Tools & Techniques to Mitigate Pain Associated With Upper-Limb Loss

Prosthetics providers and their patients are all too familiar with the persistent types of pain experienced by more than half a million Americans with upper-limb loss—a number that is projected to double by 2050. 1 In a cross-sectional survey of 104 people with upper-limb loss, 79 percent reported phantom limb pain and 71 percent reported residual limb pain, including nerve-related and neuroma pain. 2 Other types of reported pain include back pain (52 percent), neck pain (43 percent), pain in the contralateral arm (33 percent), and shoulder pain (30 percent). 3 Pain in the back and neck may be linked to the lack of body symmetry after an amputation, while pain in the contralateral arm is most often the result of overuse syndrome. 4 Reducing pain after upper-limb loss is an important goal that requires the efforts of a holistic team, including surgeons, prosthetists, occupational therapists, physiatrists, psychologists, and the patient’s support network. Recovering from the life-altering realities of limb loss can be a lengthy process. Consulting early with a prosthetist and occupational therapist who specialize in upper-limb prosthetic rehabilitation supports patients as they move toward physical and psychological balance. Introducing strategies that reduce pain, while making it possible to comfortably wear and use a prosthesis, helps people begin to accept their limb difference. [caption id="attachment_269575" align="alignright" width="357"] Managing farm tasks with a transhumeral prosthesis and an adjustable socket with dial closure. Photographs courtesy of Arm Dynamics.[/caption] Chronic pain is strongly linked to mental health concerns like depression, anxiety, and post-traumatic stress disorder (PTSD). It can also intensify psychosocial challenges such as lack of emotional support, financial strain, and substance abuse. Relying on prescription drugs, especially opioids, to manage residual limb pain is a common occurrence, and long-term use can lead to dependency and multiple negative side effects. Reducing or eliminating pain significantly improves patients’ quality of life by allowing them to: Use their prostheses to improve bimanual function and regain personal independence Participate more fully in family, work, social, and recreational activities Experience adequate sleep and rest that is essential to healing Reduce the risk of mental health issues Decrease overall healthcare needs and associated costs As prosthetists and occupational therapists who work exclusively with upper-limb patients, we focus on various methods, materials, and techniques that support the goals of reducing or eliminating pain, increasing prosthesis wear time, and training people how to effectively use their devices. A Toolbox of Proven Strategies Our process of evaluating patients with chronic pain begins with listening to their needs, challenges, and ideas. A prosthetist and a clinical therapy specialist work side by side with patients, answering and asking questions, identifying their goals, examining the limb, and educating them on prosthetic options. People with upper-limb loss are looking for solutions that address the multiple types of pain, and challenges like skin grafts, scar tissue, reshaping the residual limb, and other surgical considerations. Our clinical team relies on three broad approaches to mitigating pain: Customizing the design and materials for each unique prosthesis Providing specific therapeutic interventions and one-on-one occupational therapy at every visit Collaborating with physicians to support surgical interventions that relieve pain While fitting a diagnostic socket and preparatory prosthesis over the course of five days, the prosthetist and therapist receive a continuum of feedback from the patient that guides adjustments. This makes it possible for patients to start wearing a prosthesis right away versus waiting weeks or months for the socket to be modified and the prosthesis to be built. As the prosthetist perfects the socket and design, the therapist starts basic prosthetic training, and the patient begins to accomplish small goals. [caption id="attachment_269576" align="alignleft" width="229"] A prosthetist hand casting a mold for the socket.[/caption] 1: Design and Materials for Prostheses Designing and creating a well-fitting socket is the starting point of reducing pain and ensuring that the socket does not apply pressure to sensitive areas. We believe that using plaster to hand cast the residual limb and make the mold for a diagnostic socket is the most accurate way to achieve a precise fit and optimal comfort. This foundational step requires careful consideration of the anatomy to feel and shape the impression while it’s on the patient’s limb, capturing the bony anatomy underneath the soft tissues. Prosthetists need to examine the fit and stabilization of the bones while paying attention to compromised tissue or painful areas of the residual limb. There should be multiple iterations of the diagnostic/test socket as adjustments are made based on real-time patient feedback. Effective use of test sockets paves the way to an optimized and comfortable definitive socket. In our practice, we have observed that using rolled HTV and injected RTV silicone to create custom sockets significantly increases comfort in the residual limb, allowing for longer wearing times. A multidurometer silicone interface can cushion and protect sensitive residual limb tissue and bony prominences. The weight of the prosthesis can also contribute to discomfort, so we routinely integrate lighter composite materials into the frame. The result is a prosthesis that is both lightweight and strong. A comfortable prosthesis has been proven to increase wear time and independence. People with persistent discomfort are much more likely to stop wearing their devices, which can lead to a cascade of issues that include overuse of the contralateral side, body asymmetry, strain in the shoulder, neck, and