, 2009). Touching or
massaging an amputated area
may cause more pain.
Hyperalgesia: Increased
response to painful stimuli and
lowered pain threshold
(Jensen et al, 2001).
Central sensitisation: Can
occur in the dorsal horn of the
spinal cord due to the
increased number or intensity
of the impulses generated.
This results in permanent
changes to the dorsal horn
neurons (Flor, 2002).
Neuromas: Commonly form
after nerves are cut and can
lead to spontaneous activity
and increased sensitivity to
stimulation (Wood, 2008;
Nikolajsen et al, 2006).
Regenerative sprouting:
Occurs at the site of nerve
injury, which can lead to an
increase in pain impulses
(Wood, 2008).

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