Promoting Biopsychosocial Assessment of Phantom Limb Pain in Veterans With Amputation

Abstract

Pain management is a focus of rehabilitation for Veterans after amputation, and occupational therapy practitioners play a key role in providing this care as part of an interdisciplinary team. However, the evaluation and treatment of phantom limb pain (PLP) after amputation lack guidance with respect to best practices. There is a need for improved identification of factors that contribute to PLP so that treatment targets can be identified. In this column, we discuss the application of the biopsychosocial model to the clinical management of PLP as part of comprehensive care for Veterans after amputation. We present factors associated with PLP, categorized using the biopsychosocial model, and discuss specific considerations for Veterans. We also provide recommendations for the biopsychosocial evaluation of PLP in occupational therapy practice, and we highlight the value of involving occupational therapists in interdisciplinary health care teams. Furthermore, we recommend continued evaluation and discussion to monitor changes in PLP and its associated factors over time.

The authors present factors associated with phantom leg pain and discuss specific considerations for Veterans, including highlighting the value of involving occupational therapists in interdisciplinary health care teams.

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References

Ahmed

Bhatnagar

Mishra

Khurana

Joshi

, & Ahmad

S. M.

(2017). Prevalence of phantom limb pain, stump pain, and phantom limb sensation among the amputated cancer patients in India: A prospective, observational study. Indian Journal of Palliative Care, 23, 24–35. https://doi.org/10.4103/0973-1075.197944

American Occupational Therapy Association. (2021). Role of occupational therapy in pain management. American Journal of Occupational Therapy, 75 (Suppl. 3), 7513410010. https://doi.org/10.5014/ajot.2021.75S3001

Asano

Rushton

Miller

W. C.

, & Deathe

B. A.

(2008). Predictors of quality of life among individuals who have a lower limb amputation. Prosthetics and Orthotics International, 32, 231–243. https://doi.org/10.1080/03093640802024955

Bevers

Watts

Kishino

N. D.

, & Gatchel

R. J.

(2016). The biopsychosocial model of the assessment, prevention, and treatment of chronic pain. US Neurology, 12, 98–104. https://doi.org/10.17925/USN.2016.12.02.98

Cai

Xie

Bowe

Gibson

A. K.

Zayed

M. A.

, & Al-Aly

(2021). Temporal trends in incidence rates of lower extremity amputation and associated risk factors among patients using Veterans Health Administration services from 2008 to 2018. JAMA Network Open, 4, e2033953. https://doi.org/10.1001/jamanetworkopen.2020.33953

Cheatle

M. D.

(2016). Biopsychosocial approach to assessing and managing patients with chronic pain. Medical Clinics of North America, 100, 43–53. https://doi.org/10.1016/j.mcna.2015.08.007

Eibner

Krull

Brown

K. M.

Cefalu

Mulcahy

A. W.

Pollard

M. S.

, … Farmer

C. M.

(2015). Current and projected characteristics and unique health care needs of the patient population served by the Department of Veterans Affairs . RAND Corporation. https://doi.org/10.7249/RR1165.1

Ephraim

P. L.

Wegener

S. T.

MacKenzie

E. J.

Dillingham

T. R.

, & Pezzin

L. E.

(2005). Phantom pain, residual limb pain, and back pain in amputees: Results of a national survey. Archives of Physical Medicine and Rehabilitation, 86, 1910–1919. https://doi.org/10.1016/j.apmr.2005.03.031

Fisher

G. S.

Emerson

Firpo

Ptak

Wonn

, & Bartolacci

(2007). Chronic pain and occupation: An exploration of the lived experience. American Journal of Occupational Therapy, 61, 290–302. https://doi.org/10.5014/ajot.61.3.290

10.

Gallagher

Allen

, & Maclachlan

(2001). Phantom limb pain and residual limb pain following lower limb amputation: A descriptive analysis. Disability and Rehabilitation, 23, 522–530. https://doi.org/10.1080/09638280010029859

11.

Giummarra

M. J.

Georgiou‐Karistianis

Nicholls

M. E. R.

Gibson

S. J.

Chou

, & Bradshaw

J. L.

(2011). The menacing phantom: What pulls the trigger? European Journal of Pain, 15, 691.e1–691.e8. https://doi.org/10.1016/j.ejpain.2011.01.005

12.

Hawley

C. E.

Armstrong

A. J.

Darter

B. J.

Sima

, & Fields

(2022). Veterans of Operation Enduring Freedom and Operation Iraqi Freedom: Employment status following traumatic amputation. Journal of Applied Rehabilitation Counseling, 53, 68–80. https://doi.org/10.1891/jarc-d-20-00027

13.

Hesselstrand

Samuelsson

, & Liedberg

(2015). Occupational therapy interventions in chronic pain—A systematic review. Occupational Therapy International, 22, 183–194. https://doi.org/10.1002/oti.1396

14.