back, and maladaptation. Patient A presented with a wrist disarticulation amputation and one extremely sensitive nerve on the distal end. He frequently used his limb without a prosthesis to interact with objects and complete tasks, and any pressure on that spot caused shooting pain. His fear of triggering the pain caused him to step back and do less with his limb. He was fitted with a prosthesis that incorporated a section of custom, low-Shore gel silicone over the sensitive spot and an added protective hard shell to shield it from the pressure of the frame. Now when he encounters pressure while wearing the prosthesis, the sensitive area is supported by the entire socket and frame, not just the part that covers the nerve. Free from the fear of experiencing shooting pain, the patient is relaxing into being able to use his prosthesis to navigate daily life. [caption id="attachment_269577" align="alignright" width="273"] HTV rolled silicone[/caption] Adjustable sockets provide another opportunity to reduce pain for upper-limb prosthesis users, allowing them to choose when to tighten or loosen the socket with an adjustable dial closure system. When the volume of the residual limb fluctuates or there is a need to adjust the prosthesis for tasks that involve pushing, pulling, or lifting, it is helpful to have more control over the suspension and stabilization of the device. The patient may only need to tighten the dial briefly to complete a task and then reduce the pressure for more comfort. Some adjustable sockets are made with floating panels that pull together when the dial is adjusted. This better distributes pressure across the residual limb for people who have sensitivity in specific locations. 2: Therapeutic Intervention On-site occupational therapy services go a long way to address chronic pain. In our care model, an experienced clinical therapy specialist is at every appointment, starting with the patient’s initial evaluation. It’s important for the therapist to assess the residual limb over time, listen to the patient’s goals, and talk about how to prepare and strengthen the body for wearing a prosthesis. Therapists have a range of techniques that reduce overall residual limb pain, including wound care, management of scar tissue and edema, limb desensitization, and improving range of motion and strength. They introduce pre-prosthetic training based on the type of prosthesis the patient is going to use, and when the patient begins wearing his or her initial device, therapists add control and skills training to the care plan. Therapists also address the psychosocial impact of traumatic injury and limb loss. Some patients may need additional support to help them manage the mental pain of issues like depression, PTSD, and anxiety. Our therapists screen patients for common mental health concerns and connect them with counseling and peer support as needed. Some people with upper-limb amputations and persistent residual limb pain get relief when they wear a prosthesis, but when they take it off, the pain may resurface. Why is that? A properly fitted prosthesis applies balanced pressure to the residual limb and silicone cushioning for sensitive areas like skin grafts or bony prominences. [caption id="attachment_269578" align="alignright" width="216"] RTV injectable silicone[/caption] Patient B injured his left arm in an accident at work. His surgeon attempted limb salvage, but infection set in, which led to a transhumeral amputation. The patient endured months of phantom limb pain while his residual limb was healing from surgery. When he was able to be fitted with a custom socket and body-powered prosthesis, he found significant pain relief while wearing the prosthesis, but the pain returned when he took it off, making sleep difficult. To continue moving toward pain reduction, his occupational therapist introduced Graded Motor Imagery (GMI), a three-step process that strengthens the neurologic connection between the brain and the missing limb. Research shows that practicing GMI reactivates dormant neural pathways, reducing phantom limb pain and stimulating muscles in the residual limb. The success of GMI is dependent on the patient performing a series of specific exercises at home multiple times each day for several weeks. The first phase is laterality reconstruction (right/left recognition), the second is motor imagery (imagined movements), and the third is mirror therapy (creating a visual illusion of movement). Each phase lasts about two weeks. Over time, the combination of wearing a prosthesis and practicing GMI relieved this patient’s phantom limb pain. He wears his prosthesis daily, working on his family’s farm and managing oil and gas wells on their land. 3: Surgical Intervention Some causes of residual limb pain can only be mitigated or eliminated with surgery. For many patients, the possibility of having revision surgery on their residual limbs is anxiety-inducing, and they often resist the idea. It can be daunting for prosthetists to bring up the topic of revision surgery with patients, who, in addition to their amputations, may have experienced multiple surgical procedures like debridement, limb shaping, and more. Regardless, patients must be informed when surgery is the only viable path to pain relief and prosthetic success. Pursuing ineffective treatments wastes time and delays progress. Open communication between prosthetists and surgeons, particularly regarding how residual limb characteristics impact prosthetic success, is key to establishing trust and optimizing long-term outcomes. Surgical intervention can include reducing or reshaping a limb that is too long or adding soft tissue coverage to cushion the bone. Skeletal recontouring of sharp or damaged bones may be needed. In the case of very short residual limbs, it may be necessary to add a bone allograft and soft tissue coverage to lengthen and strengthen the limb so it’s possible to wear a prosthesis. Close collaboration between the surgeon, prosthetist, and therapist helps patients stay focused on the goal of a mostly pain-free outcome. [caption id="attachment_269579" align="alignleft" width="273"] A definitive socket with cushioning multidurometer silicone interface.