More than half of persons with lower limb amputation suffer from chronic back pain or residual limb pain: a systematic review with meta-analysis

Figures & data

Figure 1. Flowchart showing the inclusion process.

Table 1. Study and patient characteristics.

Author, publication year	Study design	Patient recruitment	Source of pain data	Reason for amputation (%)							♂/♀	Age Mean (range)	Years (range) since amputation	Amputation level	Level of functioning
				Trauma	Vascular	Diabetes	Infection	Tumor	Congenital	Other/ unknown
Burke et al., 1978 [37]	CS	PO	Q,PE,RA	81			12	7			38/4	48.4	24.6	1 HD 19 AK 22 BK	100% prosthesis use
Kramer et al., 1979 [38]	CS	H	FI,PE,RA	100							111/–	56.4	31.5 (27–36)	111 TF	98% prosthesis use
Hoaglund et al., 1983 (trauma) [39]^a	CS	PO,H	Q,TI,PE	74	23			2			132/–	47	20.7 (1–39)	38 AK 74 BK 1 KD 2 Syme 17 BL	Prosthesis use: 86% all day, 11% 5–8 h Walking distance: 3% none, 5% only in home, 45% 1–6 blocks, 23% >6 blocks, 24% unlimited Devices: 61% none, 28% one cane, 5% two canes, 5% wheelchair. 12% assistance in ADL 72% employed. 11% unemployed due to amputation
Hoaglund et al., 1983 (vascular) [39]^a											42/–	60	2.3 (1–21)	1 HD 8 AK 21 BK 1 Syme 11 BL	Prosthesis use: 51% all day, 24% 5–8 h Walking distance: 10% none, 21% only in home, 55% 1–6 blocks, 10% >6 blocks, 5% unlimited Devices: 25% none, 39% cane, 19% 2 canes, 17% wheelchair. 38% assistance in ADL 26% employed. 21% unemployed due to amputation
Friberg, 1984 [8]	CS	RC	Q,PE,RA	100							113/–	65.1 (54–80)		29 AK 84 BK	100% prosthesis use TF 41% highly physical active TT 51% highly physical active
Jensen et al., 1984 [40]	P,CO	H	FI,PE		88		2	9			29/29	69.8 (24–91)		23 AK 1 KD 32 BK 2 UPL	71% prosthesis use at latest examination
Pohjolainen, 1991 [31]	R,CO	PO	FI,PE	9.7	81		0.6	6.5		1.9	124	62.8 (14–87)^b		46 AK 78 BK	100% prosthesis use
McCartney et al., 1999 [32]	R,CO	DB	Q							100	24/16			12 AK 28 BK	93% prosthesis use 40% received home help services, 23% additional nursing support, 13% both
Smith et al., 1999 [41]	CS	H	Q	66.6	40.7^c	40.7^c	40.7^c	1.1	33.3		79/13	(22–81)	18.0, SD 17.2 (1–53)	23 TF 3 KD 58 TT 8 Syme	100% prosthesis use 37% employed
Ehde et al., 2000 [5,6]^d^,^e	R,CS	H	Q	57.2	17.4	8.5	20.9	6.0	2.0	37.3	165/36	56.0, SD 14.0	15.4, SD 16.0	65 TF 12 KD 115 TT 3 Syme 6 HD	83% prosthesis use: average 13.2 h/day, SD 4.1 31% employed. 29% unemployed due to disability, 3% due to pain
Dillingham et al., 2001 [42]	CS	H	TI	100							68/10	32.9, SD 10.6	7.5, SD 2.8	16 TF 13 KD 40 TT 2 F 7 BL	95% prosthesis use. Average prosthesis use 80.5 h/week, SD 32.9 19% used a cane; 13% crutches; 12% wheelchair all or mostly
