1910

ORIGINAL ARTICLE

Phantom Pain, Residual Limb Pain, and Back Pain in

Amputees: Results of a National Survey
Patti L. Ephraim, MPH, Stephen T. Wegener, PhD, Ellen J. MacKenzie, PhD, Timothy R. Dillingham, MD,
Liliana E. Pezzin, JD, PhD
ABSTRACT. 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. Arch
Phys Med Rehabil 2005;86:1910-9.
Objectives: 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.
Design: Cross-sectional survey.
Setting: A sample of persons who contacted the Amputee
Coalition of America from 1998 to 2000 were interviewed by
telephone.
Participants: A stratified sample by etiology of 914 persons
with limb loss.
Interventions: 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.
Results: 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
710). 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 amputationrelated 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.
Conclusions: 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

From the Limb Loss Research and Statistics Program, Bloomberg School of Public
Health (Ephraim, MacKenzie); Department of Physical Medicine and Rehabilitation,
School of Medicine (Wegener), Johns Hopkins University, Baltimore, MD; and
Departments of Physical Medicine and Rehabilitation (Dillingham) and Medicine and
Institute for Health Policy Studies (Pezzin), Medical College of Wisconsin, Milwaukee, WI.
Supported by the National Center for Birth Defects and Developmental Disabilities,
Centers for Disease Control and Prevention (CDC; grant no. U59/CCU416733). The
contents of this article are solely the responsibility of the authors and do not
necessarily represent the official views of CDC.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors or upon any
organization with which the authors are associated.
Reprint requests to Patti Ephraim, MPH, Limb Loss Research and Statistics
Program, Johns Hopkins University Bloomberg School of Public Health, 624 N
Broadway, Rm 502, Baltimore, MD 21205, e-mail: pephraim@jhsph.edu.
0003-9993/05/8610-9614$30.00/0
doi:10.1016/j.apmr.2005.03.031

Arch Phys Med Rehabil Vol 86, October 2005

symptoms. Further studies are needed to elucidate the relationship between pain and depressive symptoms among amputees.
Key Words: Amputation; Depression; Pain; Rehabilitation.
2005 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and
Rehabilitation
IMB LOSS IS A POTENTIALLY disabling condition
affecting nearly 1.2 million Americans. Each year, apL
proximately 185,000 persons undergo amputation of a limb in
1

the United States. With the increasing trend in the incidence of

limb loss, there is a growing interest in the development of
programs aimed at prevention of secondary conditions affecting those living with the loss of a limb.
Chronic pain is a secondary condition affecting many persons with limb loss. In a study of unilateral lower-limb amputees, Smith et al2 reported that only 9% of participants were
pain free during the previous 4-week assessment period, with
nearly half (47.1%) reporting an episode of phantom, residual
limb, and back pain during that period. The prevalence of
phantom pain, defined as pain in the limb that is no longer
present, has been reported to be as high as 85%,2-16 while the
reports on the prevalence of residual limb pain vary from 10%
to 13% at 2 years postamputation to 55% to 76% in longstanding amputees.2,10,13,15,17,18 In addition to amputation specific pain, chronic pain in other parts of the body may contribute to disability in persons with limb loss. In particular, back
pain has been reported to affect 52% to 71% of amputees in the
United States.2,18,19 Previously identified correlates of chronic
pain in the amputee include the level of amputation, presence
of preamputation pain, and particularly in the case of stump
pain, the fit of the prosthesis and presence of neuromas.12,20-22
Chronic, persistent pain can lead to limitations in function,
both physical and psychosocial. Among persons with chronic
pain, it has been noted that it is often not the underlying
condition (eg, amputation of a limb) that primarily impairs the
individual, but rather the chronic pain they experience. Chronic
amputation-related pain, including pain in the phantom limb,
residual limb, and back, impairs function23,24 and is negatively
correlated with employment.25-27 Likewise, amputees with
chronic pain have been shown to report significantly more
disability than persons without pain.28 Depressed mood and
clinical depression following limb loss have been reported to
range from 35% to 51.4% among inpatients, 3 to 5 times that
of the general population.29-32 Limitations in activity, time
since amputation, and age have been shown to be a significant
predictors of poor psychologic adjustment following the loss of
a limb.29,30,33-35 The relationship between amputation-related
pain and depression, however, has not been well described.
Improving our knowledge of the factors that contribute to the
experience of chronic pain in the amputee can lead to new and
improved therapies that will result in an enhanced quality of
life. Much of the focus to date has been on the consequences of
chronic pain among amputees, with little information available
on the factors that may predict pain following an amputation.

LIMB AND BACK PAIN IN AMPUTEES, Ephraim

We conducted a survey of amputees: (1) to characterize the

prevalence of amputation-related pain; (2) to ascertain the
intensity and affective quality of phantom pain, residual limb
pain, back pain, and nonamputated limb pain; and (3) to identify the relationship among demographic variables, amputation-related factors, and depressed mood and the experience of
pain in the amputee.
METHODS
Study Design and Sample
The study was a cross-sectional survey design that was
conducted as part of a larger project, the Limb Loss Research
and Statistics Program (LLRSP). The LLRSP is a partnership
between the Johns Hopkins University Bloomberg School of
Public Health and the Amputee Coalition of America (ACA).
Using an existing database, we identified 6500 amputees who
had contacted the ACA between 1998 and 2000. Of these, we
selected a sample of 1538 amputees stratified by etiology (608
persons with amputation secondary to peripheral vascular disease, including those with diabetes mellitus; 579 persons with
traumatic amputation; 351 persons with amputation due to
malignancy). Eligible for inclusion in the sample were Englishspeaking persons aged 18 to 84 years with amputation of either
an upper- or lower-limb or bilateral amputation of upper or
lower limbs.
Survey Procedure
The ACA mailed a letter that outlined the purpose and
objectives of the survey to individuals who were chosen for
participation in the study. Individuals who were not interested
in participating in the study were asked to return a contact sheet
indicating their desire not to be contacted. Two weeks after the
letter was mailed, if the subject had not returned a contact
sheet, trained interviewers began attempts to contact the subject by telephone. Tracing procedures were employed in the
case of returned letters with no forwarding address and nonworking telephone numbers. Prior to the interview, oral informed consent was obtained from the subjects by the interviewer. All interviews were conducted by telephone between
January and August 2001.
We obtained a proxy interview if the interviewer determined
after speaking with someone in the household that the subject
was unable to complete an interview due to a mental or physical impairment. The proxy respondents were advised to answer the questions in the survey as they applied to the subject
who resided in the household. Questions pertaining to areas of
the respondents life that were not directly observable by the
proxy (eg, depressed mood, environmental barriers and prevalence, frequency, bothersomeness of pain) were skipped during the proxy interview. The study was reviewed and approved
by the Committee on Human Research at the Johns Hopkins
Bloomberg School of Public Health.
MEASURES
The survey consisted of 5 parts: (1) demographics and characteristics of the amputation; (2) general health and well-being;
(3) measures of pain and depressed mood; (4) use and satisfaction with prosthesis; and (5) use and unmet needs for medical services. Our primary outcome measures for this analysis
were phantom pain, residual limb pain, back pain, and nonamputated limb pain.
Pain Measures
For survey participants, we defined phantom pain as pain in
the missing part of your limb. Residual limb pain was defined

