Skip to main content

Managing acute phantom limb pain with transcutaneous electrical nerve stimulation: a case report



Phantom limb pain is characterized by painful sensations in the amputated limb. The clinical presentation of acute phantom limb pain may differ from that of patients with chronic phantom limb pain. The variation observed implies that acute phantom limb pain may be driven by peripheral mechanisms, indicating that therapies focused on the peripheral nervous system might be successful in reducing pain.

Case presentation

A 36-year-old African male with acute phantom limb pain in the left lower limb, was treated with transcutaneous electrical nerve stimulation.


The assessment results of the presented case and the evidence on acute phantom limb pain mechanisms contribute to the current body of literature, indicating that acute phantom limb pain presents differently to chronic phantom limb pain. These findings emphasize the importance of testing treatments that target the peripheral mechanisms responsible for phantom limb pain in relevant individuals with acquired amputations.

Peer Review reports


Phantom limb pain (PLP), pain felt in the amputated limb, is a disabling condition associated with depression, decreased mobility, and low quality of life [1]. This condition characterized by painful sharp, shooting, or cramping sensations is estimated to occur in approximately 64% [95% CI: 60.01–68.05] of people who have undergone limb amputations, regardless of the cause of amputation [2, 3]. Phantom limb pain occurs as early as the first day after amputation [4]. However, in some cases the onset may be many months or years after the amputation of a limb [5].

Peripheral and cortical mechanisms for PLP have been proposed [6]. However, it is unclear whether these mechanisms underlie acute or chronic PLP. Acute PLP is classified as pain with an early onset (less than 5 weeks after amputation) and persisting for less than 3 months [4]. Chronic PLP is classified as pain that persists for 3 months or more [4, 7]. Neuroimaging studies of the brains of people with amputations suggest that PLP is driven by neuroplastic changes in the somatosensory, premotor, and primary motor cortices of the brain contralateral to the amputated limb [8,9,10,11,12,13,14]. On the contrary, a study by Vaso et al. [15] provided compelling evidence that PLP is primarily a bottom-up phenomenon that is initiated by exaggerated input generated ectopically in the dorsal root ganglion of the severed peripheral nerve, and that maladaptive changes in the central nervous system (spinal cord and brain) maybe involved in maintaining the chronicity of pain. The various underlying mechanisms suggest the clinical presentation of people with PLP varies at different stages after amputation.

A substantial difference has been seen in the clinical presentation of acute and chronic PLP [16]. Patients with chronic PLP present (at baseline) with signs and symptoms associated with neuroplastic changes in the sensory and motor areas of the brain: inaccurate left/right judgement scores (< 80%) and/or pain triggered or aggravated by imagined or actual movements of the phantom limb [17]. On the contrary, patients with acute PLP consistently present with accurate left/right judgement scores (> 80%) and report no aggravation of pain with imagined or actual movement of the phantom limb [18,19,20]. These findings support the existing evidence, suggesting that cortical mechanisms may have a limited role in initiating PLP [15]. Furthermore, this suggests that patients with acute PLP may benefit from treatments targeting maladaptive changes in the peripheral nervous system.

Pharmacological treatments including pregabalin have shown some effect in alleviating PLP [4, 21]. However, the evidence is promising for non-pharmacological interventions such as Transcutaneous Electrical Nerve Stimulation (TENS), which often presents with relatively fewer or no adverse treatment effects [22,23,24,25]. Transcutaneous electrical nerve stimulation is a treatment delivered by a battery-powered device via electrodes positioned on the nerve root or along the distribution of the nerve that innervates the painful area [26]. The role of TENS in reducing pain via peripheral mechanisms has been noted in the literature [26]. Given these positive outcomes, TENS might be beneficial for reducing acute PLP in people with amputations. Here we report a case of acute PLP in the left lower limb, treated with a combination of high- and low-frequency TENS.

Case presentation

A 36-year-old African man, who is 1.8 m in tall, weighs 76 kg, smokes 20 cigarettes per day, and has no prior medical history, was assaulted with a sharp object. He was unconscious upon admission at a tertiary healthcare facility where his left leg was later amputated just below the hip joint. Two days after the amputation, the patient reported excruciating PLP along the length of his missing leg and toes. He reported a pain severity of 7/10 (on a 0–10 scale) and described the pain as shocking and cramping—as if the leg was being twisted. His pain was constant throughout the day and night, and without any notable relief. To manage his pain, he was initiated on Lyrica (25 mg during the day; 150 mg at night), venlafaxine (75 mg), and ibuprofen (200 mg). However, after seven days of treatment, there was no significant improvement in his symptoms. He was referred to the Pain Clinic at Groote Schuur Hospital for reassessment and management of acute PLP.