Gallagher et al., 2001 [43]	CS	PO	Q	49				23.1	6.7	19.3	78/26	45.3, SD 18.9	8.3, SD 9.9	44 AK 54 BK 6 BL	Average prosthesis use 12.9 h/day, SD 3.88
Hagberg and Branemark, 2001 [44]	CS	PF,RC	Q	55				35		10	60/37	48 (20–69)	22 (2–52)	97 TF	95% prosthesis use: 67% >13 h/day, 22% 7–12 h/day, 11% not daily Walking aids outdoor: 60% none, 27% 1 crutch/stick, 10% 2 crutches/sticks Walking habits outdoor last 3 months > several days/week: 85% 50 m, 63% 200 m, 35% 500 m, 14% 2 km 63% employed. 22% full sickness benefit
Stam et al., 2004 [45]	CS	PF	Q	55	15.8			16.2			161/79		–^f	240 TF	100% prosthesis use Activity level males: 13% low, 67% moderate, 19% high. Activity level females: 15% low, 60% moderate, 25% high
Ephraim et al., 2005 [4]	CS	DB,PF	TI	39.1	37.2^g	37.2^g		23.7			552/362	50.3, SD 13.3.	Median 4 (0–66)	352 AK 372 BK 88 BL	Prosthesis use: 20% none, 18% 1–8 h/day, 63% 9 h+/day
Friel et al., 2005 [46]	CS	PF,AD,PO	Q,PE	42						58	16/3	56.5, SD 14.3	11.8, SD 9.3	8 TF 11 TT	100% prosthesis use 5% limited mobility; 53% unrestricted community ambulation; 37% high mobility OSW mean 13.03, range 0–36
Kulkarni et al., 2005 [47]	CS	RC	Q,PE,RA	100							17 4/28	48 (20–62)	19 (2–40)	77 TF 115 TT 10 BL
Norvell et al., 2005 [11]	R,CO	H	TI	100							62/0	63.9, SD 11.9		18 TF 44 TT	100% prosthesis use
Kusljugic et al., 2006 [48]	CS	–	Q	70.2						29.8	37	46.2, SD 10.9		5 AK 27 BK 5 F	30% employed
Richardson et al., 2006 [35]	P,CO	H	FI		100						37/22	63.8, SD 10.4	0.5	29 AK 27 BK 1 BL AK 2 BL BK
Ebrahimzadeh and Rajabi, 2007 [24]	CS	DB	Q,FI,PE	100							27/–	At injury: 21.3 (16–54)	17.4 (15–22)	20 Syme 7 F	48% employed
Hanley et al., 2007 [25]	RCT	H	FI,TI	70	4	16	5			5	39/18	44.2, SD 12.6 (17–68)	2	8 TF 2 KD 42 TT 3 F 2 O
Smith et al., 2007 [49]	CS	PO,RC	Q, RA	42	21	13					88/19	51.1, SD 14.3 (16–83)	17, SD 14.6	2 HD 32 TF 4 KD 57 TT 2 Syme 10 BL	100% prosthesis use 42% employed; 31% unemployed, mostly due to disability
Raichle et al., 2008 [26]^,^e	CS	H, RC,AD	Q	58.6	20.4	11.5	22.8	5.2	2.7	31.5	431/161	54.7, SD 14.7	14.9, SD 15.7	3 HEP 17 HD 193 TF 28 KD 343 TT 8 Syme	84% prosthesis use 30% employed; 39% unemployed due to pain or disability
Desmond et al., 2008 [15]	CS	RC,PO	Q	35.2	18.0	15.7		3.4		27.3	62/27			30 AK 4 KD 55 BK
Behr et al., 2009 [13]	CS,CC	H,PO,AD	Q	74	41		12				35/7	55.1, SD 11.0	12.4, SD 14.9	14 TF 14 KD 14 TT	TF prosthesis use 87%: 8.9, SD 6.4 h/day KD prosthesis use 79%: 7.6, SD 6.2 h/day TT prosthesis use 100%: 13.0 SD 4.5 h/day 36% employed, 45% unemployed due to pain or disability
Ebrahimzadeh et al., 2009 [22,23]^h	CS	DB	Q,FI,PE	100							200/–^i	40.5	17.4	31 TF 96 TT	TF prosthesis use 83%: average 11.5 h/day. 61% employed TT prosthesis use 100%: average 11.5 h/day. 65% employed