1911

as pain in the part of your amputated limb that is physically

present. For each type of pain, we measured frequency (never,
sometimes, always) over the previous 4 weeks prior to the
interview. Among those reporting pain, we assessed intensity
and bothersomeness of each type of pain, except in the case of
back pain where only bothersomeness was evaluated. Pain
intensity was measured using a 10-point numeric rating pain
scale (1, mild pain; 10, extremely intense pain). Based on the
work of Jensen et al,36 pain intensity was further classified into
3 categories: mild (rating 1 4), moderate (rating 5 6), and
severe (rating 710). Pain bothersomeness was measured using
a 3-point Likert scale (0, not at all bothered; 1, somewhat
bothered; 2, extremely bothered). In the case of bilateral amputation, participants were asked to rate pain intensity and
bothersomeness for the limb they considered most severely
affected.
Depressed Mood
Depressed mood was measured using the 10-item Center for
Epidemiologic Studies Depression Scale (CES-D 10-item).
The scale includes 10 items with response values on a 4-point
Likert scales that range from 0 (none or less than 1 day) to 3
(57 days a week). The final score ranges from 0 to 30, with a
higher score indicating greater impairment. The CES-D has
been found to be both valid and reliable for the screening of
depressive symptoms in the general population.37,38 For the
purpose of analysis, we defined the dichotomous variable for
depressed mood as a score of 10 or greater.37
Demographics and Characteristics of the Amputation
Additional measures included demographic information
(sex, current age, race and ethnicity, marital status, educational
level, household poverty status), amputation specific measures
(etiology, level, years since amputation), and the number of
self-reported comorbid conditions. Community type (rural vs
urban) was computed using subject zip code and area defined
by the Multiple Statistical Area Urban Influence and Urban
Continuum codes; residential region of the United States
(Northeast, Midwest, South, West) was determined by using
state of residence in accordance with the U.S. Census. Information collected on household size and family income was
used to generate household poverty status (poor, near poor, not
poor) according to the U.S. Census definition.39
Data Analysis
For each type of pain (phantom pain, residual limb pain,
nonamputated limb pain, back pain), we estimated the prevalence, frequency, intensity and bothersomeness as described
above. Appropriate statistics were used to examine the bivariate relationships between pain characteristics and each of the
covariates taken 1 at a time (ie, Student t test and analysis of
variance to compare means, chi-square statistics to compare
proportions). To estimate the combined effect of multiple covariates on the presence of pain, multivariate logistic techniques were used. The odds of having pain adjusted for multiple covariates are reported. Multinomial logistic regression
techniques were then used to estimate adjusted odds ratios for
the 3 levels of bothersomeness among those respondents who
reported experiencing pain with the not bothered category as
the base reference group. A similar procedure was used to
estimate adjusted odds ratios for pain intensity categories with
the mild category as the base reference group. Odds ratios
(ORs) with 95% confidence intervals (CIs) are reported. All
analysis was performed using Stata 6.0.a Statistical significance
was determined at the P less than .05 level.
Arch Phys Med Rehabil Vol 86, October 2005

1912

LIMB AND BACK PAIN IN AMPUTEES, Ephraim

RESULTS
Characteristics of the Study Population
Of the 1538 persons identified for the survey, 182 were
ineligible due to age (n5; 2.2%), type or level of amputation
(n12; 6.6%), lack of an amputation (n29; 15.9%), nonEnglish speaking (n6; 3.3%), physically or mentally unable
to respond (n19; 10.4%), or death or institutionalization
(n111; 61.0%). Of those eligible for participation, 960
(71.3%) completed the interview, of which 21 were conducted
with a proxy respondent who resided in the home. One hundred
forty-seven persons could not be traced and/or contacted and
249 subjects refused to complete an interview. For the purpose
of our analysis, we excluded persons whose amputation was to
a finger or toe (n10) or with unknown etiology (n9) and
those in whom a proxy interview was conducted (n21) and
the interview was incomplete (n6). Data on the remaining
914 respondents form the basis of the present analysis.

Characteristics of the population surveyed are presented in

table 1. Overall, the sample was predominantly male (60.4%),
white non-Hispanic (85.8%), with a high school education
level or greater (93.8%), and living in households with income
above the U.S. poverty line (89.3%).
Dysvascular amputees comprised 38% of the sample with
less than half of those being persons with diabetes mellitus.
The level of amputation varied by etiology with 52.4% of
dysvascular amputees and 43.2% of traumatic amputees having
a below knee amputation and 75% of cancer amputees having
an above knee amputation. The median time since amputation
was 4 years (range, 1 66y) and varied by etiology with
cancer amputees having the greatest time since amputation, 13
years (range, 1 66y), and dysvascular amputees having the
least, 3 years (range, 1 48y). The majority of amputees in
the sample reported using a prosthesis with 62.7% reporting 9
or more hours of daily wear, with no variation by etiology.