On assessment, the Douleur Neuropathique four questions (DN4) questionnaire for neuropathic pain revealed a score of 4 out of 10, thus indicating the presence of neuropathic pain [27]. In this questionnaire, he reported symptoms such as hypesthesia to touch, electric shocks, numbness, and itching of the stump.

The overall pain severity score assessed by the pain severity scale of the Brief Pain Inventory (BPI) was 5.5 (on a 0–10 scale) [28]. The individual components of the BPI showed that his pain (out of 10 in the last 24 hours) was five at its worst, four at its least, five on average, and five at the time of assessment. The pain interference score assessed using the pain interference scale of the BPI was five (on a 0–10 scale). Pain had a substantial negative impact on his sleep (9 out of 10) and his walking ability with crutches (7 out of 10), and had minimal interference with general activity (4 out of 10), mood (3 out of 10), relations with other people (2 out of 10), and enjoyment of life (3 out of 10). Because he was an inpatient, we could not rate the interference of pain with normal work. Therefore, the overall pain interference score was derived from six items of the pain interference scale.

The patient reported primary hyperalgesia but no allodynia near the site of amputation. The visual inspection of the stump showed redness and swelling. On left/right judgements he scored: left limb 98%, time 1.4 seconds; right limb 100%, time 1.5 seconds. Imagined and actual movements (knee flexion/extension) of the phantom limb did not aggravate pain. The Tinel's test on the residual limb elicited a shocking pain radiating down the phantom leg into the toes.

Treatment began with educating the patient about PLP and its underlying peripheral mechanisms. He was told in lay terms that spontaneous nociceptive activity at the site of the severed nerve may have a role in initiating PLP and that TENS may provide pain relief. The patient underwent high-frequency TENS (100 Hz) for 15 minutes, followed immediately by 15 minutes of low-frequency TENS (10 Hz). In both instances, the intensity was gradually increased three times to the highest tolerable level. The electrodes were positioned on the posterolateral aspect of the residual limb along the distribution of the sciatic nerve (Fig. 1). At the end of the session, the patient reported complete pain relief and increased awareness of the phantom limb. In addition, the patient reported a high level of satisfaction with the treatment and its effects.

Fig. 1
figure 1

The patient undergoing high- and low-frequency transcutaneous electrical nerve stimulation

Treatment was provided once a day for three consecutive days, following which outcomes were reassessed. The patient reported no PLP. Further, he reported that his sleep had improved remarkably since the first treatment session. At this point, he was mobilizing with elbow crutches under supervision. No adverse effects were reported.


This is a case report of a patient with PLP in the left lower limb, who was treated with high- and low-frequency TENS. The results of this case indicate that TENS may be effective for reducing acute PLP and its interference with sleep and mobility.

Previous studies on PLP indicate that acute and chronic PLP have been managed using the same approach, which unsurprisingly yielded mixed findings [29,30,31,32]. For example, although some people with chronic PLP may benefit from treatments targeting central mechanisms (e.g., mirror therapy), it appears that individuals with acute PLP do not derive any significant benefits from these treatments [32, 33]. This highlights the importance of differentiating between the two PLP classifications and utilizing treatments that address mechanisms underlying each pain type.

Recent neuroimaging evidence has linked PLP to maladaptive changes in the somatosensory, premotor, and motor cortices of the brain—where the neighboring cortical areas shift into the cortical area that previously innervated the amputated limb [34]. The maladaptive changes in these areas are associated with low left/right judgement scores [decreased accuracy (< 80%) and increased recognition time (in seconds)] and aggravated pain with imagined or actual movements of the phantom limb [35,36,37,38]. In this case, however, the patient presented with almost perfect left/right judgement scores (left 98%, time 1.4 seconds; right 100%, time 1.5 seconds). In addition, he did not report aggravated pain during the imagined or actual movements of the phantom limb. Therefore, the results of this assessment suggest that cortical mechanisms proposed to drive chronic pain may have a limited role in acute PLP.