Taghipour et al., 2009 [50]	CS	PO	FI	100							141/–	45.2, SD 6.5 (36–63)	21.6, SD 4 (20–27)	43 TF 38 KD 60 TT	100% prosthesis use 60% employed
Berke et al., 2010 [29]^,^j	CS	DB	Q,TI	100							473/8^k	45.4, SD 4.4^l		110 TF 203 TT 7 F	89% prosthesis use 1% not walking; 7% household walker; 16% community walker; 29% varying speed walker; 21% low impact activities; 15% high impact activities 67% employed
Hammarlund et al., 2011 [51]	CS	PO	Q	72				28			34/12	48 (19–79)	23 (3–58)	19 TF 9 KD 18 TT	100% prosthesis use TF prosthesis use: 100% everyday, 47% >15 h/day, 47% no walking aids KD prosthesis use: 89% everyday, 33% >15 h/day, 98% no walking aids TT prosthesis use: 94% everyday, 33% >15 h/day, 72% no walking aids
Sinha et al., 2011 [30]	CS	RC,PO	FI	63	22^m	22^m				15	530/75	43.7, SD15.0	9.9, SD 10.3	151 AK/KD 410 BK 14 O (HD/HEP/ F/A) 29 BL	AK/KD: 60% prosthesis use. Use of cane/crutches 41% Walking distance <500 m 33%. In total 48% employed BK: 68% prosthesis use. Use of cane/crutches 46% Walking distance <500 m 31%. In total 48% employed Other: 67% prosthesis use. Use of cane/crutches 60% Walking distance <500 m 13%. In total 48% employed BL: 69% prosthesis use. Use of cane/crutches 24% Walking distance <500 m 41%. In total 48% employed
Ashraf et al., 2012 [20,21]^,^n	CS	DB	Q	100							327/8	42		75 TF BL 126 TT BL 83 TF + TT 51 ≥ 1 from the knee BL	71.9% prosthesis use 28% dependent with transfers, 23% with bathing, 13% with toileting 30% employed, 70% unemployed or student
Devan et al., 2012 [52]^,^o	CS	DB	Q	100							120/25	56.8, SD 14.6	27.1, SD 16.1	145 TF	96% prosthesis use
Sprunger et al., 2012 [53]	CS	AD	Q	88.2						11.8	58/0	48.3 SD 14.3 (23–67)		22 TF + KD UL 26 TT UL and below 10 above TF + BL	100% prosthesis use. 14% prosthesis wear <4 h/day, 19% 4–6 h/day, 77% >6 h/day. 58% wheeled mobility devices usage besides prosthetic device, of those 62% daily TF + KD 14% walker, 18% crutches, 18% single cane, 5% canes TT 4% walker, 15% crutches, 23% single cane BL 20% walker, 10% crutches, 20% single cane
Akarsu et al., 2013 (UL) [54]^,^p	CS	RC	Q, PE	100							15/–	27.3 SD 6.6	9.06, SD 5.6	2 AK 13 BK	100% prosthesis use: 100% everyday, 87% all day, 13% 6–10 h/day 6MWT 524m
Akarsu et al., 2013 (BL) [54]^,^p	CS	RC	Q, PE	100							15/–	31.9 SD 8.4	7.3 SD 5.0	6 AK BL 4 BK BL 5 AK + BK	100% prosthesis use: 73% everyday, 7% often, 20% occasionally. 73% all day, 13% 6–10 h/day, 13% <1 h/day 6MWT 350m
Akyol et al., 2013 [28]	CS	RC	Q	100							30/–	31.3 SD 6.02	6.6 SD 0.5	1 HD 12 TF 6 KD 18 TT 2 F-A	LCI 34.6 SD 1.2