Table 1: Characteristics of Study Participants (N914)

Characteristics

Total

Dysvascular* (n340)

Trauma (n357)

Cancer (n217)

Sex (% men)
Mean age SD (y)
Race/ethnicity, n (%)
White, non-Hispanic
Black, non-Hispanic
Other
Median time since amputation (range), (y)
Amputation level, n (%)
Upper limb
Below elbow
Above elbow
Bilateral
Lower limb
Below knee
Above knee
Bilateral
Education level, n (%)
Less than grade 12
HS graduate/GED
Greater than grade 12
Household poverty status, n (%)
Not poor
Near poor
Poor
Health insurance, n (%)
Uninsured
Medicare
Medicaid
Private
Other
Population area, n (% urban)
Region, n (%)
Northeast
Midwest
South
West
Daily prosthesis use, n (%)
None
18h
9h

552 (60.4)
50.313.3

198 (58.2)
55.610.9

276 (77.3)
46.913.2

78 (36.0)
47.514.1

784 (85.8)
66 (7.2)
64 (7.0)
4 (066)

279 (82.1)
39 (11.6)
22 (4.8)
3 (048)

312 (87.4)
15 (4.2)
30 (8.4)
5 (062)

193 (89.0)
12 (5.5)
12 (5.5)
13 (166)

45 (4.9)
47 (5.1)
8 (0.9)

1 (0.3)
2 (0.6)
2 (0.6)

40 (11.2)
33 (9.2)
6 (1.7)

4 (1.8)
12 (5.6)
0

372 (40.7)
352 (38.6)
88 (9.6)

178 (52.4)
93 (27.4)
64 (18.8)

156 (43.7)
98 (275)
24 (6.7)

38 (17.7)
161 (74.9)
0 (0.0)

57 (6.2)
243 (26.6)
614 (67.2)

26 (7.7)
99 (29.1)
215 (62.2)

21 (5.9)
111 (31.1)
225 (63.0)

10 (4.6)
33 (15.2)
174 (80.2)

578 (63.2)
238 (26.1)
98 (10.7)

197 (57.9)
99 (29.1)
44 (13.0)

216 (60.5)
100 (28.0)
41 (11.5)

165 (76.0)
39 (18.0)
13 (6.0)

57 (6.5)
181 (20.5)
140 (15.9)
439 (48.8)
64 (7.3)
717 (78.5)

15 (4.5)
118 (35.3)
69 (20.7)
112 (33.5)
20 (6.0)
272 (80.0)

36 (10.6)
33 (9.7)
51 (15.0)
187 (55.0)
33 (9.7)
258 (72.3)

6 (2.9)
30 (14.5)
20 (9.7)
140 (67.6)
11 (5.3)
187 (86.6)

157 (17.2)
307 (33.6)
239 (26.2)
210 (23.0)

52 (15.3)
121 (35.6)
86 (25.3)
81 (23.8)

68 (19.0)
116 (32.5)
84 (23.5)
89 (25.0)

37 (17.1)
70 (32.4)
69 (32.0)
40 (18.5)

183 (19.7)
163 (17.6)
582 (62.7)

65 (18.4)
76 (21.5)
212 (60.1)

67 (18.7)
64 (17.9)
227 (63.4)

51 (28.5)
23 (10.6)
143 (65.9)

Abbreviations: GED, general education development; HS, high school; SD, standard deviation.
*Includes persons with diabetes mellitus.

Missing amputation level information for 2 respondents.

Missing information for 12 respondents.

Arch Phys Med Rehabil Vol 86, October 2005

1913

LIMB AND BACK PAIN IN AMPUTEES, Ephraim

Over 90% of respondents had health insurance at the time of

the interview. Insurance type varied by etiology with the dysvascular amputees being predominantly insured by Medicare
(36.5%) or Medicaid (20.4%) while the majority of traumatic
and cancer-related amputees reported private insurance as their
primary health insurance. A higher proportion of respondents
resided in the Midwest region of the United States; over 75%
of respondents resided in an urban area.
Prevalence, Intensity, and Bothersomeness of Phantom
Pain
The prevalence of phantom pain during the preceding 4
weeks was 80% in this sample (table 2). The prevalence of
phantom pain by demographic characteristics is presented in
table 3. Mean intensity of phantom pain standard deviation
was 5.52.6. More than a third (38.9%) of amputees reported
phantom limb pain that could be characterized as severe in
intensity (710). The intensity of phantom limb pain was
highly correlated with the bothersomeness rating (r.61). In
the multivariate analysis, amputees with 2 or more comorbid
conditions were 2.7 (95% CI, 1.35.8) more likely than amputees with no comorbidity to rate the intensity of their phantom
pain in the moderate range (5 6) versus mild range (1 4) after
controlling for amputation-related and sociodemographic factors (table 4). Depressed mood was highly predictive of phantom pain intensity category with those scoring 10 or greater on
the depression scale having an adjusted odds of 2.0 (95% CI,
1.33.1) for rating the intensity as severe versus mild.
Over half (53.9%) of all amputees reported their phantom pain
to be somewhat bothersome, whereas slightly less than a third
(27.0%) described their phantom pain to be extremely bothersome. In the multinomial model, amputees aged 55 to 64 years
were less likely than amputees aged 18 to 44 years to report being
extremely bothered by their pain versus not bothered (table 5).
Comorbidity increased the adjusted odds of phantom limb pain
being extremely bothersome versus not bothersome by 2.6
(95% CI, 1.0 6.4) for persons with 1 comorbid conditions and 2.8
(95% CI, 1.2 6.7) for those with 2 or more conditions. Amputees
with depressed mood were more likely than those without depressed mood to characterize their pain as somewhat bothersome
and extremely bothersome versus not bothersome, adjusted OR of
2.5 (95% CI, 1.4 4.3) and 3.9 (2.17.2), respectively.

Prevalence, Intensity, and Bothersomeness of Residual

Limb Pain
The prevalence of residual limb pain was 67.7%. In the
multivariate analysis, age, etiology, amputation level, and comorbidity proved to be significant predictors of residual limb
pain. The adjusted odds of residual limb pain in older amputees
(aged 55 to 64 years and 65 and older) were nearly half those
of amputees aged 18 to 44 years (OR0.6; 95% CI, 0.3 0.7;
OR0.4; 95% CI, 0.2 0.6). Traumatic amputees were 1.7
times (95% CI, 1.12.6) more likely to report residual limb
pain than dysvascular amputees were after controlling for potential confounders. Additionally, the prevalence of residual
limb pain varied by number of comorbid conditions, with an
adjusted odds of 2.2 (95% CI, 1.33.7) for those amputees
reporting 2 or more conditions.
Among those reporting residual limb pain, the mean intensity was 5.12.4, with the majority (41.8%) reporting
mild and 29.9% reporting severe pain intensity. In the multinomial analysis, persons with amputation secondary to malignancy were less likely than dysvascular amputees to
report severe residual limb pain intensity versus mild intensity (OR0.4; 95% CI, 0.2 0.7). Amputees with depressed
mood were more likely than those without depressed mood
to rate the intensity of their pain as moderate or severe
versus mild, adjusted OR of 2.0 (95% CI, 1.33.2) and 2.5
(1.6 4.1), respectively.
More than half of those surveyed described their pain as
somewhat bothersome (59.7%), with 26.5% reporting residual limb pain that was extremely bothersome. Lower-limb
amputees were 3.0 times more likely than upper-limb amputees
to report that their residual limb pain was extremely bothersome versus not bothersome (95% CI, 1.0 8.5). There were no
other significant differences found in the level of bothersomeness by sociodemographic or amputation related factors. However, depressed mood was a significant predictor of bothersomeness. Amputees with depressed mood were 3.8 (95% CI,
1.8 8.1) times more likely than those without depressed mood
to report their pain was somewhat bothersome versus not
bothersome. Among those with depressed mood, the adjusted
odds of rating their pain as extremely bothersome versus not
bothersome was 7.2 (95% CI, 3.216.1).