The peripheral afferent theory of PLP suggests that increased ectopic firing from an injured nerve is the generator of acute PLP, and potentially a driver of secondary central changes linked to chronic PLP [39]. In fact, the mechanistic study by Vaso et al., [15] provided evidence showing that PLP after amputation may be triggered by increased nociceptive activity in the dorsal root ganglion of the severed peripheral nerve. These findings corroborate those of a previous study suggesting that acute PLP is triggered by increased production of substance P and calcitonin gene-related peptide in the dorsal root ganglion and maintained by exaggerated nociceptive activity between the first and second order neurons in the dorsal horn of the spinal cord [40, 41]. Further, it is known that triggering nociceptive activity at the nerve site evokes symptoms distally in regions that are innervated by that particular nerve. A positive Tinel's test in this case highlights the peripheral nerve as an important treatment target.

High-frequency (100 Hz) TENS has been shown to provide analgesia by activating the gate-control mechanism via the fast-conducting, heavily myelinated A-beta fibers that compete with the transmission of nociception from the periphery by the slow-conducting C fibers [42]. Low-frequency TENS (10 Hz) provides analgesia by activating the opioid receptors in the periphery and dorsal horn of the spinal cord [26]. Although there is some preliminary evidence suggesting the mechanisms by which TENS reduces acute PLP, further mechanistic studies are necessary to elucidate this association.

Transcutaneous electrical nerve stimulation has consistently shown positive results in patients with neuropathic pain syndromes [23, 43]. In addition, the treatment is inexpensive, and it requires minimal patient training [44]. The effectiveness of TENS coupled with its safety and a lack of adverse effects makes it a suitable complementary analgesic intervention for patients with acute PLP.


The results of the assessment of the presented case and the neurophysiological evidence on acute PLP mechanisms adds to the existing literature indicating that acute PLP presents differently to chronic PLP. This, therefore, highlights the need for testing the efficacy of treatments targeting peripheral mechanisms underlying acute PLP in people with acquired amputations.

Availability of data and materials

The participant’s de-identified data will be made available upon reasonable request.



Phantom limb pain


Transcutaneous electrical nerve stimulation


  1. Padovani MT, Martins MR, Venancio A, Forni JE. Anxiety, depression and quality of life in individuals with phantom limb pain. Acta Ortop Bras. 2015;23(2):107–10.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Ahmed A, Bhatnagar S, Mishra S, Khurana D, Joshi S, Ahmad S. Prevalence of phantom limb pain, stump pain, and phantom limb sensation among the amputated cancer patients in India: a prospective, observational study. Indian J Palliat Care. 2017;23(1):24–35.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Clark RL, Bowling FL, Fergus J, Rajbhandari S. Phantom limb pain after amputation in diabetic patients does not differ from that after amputation in nondiabetic patients. Pain. 2013;154(5):729–32.

    Article  PubMed  Google Scholar 

  4. Neil M. Pain after amputation. BJA Educ. 2015;16(3):107–12.

    Article  Google Scholar 

  5. Bornemann-Cimenti H, Dorn C, Rumpold-Seitlinger G. Early onset and treatment of phantom limb pain following surgical amputation. Pain Med. 2017;18(12):2510–2.

    Article  PubMed  Google Scholar 

  6. Subedi B, Grossberg GT. Phantom limb pain: mechanisms and treatment approaches. Pain Res Treat. 2011;2011: 864605.

    PubMed  PubMed Central  Google Scholar 

  7. Ehde DM, Wegener ST. Management of chronic pain after limb loss. In: Gallagher P, Desmond D, MacLachlan M, editors. Psychoprosthetics. London: Springer; 2008. p. 33–51.

    Chapter  Google Scholar 

  8. Diers M, Christmann C, Koeppe C, Ruf M, Flor H. Mirrored, imagined and executed movements differentially activate sensorimotor cortex in amputees with and without phantom limb pain. Pain. 2010;149(2):296–304.

  9. Flor H. Cortical reorganisation and chronic pain: Implications for rehabilitation. J Rehabil Med. 2003;35:66–72.

    Article  Google Scholar 

  10. Flor H, Elbert T, Knecht S, Wienbruch C, Pantev C, Birbaumers N, et al. Phantom-limb pain as a perceptual correlate of cortical reorganization following arm amputation. Nature. 1995;375(6531):482–4.

