Post-Amputation Pain Presentations: Considering Biological Sex

Samantha J. Stauffer MSOP, FAAOP
J. Megan Sions PT, DPT, PhD

Evidence Table ● References ● Full Download

Clinical Question

Do pain presentations differ between male and female adults with lower-limb loss?

Background

Following lower-limb loss (LLL), up to 95% of adults experience persistent, bothersome pain that impacts mobility and quality-of-life.¹ In comparison, only about 20% of the general population experiences chronic pain.² Prior research in the general population has identified sex-specific differences in pain sensitivity and pain processing, which predispose female adults to chronic pain.³ The purpose of this CAT is to evaluate the current literature identifying sex-specific differences in post-amputation pain presentations, including amputation-site pain (i.e., phantom limb, residual limb) and remote-site pain (e.g., low back, contralateral limb).

Search Strategy

Synthesis of Results

Six articles were identified and reviewed that evaluated sex-specific differences in post-amputation pain prevalence.^4-9 Samples were approximately 30-40% female, which is consistent with prior findings that males are at higher risk of LLL. Beisheim et al.⁶ conducted a cross-sectional study of post-amputation pain distribution, finding female individuals were more likely to report pain in the residual limb, low back, and contralateral hip and knee; female sex was also associated with 2.4x increased odds of multi-site pain. Mioton et al.⁷ also conducted a survey study, reporting female sex elevated risk of residual limb pain. Some observational cross-sectional⁷ and longitudinal⁵ studies have found greater prevalence of phantom-limb pain among female participants,^5,7 but this was not ubiquitous as Beisheim et al.⁶ reported no between-sex differences in phantom-limb pain prevalence, and Hirsch et al.⁴ reported no significant between-sex differences in phantom or residual-limb pain presence or severity after controlling for cause of amputation. However, Hirsch et al.⁴ found females reported significantly greater overall pain intensity. Beisheim-Ryan et al.⁸ cross-sectionally evaluated pain-pressure sensitivity and found female participants had greater sensitivity in the amputated region and at remote sites, which may help to explain elevated reporting of post-amputation pain among females. Liston et al.⁹ reported inconsistent findings, stating male individuals were at higher risk of developing neuropathic pain (i.e., phantom-limb pain, neuroma, neuralgia) post-LLL, despite the adjusted odds ratio indicating a 14% reduction in risk (see Evidence Table). While all studies evaluated post-amputation pain presentations, none reported on participant medication use, which may have affected pain reporting.

Clinical Message

Current literature largely suggests that females are at greater risk of developing post-amputation pain, including residual-limb pain and remote-site pain. There are conflicting reports related to the risk of phantom-limb pain based on sex. Existing post-amputation evidence suggests that pain processing may differ between sexes, as evidenced by lower pain-pressure thresholds and greater overall pain intensity among female adults. Additional research is necessary to determine the underlying pathophysiologic mechanisms that elevate risk in females, so that targeted post-amputation pain interventions may be implemented. Based on current evidence, clinicians should consider early evaluation and referral to manage post-amputation pain among female clients undergoing LLL.