Table 2: Amputation-Related Pain Measures: Frequency, Intensity, and Bothersomeness

Measures

Frequency
Never
Sometimes
Always
Intensity (range, 110)
Mild (14)
Moderate (56)
Severe (710)
Bothered
Not bothered
Somewhat bothered
Extremely bothered

Phantom Limb Pain, n (%)

Residual Limb Pain, n (%)

Back Pain, n (%)

Nonamputated Limb Pain,* n (%)

183 (20.1)
534 (58.7)
193 (21.2)

295 (32.3)
414 (45.4)
204 (22.3)

344 (37.7)
409 (44.8)
160 (17.5)

410 (50.9)
311 (38.6)
84 (10.4)

251 (34.7)
191 (26.4)
282 (38.9)

262 (41.8)
177 (28.3)
187 (29.9)

NA
NA
NA

197 (50.4)
121 (30.9)
73 (18.7)

139 (19.1)
392 (53.9)
196 (26.9)

85 (13.8)
368 (59.7)
163 (26.5)

41 (7.2)
393 (69.2)
134 (23.6)

47 (11.9)
251 (63.7)
96 (24.4)

Abbreviation: NA, not applicable.

*Includes only survey respondents with unilateral amputation.
Reported bothersomeness among survey respondents with pain.

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LIMB AND BACK PAIN IN AMPUTEES, Ephraim

Table 3: Prevalence of Pain by Demographic Characteristics
Characteristics

Sex
Female
Male
Age (y)
1844
4554
5564
65
Etiology
Dysvascular
Trauma
Cancer
Years since amputation
2
25
59
10
Amputation level
Upper
Lower
Comorbidity
None
1
2
Education
grade 12
HS graduate/GED
grade 12
Health Insurance
Uninsured
Medicare
Medicaid
Private
Other
Household poverty
Not poor
Near poor
Poor
Daily prosthesis wear (h)
None
18
9
Depressed mood
CES-D score 10
CES-D score 10

Phantom Limb Pain, n

(%)

Residual Limb Pain, n

(%)

Back Pain, n
(%)

Nonamputated Limb Pain,* n

(%)

285 (79.2)
442 (80.4)

230 (63.7)
388 (70.3)

240 (66.5)
329 (59.6)

218 (54.1)
177 (45.6)

245 (78.3)
205 (79.5)
161 (83.9)
116 (79.0)

230 (73.3)
195 (75.3)
113 (58.9)
80 (54.1)

199 (63.6)
179 (69.1)
113 (58.9)
78 (52.4)

127 (45.4)
116 (51.6)
81 (49.4)
71 (52.2)

281 (82.9)
289 (81.2)
157 (73.0)

222 (65.3)
267 (74.8)
129 (59.7)

208 (61.2)
227 (63.6)
134 (62.0)

144 (55.0)
159 (48.8)
92 (42.4)

100 (82.2)
333 (81.8)
78 (83.8)
213 (73.7)

89 (76.1)
266 (65.5)
67 (72.0)
192 (65.8)

70 (59.8)
251 (61.8)
61 (65.6)
183 (62.7)

44 (40.7)
46 (59.0)
44 (58.7)
126 (47.0)

644 (79.1)
83 (83.0)

552 (67.8)
66 (66.0)

505 (62.0)
64 (64.0)

362 (50.7)
33 (35.9)

88 (79.3)
150 (73.2)
489 (82.3)

72 (64.9)
141 (68.1)
405 (68.1)

67 (60.4)
122 (59.2)
380 (63.8)

33 (35.5)
77 (39.7)
280 (55.6)

50 (87.7)
209 (86.7)
468 (76.5)

41 (71.9)
179 (73.7)
398 (64.9)

42 (73.7)
160 (66.1)
367 (49.8)

32 (65.3)
113 (55.1)
250 (45.4)

48 (84.2)
145 (81.0)
119 (85.0)
336 (76.9)
53 (82.8)

38 (66.7)
101 (56.1)
107 (76.4)
301 (68.6)
48 (75.0)

35 (61.4)
97 (53.6)
104 (74.3)
265 (60.5)
42 (65.6)

23 (42.6)
81 (50.6)
63 (58.9)
184 (46.0)
27 (50.9)

443 (77.2)
197 (82.8)
87 (88.8)

371 (64.3)
172 (72.3)
75 (76.5)

329 (57.0)
164 (68.9)
76 (77.6)

237 (45.2)
112 (55.2)
46 (59.0)

152 (87.9)
137 (87.3)
431 (75.2)

120 (69.8)
121 (76.1)
372 (64.7)

116 (67.1)
109 (68.6)
340 (59.2)

74 (49.7)
74 (54.4)
246 (47.8)

493 (76.2)
233 (88.9)

408 (62.8)
210 (80.2)

358 (55.1)
210 (80.2)

244 (42.4)
151 (66.2)

*Includes survey respondents with only unilateral amputation.

Missing health insurance information for 12 respondents.

Prevalence, Intensity, and Bothersomeness of Back Pain

Back pain was reported by 62.3% of respondents. In the
multivariate analysis, prevalence of back pain varied by sex,
age, and poverty status. Men were less likely to report back
pain than women (OR0.7; 95% CI, 0.51.0). As age increased, the odds of back pain decreased. However, this was
only significant for the oldest amputees, those aged 65 year or
older, who were nearly half as likely than the youngest (aged
18 to 44y) to report back pain (OR0.6; 95% CI, 0.4 0.9).
Household poverty increased the odds of back pain with near
poor being 1.4 times more likely (95% CI, 1.0 2.0) and the
Arch Phys Med Rehabil Vol 86, October 2005

poor 1.9 times more likely (95% CI, 1.13.3) to report back
pain than those who were not poor.
Among lower-limb amputees, there was no significant difference in the prevalence of back pain among those with an
above-knee versus below-knee amputation (21 test1.64,
P.200). Similar to the other pain items, the majority of those
surveyed (69.2%) characterized their back pain as somewhat
bothersome with nearly a quarter (23.6%) reporting extremely bothersome pain. In the multinomial model to evaluate bothersomeness by sociodemographic and amputationrelated characteristics, there were no significant differences
found. However, among those with depressed mood, the ad-