    Article  CAS  PubMed  Google Scholar 

  11. Foell J, Bekrater-Bodmann R, Diers M, Flor H. Mirror therapy for phantom limb pain: brain changes and the role of body representation. Eur J Pain. 2014;18(5):729–39.

    Article  CAS  PubMed  Google Scholar 

  12. Gruesser SM, Winter C, Schaefer M, Fritzsche K, Benhidjeb T, Tunn P-U, et al. Perceptual phenomena after unilateral arm amputation: a pre-post-surgical comparison. Neurosci Lett. 2001;302(1):13–6.

    Article  Google Scholar 

  13. Guo X, Lin Z, Lyu Y, Bekrater-Bodmann R, Flor H, Tong S. The effect of prosthesis use on hand mental rotation after unilateral upper-limb amputation. IEEE Trans Neural Syst Rehabilitation Eng. 2017;25(11):2046–53.

    Article  Google Scholar 

  14. Karl A, Birbaumer N, Lutzenberger W, Cohen LG, Flor H. Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain. J Neurosci. 2001;21(10):3609–18.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Vaso A, Adahan H-M, Gjika A, Zahaj S, Zhurda T, Vyshka G, et al. Peripheral nervous system origin of phantom limb pain. Pain. 2014;155(7):1384–91.

    Article  PubMed  Google Scholar 

  16. Kuffler DP. Origins of phantom limb pain. Mol Neurobiol. 2018;55(1):60–9.

    Article  CAS  PubMed  Google Scholar 

  17. Wong CK, Wong CK. Limb laterality recognition score: a reliable clinical measure related to phantom limb pain. Pain Med. 2018;19(4):753–6.

    Article  PubMed  Google Scholar 

  18. Margarita Cadavid Puentes A, Castañeda Marin EM. Very early phantom limb pain following amputation of a lower extremity: case report. Colomb J Anesthesiol. 2013;41:236.

    Google Scholar 

  19. Reinersmann A, Haarmeyer GS, Blankenburg M, Frettlöh J, Krumova EK, Ocklenburg S, et al. Left is where the L is right. Significantly delayed reaction time in limb laterality recognition in both CRPS and phantom limb pain patients. Neurosci Lett. 2010;486(3):240–5.

    Article  CAS  PubMed  Google Scholar 

  20. Wong CK, Wong CK. Limb laterality recognition score: a reliable clinical measure related to phantom limb pain. Pain Med. 2017.

    Article  Google Scholar 

  21. Hall N, Eldabe S. Phantom limb pain: a review of pharmacological management. Br J Pain. 2018;12(4):202–7.

    Article  PubMed  Google Scholar 

  22. Turan Z, Topaloğlu M, Özyemişçi-Taşkıran Ö. What is the effectiveness and adverse event data of transcutaneous electrical nerve stimulation (TENS) in reducing pain in adults with chronic pain? An overview of Cochrane Reviews summary with commentary. Turkish J Phys Med Rehabil. 2020;66(2):210–3.

    Article  Google Scholar 

  23. Mulvey MR, Radford HE, Fawkner HJ, Hirst L, Neumann V, Johnson MI. Transcutaneous electrical nerve stimulation for phantom pain and stump pain in adult amputees. Pain Pract. 2013;13(4):289–96.

    Article  Google Scholar 

  24. Giuffrida O, Simpson L, Halligan PW. Contralateral stimulation, using TENS, of phantom limb pain: two confirmatory cases. Pain Med. 2010;11(1):133–41.

    Article  PubMed  Google Scholar 

  25. Tilak M, Isaac SA, Fletcher J, Vasanthan LT, Subbaiah RS, Babu A, et al. Mirror therapy and transcutaneous electrical nerve stimulation for management of phantom limb pain in amputees—a single blinded randomized controlled trial. Physiother Res Int. 2016;21(2):109–15.

    Article  PubMed  Google Scholar 

  26. Vance CG, Dailey DL, Rakel BA, Sluka KA. Using TENS for pain control: the state of the evidence. Pain Manag. 2014;4(3):197–209.

    Article  PubMed  Google Scholar 

  27. Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain. 2005;114(1–2):29–36.

    Article  PubMed  Google Scholar 

  28. Cleeland C, Ryan K. Pain assessment: global use of the brief pain inventory. Ann Acad Med Singap; 1994.

    Google Scholar 

  29. Chan BL, Witt R, Charrow AP, Magee A, Howard R, Pasquina PF, et al. Mirror therapy for phantom limb pain. N Engl J Med. 2007;357(21):2206–7.