Hitch

C. M.

Harper

Armour

, & Waterhouse-Bradley

(2020). How Army veterans cope with chronic pain: A grounded theory approach. Journal of Veterans Studies, 6, 122–134. https://doi.org/10.21061/jvs.v6i1.125

15.

Kikkert

Mezue

Henderson Slater

Johansen-Berg

Tracey

, & Makin

T. R.

(2017). Motor correlates of phantom limb pain. Cortex, 95, 29–36. https://doi.org/10.1016/j.cortex.2017.07.015

16.

Kintzle

Alday

Sutherland

, & Castro

C. A.

(2024). Drivers of veterans’ healthcare choices and experiences with Veterans Affairs and civilian healthcare. Healthcare, 12, 1852. https://doi.org/10.3390/healthcare12181852

17.

Knowles

K. A.

Sripada

R. K.

Defever

, & Rauch

S. A. M.

(2019). Comorbid mood and anxiety disorders and severity of posttraumatic stress disorder symptoms in treatment-seeking veterans. Psychological Trauma: Theory, Research, Practice and Policy, 11, 451–458. https://doi.org/10.1037/tra0000383

18.

Miaskowski

Blyth

Nicosia

Haan

Keefe

Smith

, & Ritchie

(2020). A biopsychosocial model of chronic pain for older adults. Pain Medicine, 21, 1793–1805. https://doi.org/10.1093/pm/pnz329

19.

Miller

C. J.

Shin

Pugatch

, & Kim

(2021). Veteran perspectives on care coordination between Veterans Affairs and community providers: A qualitative analysis. Journal of Rural Health, 37, 437–446. https://doi.org/10.1111/jrh.12526

20.

Mills

J.-A.

Marks

Reynolds

, & Cieza

(2017). Rehabilitation: Essential along the continuum of care. In Jamison

D. T.

Gelband

Horton

Jha

Laxminarayan

Mock

C. N.

, & Nugent

(Eds.), Disease control priorities: Vol. 9. Improving health and reducing poverty (3rd ed., pp. 285–295). World Bank. https://doi.org/10.1596/978-1-4648-0527-1

21.

Münger

Pinto

C. B.

Pacheco‐Barrios

Duarte

Enes Gunduz

Simis

, … Fregni

(2020). Protective and risk factors for phantom limb pain and residual limb pain severity. Pain Practice, 20, 578–587. https://doi.org/10.1111/papr.12881

22.

Murphy

J. L.

Cordova

M. J.

, & Dedert

E. A.

(2022). Cognitive behavioral therapy for chronic pain in Veterans: Evidence for clinical effectiveness in a model program. Psychological Services, 19, 95–102. https://doi.org/10.1037/ser0000506

23.

Murray

C. D.

Havlin

, & Molyneaux

(2024). Considering the psychological experience of amputation and rehabilitation for military Veterans: A systematic review and metasynthesis of qualitative research. Disability and Rehabilitation, 46, 1053–1072. https://doi.org/10.1080/09638288.2023.2182915

24.

Pascale

B. A.

, & Potter

B. K.

(2014). Residual limb complications and management strategies. Current Physical Medicine and Rehabilitation Reports, 2, 241–249. https://doi.org/10.1007/s40141-014-0063-0

25.

Pereira

Noronha

, & Bishop

(2023). Cognitive behavioral therapy for postamputation chronic pain: A case report. Cognitive and Behavioral Practice, 30, 160–168. https://doi.org/10.1016/j.cbpra.2021.07.002

26.

Stineman

M. G.

, & Streim

J. E.

(2010). The biopsycho‐ecological paradigm: A foundational theory for medicine. PM & R, 2, 1035–1045. https://doi.org/10.1016/j.pmrj.2010.06.013

27.

Taylor

K. A.

Kapos

F. P.

Sharpe

J. A.

Kosinski

A. S.

Rhon

D. I.

, & Goode

A. P.

(2024). Seventeen-year national pain prevalence trends among U.S. military Veterans. Journal of Pain, 25, 104420. https://doi.org/10.1016/j.jpain.2023.11.003

28.

U.S. Department of Veterans Affairs & U.S. Department of Defense. (2024). VA/DOD clinical practice guideline for rehabilitation of individuals with lower limb amputation (Version 3.0). https://www.healthquality.va.gov/guidelines/Rehab/amp/LLA-CPG_2024-Guideline_final_20250110.pdf

29.

Vase

Egsgaard

L. L.

Nikolajsen

Svensson

Jensen

T. S.

, & Arendt-Nielsen

(2012). Pain catastrophizing and cortical responses in amputees with varying levels of phantom limb pain: A high-density EEG brain-mapping study. Experimental Brain Research, 218, 407–417. https://doi.org/10.1007/s00221-012-3027-6

30.

Wilkins

K. L.

McGrath

P. J.

Finley

G. A.

, & Katz

(2004). Prospective diary study of nonpainful and painful phantom sensations in a preselected sample of child and adolescent amputees reporting phantom limbs. Clinical Journal of Pain, 20, 293–301. https://doi.org/10.1097/00002508-200409000-00003