1915

LIMB AND BACK PAIN IN AMPUTEES, Ephraim

Table 4: Association Between Intensity of Pain Items and Characteristics of Amputee
Phantom Limb Pain

Base: Mild

Sex
Female
Male
Age (y)
1844
4554
5564
65
Etiology
Dysvascular
Trauma
Cancer
Years since amputation
2
25
59
10
Amputation level
Upper
Lower
Daily prosthesis wear (h)
None
18
9
Comorbidity
None
1
2
Depressed mood
CES-D score 10
CES-D score 10
Education
grade 12
HS graduate
grade 12
Household poverty status
Not poor
Near poor
Poor
Marital status
Married
Divorced
Widow
Never married
Residential area
Urban
Rural

Residual Limb Pain

Nonamputated Limb Pain

Moderate
OR (95% CI)*

Severe
OR (95% CI)*

Moderate
OR (95% CI)*

Severe
OR (95% CI)*

Moderate
OR (95% CI)*

Severe
OR (95% CI)*

1.0
1.4 (0.92.2)

1.0
1.2 (0.81.8)

1.0
1.0 (0.71.6)

1.0
1.2 (0.71.9)

1.0
1.0 (0.61.8)

1.0
1.0 (0.52.0)

1.0
1.1 (0.61.8)
0.5 (0.31.0)
1.0 (0.52.0)

1.0
0.9 (0.51.4)
0.6 (0.41.1)
0.9 (0.51.6)

1.0
1.2 (0.82.1)
1.4 (0.82.6)
2.0 (1.04.0)

1.0
1.1 (0.61.8)
0.7 (0.41.3)
1.1 (0.52.4)

1.0
1.2 (0.62.4)
2.5 (1.25.5)
1.7 (0.73.9)

1.0
2.0 (0.94.6)
2.6 (1.06.7)
1.3 (0.43.7)

1.0
0.9 (0.51.7)
0.8 (0.41.4)

1.0
1.3 (0.82.1)
0.8 (0.41.4)

1.0
0.9 (0.51.5)
0.7 (0.41.3)

1.0
0.9 (0.51.5)
0.4 (0.20.7)

1.0
1.1 (0.52.2)
0.4 (0.20.9)

1.0
0.6 (0.31.4)
0.2 (0.10.6)

1.0
1.0 (0.61.9)
1.5 (0.63.3)
1.0 (0.51.9)

1.0
1.4 (0.82.4)
1.6 (0.83.5)
1.4 (0.72.6)

1.0
0.8 (0.41.5)
1.2 (0.52.7)
1.0 (0.51.9)

1.0
0.9 (0.51.7)
1.4 (0.63.3)
1.2 (0.62.5)

1.0
1.2 (0.52.9)
2.1 (0.76.2)
3.0 (1.18.1)

1.0
1.5 (0.64.0)
1.6 (0.46.0)
1.8 (0.65.7)

1.0
1.2 (0.62.4)

1.0
2.5 (1.34.7)

1.0
1.2 (0.62.5)

1.0
1.1 (0.52.3)

1.0
8.1 (2.033.1)

1.0
2.6 (0.89.3)

1.0
1.4 (0.72.7)
1.1 (0.61.9)

1.0
1.3 (0.72.3)
0.7 (0.41.2)

1.0
0.9 (0.41.8)
0.9 (0.51.6)

1.0
1.0 (0.51.9)
0.5 (0.30.9)

1.0
1.0 (0.42.5)
0.5 (0.31.2)

1.0
0.9 (0.32.3)
0.4 (0.20.9)

1.0
2.0 (0.94.4)
2.7 (1.35.8)

1.0
1.0 (0.51.9)
1.5 (0.82.7)

1.0
1.0 (0.52.1)
1.0 (0.52.1)

1.0
1.1 (0.52.5)
2.5 (1.25.4)

1.0
0.7 (0.22.0)
1.5 (0.54.2)

1.0
0.7 (0.22.3)
0.9 (0.32.9)

1.0
1.3 (0.82.1)

1.0
2.0 (1.33.1)

1.0
2.0 (1.33.2)

1.0
2.5 (1.64.1)

1.0
2.0 (1.23.6)

1.0
1.8 (1.03.5)

1.0
1.0 (0.42.4)
0.8 (0.32.0)

1.0
0.6 (0.31.4)
0.6 (0.31.2)

1.0
1.1 (0.52.9)
0.7 (0.31.7)

1.0
1.0 (0.42.5)
0.5 (0.21.3)

1.0
0.2 (0.70.8)
0.2 (0.70.8)

1.0
0.2 (0.10.7)
0.1 (0.40.5)

1.0
1.1 (0.71.8)
1.0 (0.52.1)

1.0
0.9 (0.61.4)
0.9 (0.51.8)

1.0
1.0 (0.61.6)
0.8 (0.41.8)

1.0
0.9 (0.51.4)
1.5 (0.53.1)

1.0
0.9 (0.51.7)
0.7 (0.31.9)

1.0
1.1 (0.52.2)
2.0 (0.85.2)

1.0
0.6 (0.31.1)
0.6 (0.22.0)
0.7 (0.31.4)

1.0
0.9 (0.51.4)
2.7 (1.16.5)
1.1 (0.61.9)

1.0
0.9 (0.51.5)
1.2 (0.43.8)
1.0 (0.61.9)

1.0
0.8 (0.41.4)
2.0 (0.75.8)
0.7 (0.31.3)

1.0
1.1 (0.52.1)
0.8 (0.22.8)
0.8 (0.32.1)

1.0
0.6 (0.31.5)
1.0 (0.24.5)
2.4 (0.95.9)

1.0
1.1 (0.71.8)

1.0
0.7 (0.51.2)

1.0
1.2 (0.71.9)

1.0
0.6 (0.41.1)

1.0
1.1 (0.61.9)

1.0
1.1 (0.51.2)

*ORs adjusted for independent variables listed in table.

Significance at P.05.

justed odds of characterizing their pain as extremely bothersome versus not bothersome was 3.9 (95% CI, 1.6 9.8) when
compared with those without depressed mood.
Prevalence, Intensity, and Bothersomeness of
Nonamputated Limb Pain
Half (49.7%) of all unilateral amputees reported experiencing pain in their nonamputated limb in the previous 4 weeks. In
the multivariate analysis, significant differences in the adjusted

odds of nonamputated limb pain were found for sex, time since
amputation, level of amputation, and number of comorbid
conditions. Men were 40% less likely than women to report
nonamputated limb pain (OR0.6; 95% CI, 0.5 0.9). Time
since amputation increased the odds of nonamputated limb pain
with persons 2 to 5 years postamputation 1.7 times more likely
to have nonamputated limb pain than those with less than 2
years living with the loss of a limb (95% CI, 1.0 2.8). Likewise, persons 5 to 9 years and 10 or more years living with the
Arch Phys Med Rehabil Vol 86, October 2005

1916

LIMB AND BACK PAIN IN AMPUTEES, Ephraim

Table 5: Association Between Bothersomeness of Pain and Characteristics of Amputee
Phantom Limb Pain

Base: Not Bothered

Sex
Female
Male
Age (y)
1844
4554
5564
65
Etiology
Dysvascular
Trauma
Cancer
Years since amputation
2
25
59
10
Amputation level
Upper
Lower
Daily prosthesis wear (h)
None
18
9
Comorbidity
None
1
2
Depressed mood
CES-D score 10
CES-D score 10
Education
grade 12
HS graduate
grade 12
Household poverty status
Not poor
Near poor
Poor
Marital status
Married
Divorced
Widow
Never married
Residential area
Urban
Rural

Residual Limb Pain

Back Pain

Nonamputated Limb Pain

Somewhat
OR (95% CI)*

Extremely
OR (95% CI)*

Somewhat
OR (95% CI)*

Extremely
OR (95% CI)*

Somewhat
OR (95% CI)*

Extremely
OR (95% CI)*

Somewhat
OR (95% CI)*

Extremely
OR (95% CI)*

1.0
0.9 (0.51.4)

1.0
0.7 (0.41.1)

1.0
0.6 (0.31.1)

1.0
0.4 (0.20.9)

1.0
0.4 (0.21.0)

1.0
0.5 (0.21.2)

1.0
0.4 (0.20.8)

1.0
0.4 (0.21.0)

1.0
1.0 (0.61.8)
0.8 (0.51.5)
0.9 (0.51.9)

1.0
1.0
0.8 (0.41.5) 0.9 (0.51.8)
0.4 (0.20.9) 1.0 (0.52.2)
0.8 (0.31.7) 0.9 (0.42.0)

1.0
1.2 (0.62.5)
1.0 (0.42.4)
0.6 (0.21.8)

1.0
1.1 (0.52.7)
1.1 (0.43.2)
1.6 (0.45.7)

1.0
0.9 (0.32.4)
0.8 (0.32.7)
0.8 (0.23.3)

1.0
2.3 (0.96.0)
2.2 (0.86.5)
1.5 (0.54.3)

1.0
3.7 (1.211.2)
4.6 (1.316.2)
2.2 (0.68.2)

1.0
1.1 (0.62.0)
1.0 (0.52.0)

1.0
1.4 (0.72.7)
0.8 (0.41.6)

1.0
1.4 (0.73.0)
1.1 (0.52.5)

1.0
1.5 (0.73.4)
0.8 (0.32.1)

1.0
2.0 (0.84.9)
2.4 (0.87.5)

1.0
2.6 (1.07.0)
1.5 (0.45.3)

1.0
1.5 (0.54.6)
0.7 (0.22.2)

1.0
1.9 (0.66.5)
0.8 (0.23.1)

1.0
1.0 (0.51.9)
1.3 (0.53.2)
0.7 (0.41.5)

1.0
1.3 (0.62.8)
2.0 (0.75.5)
1.3 (0.63.0)

1.0
0.9 (0.41.9)
1.0 (0.33.1)
0.8 (0.31.8)

1.0
0.8 (0.32.1)
1.5 (0.45.0)
1.0 (0.32.6)

1.0
1.7 (0.74.5)
1.6 (0.46.5)
1.7 (0.65.2)

1.0
1.0
2.8 (0.98.6)
0.9 (0.32.9)
2.5 (0.512.3) 1.4 (0.35.9)
3.1 (0.811.2) 1.2 (0.34.4)

1.0
1.6 (0.46.4)
1.3 (0.27.7)
1.9 (0.48.9)

1.0
1.1 (0.62.3)

1.0
2.1 (0.94.9)

1.0
1.6 (0.73.9)

1.0
3.0 (1.08.5)

1.0
0.5 (0.12.8)

1.0
0.8 (0.14.8)

1.0
1.0
5.3 (1.716.7) 17.9 (3.592.7)

1.0
1.5 (0.73.2)
0.9 (0.51.5)

1.0
1.0
1.4 (0.63.3) 1.9 (0.75.1)
0.5 (0.30.9) 0.8 (0.41.6)

1.0
2.3 (0.86.7)
0.6 (0.31.3)

1.0
1.3 (0.35.3)
0.6 (0.21.8)

1.0
0.6 (0.12.8)
0.4 (0.11.3)

1.0
2.3 (0.68.8)
0.9 (0.42.4)

1.0
1.3 (0.62.7)
1.4 (0.72.8)

1.0
1.0
2.6 (1.06.4) 1.5 (0.63.8)
2.8 (1.26.7) 1.2 (0.52.8)

1.0
2.0 (0.66.3)
2.5 (0.97.2)

1.0
1.9 (0.66.7)
1.6 (0.64.7)

1.0
1.0
3.1 (0.713.2) 0.5 (0.11.9)
3.6 (1.012.6) 0.7 (0.22.8)

1.0
0.5 (0.12.6)
1.0 (0.24.8)

1.0
1.0
1.0
1.0
1.0
2.5 (1.44.3) 3.9 (2.17.2) 3.8 (1.88.1) 7.2 (3.216.1) 1.7 (0.74.0)

1.0
3.9 (1.69.8)

1.0
3.2 (1.38.0)

1.0
6.6 (2.418.3)

1.0
1.0
2.6 (1.16.5) 1.2 (0.93.1)
1.8 (0.84.3) 1.0 (0.42.4)

1.0
0.5 (0.12.0)
0.6 (0.22.4)

1.0
0.6 (0.12.6)
0.7 (0.22.7)

1.0
2.3 (0.69.7)
1.9 (0.52.1)

1.0
1.8 (0.48.1)
1.1 (0.34.7)

1.0
1.0 (0.26.1)
0.8 (0.14.3)

1.0
0.4 (0.12.5)
0.3 (0.11.9)

1.0
1.0 (0.61.6)
0.8 (0.41.8)

1.0
1.3 (0.72.4)
1.0 (0.42.2)