    Article  CAS  PubMed  Google Scholar 

  30. Moseley GL. Graded motor imagery for pathologic pain: a randomized controlled trial. Neurology. 2006;67(12):2129–34.

    Article  PubMed  Google Scholar 

  31. Barbin J, Seetha V, Casillas JM, Paysant J, Perennou D. The effects of mirror therapy on pain and motor control of phantom limb in amputees: a systematic review. Ann Phys Rehabil Med. 2016;59(4):270–5.

    Article  CAS  PubMed  Google Scholar 

  32. Bowering KJ, O’Connell NE, Tabor A, Catley MJ, Leake HB, Moseley GL, et al. The effects of graded motor imagery and its components on chronic pain: a systematic review and meta-analysis. J Pain. 2013;14(1):3–13.

    Article  PubMed  Google Scholar 

  33. Thieme H, Morkisch N, Rietz C, Dohle C, Borgetto B. The efficacy of movement representation techniques for treatment of limb pain—a systematic review and meta-analysis. J Pain. 2016;17(2):167–80.

    Article  PubMed  Google Scholar 

  34. Flor H, Elbert T. Phantom-limb pain as a perceptual correlate of cortical reorganization following arm amputation. Nature. 1995;375(6531):482.

    Article  CAS  PubMed  Google Scholar 

  35. Parsons LM. Imagined spatial transformation of one’s body. J Exp Psychol Gen. 1987;116(2):172.

    Article  CAS  PubMed  Google Scholar 

  36. Parsons LM, Fox PT. The neural basis of implicit movements used in recognising hand shape. Cogn Neuropsychol. 1998;15:583–616.

    Google Scholar 

  37. Moseley GL. Imagined movements cause pain and swelling in a patient with complex regional pain syndrome. Neurology. 2004;62(9):1644.

    Article  PubMed  Google Scholar 

  38. Makin TR, Scholz J, Filippini N, Henderson Slater D, Tracey I, Johansen-Berg H. Phantom pain is associated with preserved structure and function in the former hand area. Nat Commun. 2013;4:1570.

    Article  PubMed  Google Scholar 

  39. McCormick Z, Chang-Chien G, Marshall B, Huang M, Harden RN. Phantom limb pain: a systematic neuroanatomical-based review of pharmacologic treatment. Pain Med. 2014;15(2):292–305.

    Article  PubMed  Google Scholar 

  40. Flor H, Nikolajsen L, Jensen TS. Phantom limb pain: a case of maladaptive CNS plasticity? Nat Rev Neurosci. 2006;7(11):873.

    Article  CAS  PubMed  Google Scholar 

  41. Rokugo T, Takeuchi T, Ito H. A histochemical study of substance P in the rat spinal cord: effect of transcutaneous electrical nerve stimulation. J Nippon Med Sch. 2002;69(5):428–33.

    Article  CAS  PubMed  Google Scholar 

  42. Palmer ST, Martin DJ, Steedman WM, Ravey J. Effects of electric stimulation on C and A delta fiber-mediated thermal perception thresholds. Arch Phys Med Rehabil. 2004;85(1):119–28.

    Article  PubMed  Google Scholar 

  43. Hu X, Trevelyan E, Yang G, Lee MS, Lorenc A, Liu J, et al. The effectiveness of acupuncture/TENS for phantom limb syndrome. I: A systematic review of controlled clinical trials. Eur J Integr Med. 2014;6(3):355–64.

    Article  Google Scholar 

  44. Johnson MI, Mulvey MR, Bagnall AM. Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults. Cochrane Database Syst Rev. 2015;8(8):7264.

    Google Scholar 

Download references


The author thanks the patient for participating in this case study.


The author received no funding for this study.

Author information

Authors and Affiliations



KL conceptualized the study, analyzed data, and drafted the manuscript. The author read and approved the final manuscript.

Corresponding author

Correspondence to Katleho Limakatso.

Ethics declarations

Ethics approval and consent to participate

Ethics approval is not required for this type of study. A written consent to participate in this study was obtained from the patient.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The author declares no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Limakatso, K. Managing acute phantom limb pain with transcutaneous electrical nerve stimulation: a case report. J Med Case Reports 17, 209 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: