Phantom Leg Pain and Mirror Therapy

Author: Anna Rose Diel, PharmD Candidate

Phantom limb pain (PLP) is a sensation of discomfort or perceived pain stemming from a part of the body that is no longer there. This sensitivity is most commonly experienced post-amputation, although the pathophysiology is not well understood. Differentiating PLP from other clinical conditions is critical before determining the treatment options available for patients (1).

Phantom Limb Pain vs. Residual Limb Pain

PLP presents as a perceived pain with significant variability in the severity of symptoms. Residual limb pain (RLP), previously known as “stump pain”, presents as a pain from the actual amputated location.  As the wound continues to heal in the early post-amputation period, RLP subsides. Nerve entrapment, neuroma formation, surgical trauma, ischemia, skin breakdown, or infection may serve as the origin source of RLP (1). Although PLP and RLP are technically separate conditions, patients may experience PLP and RLP concurrently.

Pathophysiology Speculations

PLP pathophysiology is not clearly outlined, though the complexity and variability indicate a wide range of mechanisms are involved. Below are some hypothesized mechanisms, though this list is not all-inclusive (1).

Peripheral Nerve Changes:
Afferent and efferent signals involved with the amputated limb are disrupted during the surgery, and this can cause interference with the nerves and nearby tissues. Neuromas, benign but painful swellings of nerve tissue, can form where the nerves were severed and become hyperexcitable with an increase in sodium channel density, generating ectopic discharges (1). Neuromas are a disorganized mass of nerve fibers that have low mechanical and chemical thresholds for stimulation. The axon within the soma accounts for the abnormal behavior as the axon tries to reengage the connection lost from the amputation.  It is the locally upregulated sodium channels along these axons that are correlated with more frequent pain expression (4).

Spinal Cord Changes:
Central sensitization occurs when nerves become hypersensitive as a result of increased neural activity and augmentation of neuronal receptive fields.  This happens because an increase in N-methyl-D-aspartate (NMDA) in the dorsal horn of the spinal cord increases the susceptibility of substance P, tachykinins, and neurokinins to activation, which also increases the number of receptors in that region, all amplifying pain signals. Descending inhibitory fibers lose their target sites when spinal cord neural components are restructured.  This theory suggests that an increase in nociceptive signals, combined with decreased inhibitory activity in supraspinal centers, contributes to PLP (1).

Brain Changes:
Areas of the cortex that once represented the now amputated limb are filled in with neighboring regions in the primary somatosensory and motor cortex. Changes in the brain’s cortical map interpret why stimulating nerves in the remaining limb and nearby regions can create painful sensations from the amputated site. The amount of reorganization is theorized to be proportional to the amount of pain the patient experiences (1).

Psychogenic Factors:
PLP can progress to chronic pain, and by managing the patients’ behaviors and psyche, triggers such as depression and stress can be addressed. There is a strong association between chronic pain and the patient’s psychological outlook. 

What does PLP feel like?

An amputated limb produces tingling, throbbing, sharp, and pins/needles sensations that greatly impact the patient’s quality of life.  Pain severity varies widely and presents intermittently. 

While there are many options for treatment of PLP, such as medications, physical treatment, nerve blocking, surgical treatment, and neuromodulation (2), we will discuss mirror therapy.

Mirror therapy allows a patient to see and feel an imaginary movement of the amputated limb and behave as though the limb is still attached by means of a mirror. Because visual feedback and unconscious body sensations can become disconnected, viewing the normal limb in a mirror gives the brain a chance to reorganize and integrate movement signals that are missing when the mirror is absent (3). Mirror therapy has been shown to be more clinically effective than the use of other treatments.  This is because mirror neurons, specialized cells in the mirror neuron system, replicate others’ actions as if the observer were performing them. This means that a patient with PLP can perceive the same sense of their non-amputated limb by observing the mirror image. Pain is expected to decrease by addressing the motor intention, unconscious sensations, and the visual experience to provide relief for the patient.  Its ease of use in the outpatient setting, as well as effective outcomes, has helped this treatment gain traction and is becoming widely used for PLP treatment (3).

Author Bio:

References:

1. Hanyu-Deutmeyer AA, Cascella M, Varacallo M. Phantom limb pain. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2026. Updated August 4, 2023. Accessed May 5, 2026. https://www.ncbi.nlm.nih.gov/books/NBK448188/
2. Kim SY, Kim YY. Mirror therapy for phantom limb pain. Korean Journal of Pain. 2012;25(4):272-274. doi:10.3344/kjp.2012.25.4.272
3. Rajmohan V, Mohandas E. Mirror neuron system. Indian Journal of Psychiatry. 2007;49(1):66-69. doi:10.4103/0019-5545.31522
4. Boomgaardt J, Frijlink DW, Geertzen JHB, et al. An algorithm approach to phantom limb pain. Journal of Pain Research. 2022;15:3481-3494. doi:10.2147/JPR.S389510

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