1.0
1.0 (0.51.8)
1.1 (0.42.9)

1.0
1.4 (0.72.9)
1.9 (0.65.4)

1.0
1.0
1.0
0.7 (0.31.4) 1.5 (0.63.5)
1.1 (0.52.6)
3.1 (0.616.2) 4.7 (0.826.0) 2.0 (0.410.0)

1.0
1.3 (0.53.5)
5.4 (1.028.5)

1.0
1.7 (0.93.2)
0.8 (0.32.3)
1.0 (0.51.9)

1.0
1.2 (0.62.5)
2.2 (0.76.5)
0.8 (0.41.7)

1.0
0.9 (0.41.8)
0.8 (0.23.2)
0.8 (0.41.8)

1.0
0.8 (0.31.7)
0.8 (0.23.7)
0.6 (0.21.5)

1.0
1.0
1.0
0.8 (0.32.0) 0.9 (0.32.5)
0.5 (0.21.3)
1.1 (0.110.2) 1.5 (0.114.7) 0.4 (0.11.6)
0.8 (0.32.4) 0.7 (0.22.3)
1.8 (0.56.5)

1.0
0.7 (0.32.1)
0.4 (0.12.4)
2.3 (0.510.1)

1.0
1.2 (0.72.1)

1.0
0.8 (0.41.5)

1.0
0.7 (0.41.3)

1.0
0.7 (0.41.4)

1.0
0.9 (0.41.9)

1.0
0.8 (0.32.0)

1.0
1.2 (0.53.0)

1.0
0.9 (0.42.0)

1.0
2.8 (0.612.3)
0.5 (0.21.6)

*ORs adjusted for independent variables listed in table.

Significance at P.05.

loss of a limb were 2.7 (95% CI, 1.4 5.6) and 1.9 (95% CI,
1.13.2) times more likely than amputees less than 2 years
postamputation to report nonamputated limb pain. The adjusted
odds of nonamputated limb pain were 2.3 times higher for
lower-limb amputees than upper-limb amputees (95% CI, 1.3
3.9). The number of comorbid conditions also increased the adjusted odds of nonamputated limb pain, reaching statistical significance at 2 or more conditions (OR2.7; 95% CI, 1.0 4.0).
The mean intensity score for nonamputated limb pain was
5.12.4. The majority of ratings fell into the mild category
Arch Phys Med Rehabil Vol 86, October 2005

(50.4%) with 30.9% reporting moderate intensity and 18.7%

severe intensity. In the multinomial model, age, etiology, time
since amputation, level of amputation and education were all
found to be significant predictors of intensity of nonamputated
limb pain. Amputees aged 55 to 64 years were 2.5 times (95%
CI, 1.25.5) more likely than amputees aged 18 to 44 years to
rate the intensity of their phantom pain as moderate versus mild
after controlling for amputation-related and sociodemographic
factors. Likewise, amputees with 10 or more years living with
the loss of a limb were 3.0 times (95% CI, 1.1 8.1) more likely

LIMB AND BACK PAIN IN AMPUTEES, Ephraim

than those less than 2 years postamputation to rate the intensity

of their phantom pain as moderate versus mild. Lower-limb
amputees were 8.1 times more likely than upper-limb amputees
to report moderate versus mild intensity of nonamputated limb
pain. Cancer amputees were less likely than dysvascular amputees to rate the intensity of the nonamputated limb pain as
moderate or severe versus mild (moderate: OR0.4; 95% CI,
0.2 0.9; severe: OR0.2; 95% CI, 0.1 0.6). There was a
decrease in the adjusted odds of moderate or severe pain versus
mild as the level of education increased. In contrast, those with
depressed mood were 2 times more likely to rate the intensity
of their pain as moderate versus mild (moderate: OR2.0; 95%
CI, 1.23.6).
Among those with nonamputated limb pain, the majority
(63.7%) characterized their pain as somewhat bothersome
with a quarter (24.4%) reporting extremely bothersome pain.
Men were less likely than women to report being somewhat
bothered by nonamputated limb pain versus not bothered
(OR0.4; 95% CI, 0.2 0.8). Older amputees were more likely
than younger amputees (18 44y) to report being extremely
bothered versus not bothered, with the adjusted odds of 3.7
(95% CI, 1.211.2) for those aged 45 to 54 years and 4.6 (95%
CI, 1.316.2) for those aged 55 to 64 years. Lower-limb amputees were more likely than upper-limb amputees to be somewhat or extremely bothered (somewhat: OR5.3; 95% CI,
1.716.7; extremely: OR17.9; 95% CI, 3.592.7). Depressed
mood was associated with an increase in the adjusted odds of
bothersomeness. Amputees with depressive symptoms were
3.9 (95% CI, 1.6 9.8) times more likely to characterize their
pain as somewhat bothersome and 6.6 (95% CI, 2.4 18.3)
times more likely to characterize their pain as extremely bothersome when compared with those without depressive symptoms.
DISCUSSION
Overall, 95% of amputees reported having 1 or more types
of amputation-related pain during the preceding 4 weeks. The
most common type of amputation-related pain cited was phantom limb pain (79.9%). Similar to previous reports, no statistically significant differences were found in the prevalence of
phantom pain by etiology, age or level of amputation after
controlling for other potential confounding factors.4,6,10 In a
sample comprised of traumatic and dysvascular amputees,
Houghton et al12 reported a decrease in the prevalence of
phantom pain over time. However, that study suffers from
recall bias, because participants who were a median of 6 to 10
years postamputation were asked to recall their experience at 6
months, 1 year, 2 year, and 5 years. In the current study,
phantom pain did not vary significantly by time since amputation. In fact, three quarters (74.0%; n213) of amputees who
were 10 or more years postamputation at the time of interview
reported phantom pain. Studies13,14,40-42 examining phantom
limb pain in upper-limb amputees have demonstrated a lower
prevalence than has been reported for lower-limb amputees
ranging from 50% to 59%. In contrast, 83% of upper-limb
amputees we surveyed reported experiencing phantom limb
pain in the previous 4 weeks. Similar to the finding by Sherman
and Sherman,6 58% of those with phantom pain also reported
having residual limb pain (2 test70.7, P.000).
Sixty-seven percent of those surveyed reported experiencing
residual limb pain in the previous 4 weeks. The prevalence of
residual limb pain has been shown to vary with time, with a
peak in the immediate postoperative period of 50% to 57%
declining to 10% to 13% 2 years postamputation.10,17 However, studies2,13,15,18 among long-standing amputees have demonstrated a prevalence of 55% to 76% at 18 to 50 years