[/caption] Patient C was a welder who was injured on the job. He had a transradial amputation with the distal ends of the bones having minimal soft tissue and a significant number of skin grafts. His level of pain was almost unbearable and was triggered by the slightest touch. His surgeon and prosthetist agreed the only way he would be able to wear a prosthesis was to increase soft tissue coverage. The surgeon removed muscle tissue from the patient’s right quadricep , wrapped it around the bones, and covered the tissue with skin grafts from the patient’s left leg. Later, he had a second surgery to debulk and shape the limb to work well with a prosthesis. He now wears a prosthesis daily, has minimal pain, and reports phantom sensation that is not painful, but is always present. His goal is to return to work as a safety manager. Upper-limb prosthesis users may develop painful neuromas in the residual limb, making it impossible for them to wear a prosthesis without pain. Neuromas form when nerves in the limb are severed by an amputation, losing their normal connection with tissues in the portion of the limb that was lost. Instead of healing, the bare nerve endings may grow into a tangled lump of nerve cells and scar tissue that often creates debilitating pain. There are several nerve-centric surgeries that can reduce phantom limb pain/residual limb pain. Targeted muscle reinnervation (TMR) surgery was designed to improve a person’s control of a prosthesis by increasing myoelectric sensor sites in the residual limb. It has a secondary benefit of mitigating residual limb pain because the procedure reroutes severed nerves to nearby muscles, reestablishes neural connections, restores normal signals to the brain, and decreases the chance for neuroma formation. Targeted sensory reinnervation (TSR) has emerged as an offshoot of TMR. It refines the procedure to address sensory feedback and directly mitigate phantom limb and other residual limb pain. TSR may include complicated nerve grafts and is more focused on restoring sensation. [caption id="attachment_269580" align="alignright" width="336"] Mirror therapy activates motor neurons in the patient’s brain and spinal cord.[/caption] Patient D had a transradial amputation following an accident at the paper mill where he worked. He developed debilitating neuroma pain and struggled with depression. He was fitted with a body-powered arm that allowed him to perform daily tasks, hold the handlebar of his four-wheeler, and work out at the gym. His occupational therapist introduced him to other people with limb loss and connected him with a psychologist for counseling. His surgeon and prosthetist discussed techniques for addressing neuroma pain. The procedure involved neuroma excision with transposition/implantation. Three neuromas were surgically removed, and the remaining nerve endings were implanted into a muscle, providing a safe and shielded environment. After the surgery, the patient’s pain level dropped from more than ten to between two and three. He has returned to work with a prosthesis and has a regular weightlifting routine at the gym. Regenerative peripheral nerve interface (RPNI) is a newer surgical procedure that involves taking small muscle grafts, usually from the residual limb, and attaching them to the severed nerve endings in the amputated limb. Like TMR and TSR, RPNI can significantly reduce pain scores and improve prosthetic function for people with upper-limb amputations. Conclusion When 79 percent of patients with upper-limb loss report chronic pain related to their limb difference, it’s a significant barrier to their overall recovery and ability to use prostheses. As clinicians, our responsibilities include recognizing pain as a primary rehabilitation concern, delivering evidence-based solutions, and providing consistent follow-up care. [caption id="attachment_269581" align="alignleft" width="273"] Occupational therapists rely on multiple strategies to mitigate pain.[/caption] Reducing pain radically improves quality of life, helps restore confidence, and prevents secondary complications like overuse injuries, depression, and prosthesis abandonment. A multidisciplinary team approach optimizes patient outcomes and drives more sustainable, long-term results. John M. Miguelez, CP, FAAOP(D), is the president and senior clinical director of Arm Dynamics, which he founded in 1998. Julian Wells, CPO, FAAOP, is the clinical manager at Arm Dynamics Midwest Center of Excellence. Scott Spring, CP/L, is the clinical manager at Arm Dynamics Gulf Coast Center of Excellence.Lauren Trent, OTR/L, is the senior manager of therapeutic services and research and development at Arm Dynamics. Carina Geraldez, MOT/OTR, is the clinical therapy specialist at Arm Dynamics Southwest Center of Excellence. Sherri Edge is a writer and video producer at Arm Dynamics. References Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil. 2008 Mar;89(3):422-9. doi: 10.1016/j.apmr.2007.11.005. PMID: 18295618. Hanley MA, Ehde DM, Jensen M, Czerniecki J, Smith DG, Robinson LR. Chronic pain associated with upper-limb loss. Am J Phys Med Rehabil. 2009 Sep;88(9):742-51; quiz 752, 779. doi: 10.1097/PHM.0b013e3181b306ec. PMID: 19692791; PMCID: PMC3079279. Webster JB, Webster N, Borgia M, Resnik L. Frequency, severity, and implications of shoulder pain in people with major upper limb amputation who use prostheses: Results of a National Study. PM R. 2022 Aug;14(8):901-912. doi: 10.1002/pmrj.12666. Epub 2021 Aug 19. PMID: 34219397. Flinn SR, Goodman G. Effective assessments to identify overuse injuries in unaffected limbs of persons with unilateral upper limb amputations. J Hand Ther. 2021 Apr-Jun;34(2):298-308. doi: 10.1016/j.jht.2021.05.006. Epub 2021 May 16. PMID: 34148738.

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