A review of the management of phantom limb pain: challenges and solutions

Background: Phantom limb pain (PLP) occurs in 50% and 80% of amputees. Although it is
often classified as a neuropathic pain, few of the large-scale trials of treatments for neuropathic
pain included sufficient numbers of PLP sufferers to have confidence that they are effective in
this condition. Many therapies have been administered to amputees with PLP over the years;
however, as of yet, there appears to be no first-line treatment.
Objectives: To comprehensively review the literature on treatment modalities for PLP and to
identify the challenges currently faced by clinicians dealing with this pain.
Method: MEDLINE, EMBASE, CINAHL, British Nursing Index, Cochrane and psycINFO
databases were searched using “Phantom limb” initially as a MeSH term to identify treatments
that had been tried. Then, a secondary search combining phantom limb with each treatment
was performed to find papers specific to each therapy. Each paper was assessed for its research
strength using the GRADE system.
Results: Thirty-eight therapies were identified. Overall, the quality of evidence was low. There
was one high-quality study which used repetitive transcutaneous magnetic stimulation and found
a statistical reduction in pain at day 15 but no difference at day 30. Significant results from
single studies of moderate level quality were available for gabapentin, ketamine and morphine;
however, there was a risk of bias in these papers. Mirror therapy and associated techniques were
assessed through two systematic reviews, which conclude that there is insufficient evidence to
support their use.
Conclusion: No decisions can be made for the first-line management of PLP, as the level of
evidence is too low. Robust studies on homogeneous populations, an understanding of what
amputees consider a meaningful reduction in PLP and agreement of whether pain intensity is
the legitimate therapeutic target are urgently required.