1917

postamputation. In our study, the prevalence of residual limb

pain decreased significantly with age, but did not vary by time
since amputation. Traumatic amputees were nearly 2 times
more likely to report residual limb pain than dysvascular amputees after controlling for sociodemographic and amputation
related factors. The same was true for lower-limb amputees
versus those with upper-limb amputation. With increasing
number of comorbid conditions, the likelihood of residual
increased as well.
Similar to previous studies,2,18,19 the prevalence of selfreported back pain among amputees was 2.2 times that of
estimates for the general U.S. population (28%).43 There have
been conflicting reports on the association between age and
back pain.2,18,19 In our study, we did not find any significant
variation in the prevalence of back pain by age and etiology
after controlling for other factors. However, we did find variation by time since amputation, level of amputation (upper vs
lower), and number of comorbid conditions. A possible link
between level of amputation and back pain has been noted
previously in a group of lower-limb amputee prosthesis users,
with above-knee amputees having a higher prevalence than
those with a below-knee amputation.2 Despite the large proportion of lower-limb prosthesis users in our sample (83.3%),
similar to the findings of Ehde et al,19 we found no significant
difference in the prevalence of reported back pain between
persons with above-knee versus below-knee amputation.
Half of all unilateral amputees reported pain in the nonamputated limb. As might be expected, the prevalence of nonamputated limb pain increased with the number of years living
with the loss of limb and number of comorbid conditions and
was greater for lower-limb amputees than upper-limb amputees. The relationship between time since amputation and
nonamputated limb pain may be attributed to the additional
mechanical burden on the nonamputated limb. Interestingly,
age and etiology of amputation were not found to be a significant predictors of nonamputation-related pain after controlling
for potential confounders. Men were 40% less likely than
women to report nonamputated limb pain. The significant numbers of individuals reporting amputation-related pain indicate
the need for clinicians to include pain assessment as part of
amputation care. Further, physicians need to inquire as to the
presence and impact of back pain and pain in the nonamputated
limb as well as phantom and residual limb pain.
Researchers in the field of chronic pain have observed that
the relationship between pain intensity and interference is
non-linear with pain intensity having a threshold of approximately 5 on a scale of 0 to 10 before there is an effect on
function.36 Gallagher et al16 demonstrated that amputees with
residual limb pain experienced greater level of intensity and
greater interference with daily activities than amputees with
phantom pain. In our sample, 30% of respondents with residual
limb pain and nearly 40% of respondents with phantom pain
rated the intensity of their pain as severe (710 on a scale of
110). Using similar methodology, Ehde et al15 reported comparable results, with a slightly higher proportion of respondents
reporting severe residual limb pain (38%). In a study of veteran
amputees, Hoaglund et al18 reported that 54% of amputees
rated the intensity of their residual limb pain as moderate to
severe. In contrast, the majority of amputees in our study
with residual limb pain characterized their pain as mild
(41.9%). Mean intensity rating (mean, 5.52.6) for phantom
limb pain was similar to that reported in other studies13,15 and
the mean intensity rating of phantom pain was found to be
statistically higher than that of residual limb pain (t3.296,
P.001). The mean intensity of nonamputated limb pain was
4.62.3 and was found to be statistically lower than that of
Arch Phys Med Rehabil Vol 86, October 2005

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LIMB AND BACK PAIN IN AMPUTEES, Ephraim

residual limb pain (t3.2839, P.001) and phantom limb pain

(t5.7385, P.000). In our analysis, we did not find any
statistical difference in mean pain intensity rating by any of the
covariates explored. However, in the multinomial analysis,
there were significant differences by intensity category, but
these varied by pain type. Across all pain types, depressed
mood was a significant predictor of pain intensity rating.
In terms of affective quality of pain experienced, the majority of those with phantom limb pain characterized their pain as
somewhat bothersome (53.9%). Likewise, 60.0% of those
with residual limb pain, 69.2% of those with back pain, and
63.7% of those with nonamputated limb pain described their
pain as somewhat bothersome. These results are fairly similar to other studies that have examined the affective quality of
pain.2,11,15 Using a visual analog scale, with anchors of not at
all to extremely bothered, Smith et al2 found that survey
participants were more likely to be bothered by back pain than
phantom limb pain, but not residual limb pain. While we did
not query participants directly on the type of pain they would
rank as most bothersome, among those with phantom, residual
limb, and back pain a higher proportion reported being extremely bothered by phantom pain (32.2%). In the multinomial
model, age, comorbidity, and education were all significant
predictors of phantom limb pain. For residual limb pain, only
amputation level was found to be significant. Across all pain
types, depressed mood was associated with increased odds of
characterizing pain experienced as bothersome.
In our sample, nearly a third of amputees (28.7%) surveyed
were found to have depressive symptomatology. Amputees
with pain were more likely to have depressive symptoms than
those not experiencing pain. Likewise, depression was a key
predictor of both reported intensity level and bothersomeness
of chronic pain across all pain types after controlling for other
factors. These results support the need to assess the mood of
persons reporting amputation-related pain and aggressively
treat depression as part of the pain control program.
Several limitations of the current study should be noted. Our
sample, comprised of persons who contacted the ACA, included a large number of persons who were of higher education
and income level and may not necessarily be representative of
the population of persons with amputations and therefore may
limit the generalizability of the results. In addition, our survey
response rate of 71%, although well within acceptable ranges,
may have introduced some biases into the analysis. It may be
that persons without pain were less likely to complete a telephone interview. However, given that the survey was not solely
focused on questions regarding pain, but rather on the general
well-being of persons with amputation, there is reduced probability of bias.
CONCLUSIONS
This is the first national survey to report the intensity of and
risk factors for phantom pain, residual limb pain, and nonamputated limb pain in community-dwelling persons with limb
loss. Chronic pain is highly prevalent among persons with limb
loss regardless of time since amputation. While there are several identifiable risk factors for intensity and bothersomeness of
amputation-related pain, these varied greatly by pain site. The
size of our sample allows for control of multiple factors to
identify robust variables related to pain in this population.
However, a common predictor of an increased level of intensity
and bothersomeness among all pain sites was the presence of
depressive symptoms. While further studies are needed to
elucidate the relationship between pain and depressive symptoms among amputees, targeting depression in the multimodel
treatment of pain is critical. Further, interventions designed to
Arch Phys Med Rehabil Vol 86, October 2005

rehabilitate and improve the overall quality of life among

persons with limb loss should target methods to reduce both the
amount and the quality of pain and depression among amputees.
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Arch Phys Med Rehabil Vol 86, October 2005