Ebrahimzadeh et al., 2013 [55]	CS	DB	Q,FI,PE	100							76/–	44.1, SD 7.0	26.6, SD 3.7	7 HEP 69 HD^q	68%^r prosthesis use 4% normal walking without aid, 11% abnormal walking without aid, 16% single crutch, 59% double crutch, 1% walker, 9% wheelchair. 54% active in sports
Richardson et al., 2015 [56]^,^s	CS	H	Q		100						19/5	63.7, SD 9.3	0.4, SD 0.5	17 BK 6 AK 2 BL
Buchheit et al., 2016 [57]^,^t	CS	RC	Q,PE	100							122/2	26.9, SD 6.8	0.7, SD 0.4	113 LOL 11 UPL	100% prosthesis use
George et al., 2016 [58]	R, CS	H	Q				1000				24/29	65.2, SD 10.7		53 AK UL	67% prosthesis use At last available follow up 47% non-ambulators, 28% household ambulators, 26% community ambulators
Morgan et al., 2016 [12]	CS	AD,PO,RC	Q	46.6	42.3					11.1	908/385	54.4, SD 13.7	12.2, SD 14.1	386 TF 704 TT 71 TF BL^u 135 TT BL^u	100% prosthesis use: mean 12.3 h/day, SD 4.1 33.1% on disability, 66.7% not on disability
Kelle et al., 2017 [59]^,^v	R, CS	H	FI	45	17	21	5	9		3	52/14	57.58, SD 15.9	0.5	2 HD 15 TF 8 KD 39 TT 2 Syme
Yasar et al., 2017 [60]^,^w	R	RC		100							398/1	23.4, SD 6.0	10.0, SD 5.7	1 HP 4 HD 49 TF 16 KD 223 TT 17 Syme	51.1% employed
Devan et al., 2017 [27]^,^o	CS	DB	Q								154/54	52, SD 9	21, SD 13	78 TF 130 TT	100% prosthesis use 64% employed
Esfandiari et al., 2018 [61]	CS	DB	Q,PE	100							587/0	43, SD 6.5	22, SD 4.0	29 HD 458 TF 94 KD 6 BL	76% prosthesis use 27% employed 51% active in sports
Larbig et al., 2019 [36]^,^x	P, CO	H	FI, Q		50	35	6	10			41/11	63.0
Luetmer et al., 2019 [33]	R, CO	DB	ICD	13	88			13			50/46	72.9		96 TF	25% prosthesis use
Welke et al., 2019 [34]	R, CO	DB	ICD									62.6		1569 TF	100% prosthesis use
Allami et al., 2019 [62]	CS	DB	FI, Q	100							245/2	52.4, SD 7.3	29.8, SD 6.2	247 BK	98% prosthesis use 44% use of walking aids 34% employed

A: ankle; AD: advertisement; AK: above knee; BK: below knee; BL: bilateral amputation; CC: case-by-case matching; CO: cohort study; CS: cross-sectional study; DB: database; F: foot; FI: face-to-face interview; H: hospital; HD: hip disarticulation; HEP: hemipelvectomy; ICD: International Classification of Diseases code; KD: knee disarticulation; LCI: locomotor capability index; LOL: lower limb; Mo: month(s); O: other; P: prospective; PE: physical examination; PF: patient(amputee) foundation; PO: prosthetic and orthotic clinic; Q: questionnaire; R: retrospective; RA: radiological assessment; RC: rehabilitation center; RCT: randomized clinical trial; T: toes; TF: transfemoral; TI: telephone interview; TT: transtibial; UL: unilateral; UPL: upper limb; 6MWT: 6-min walk test.

^a Data were divided between a traumatic and vascular cause of LLA.

^b Mean age of the original cohort. Out of the complete sample of 155 persons, 16 (10%) died during the first postoperative year.

^c Chronic diseases, including diabetes, ulcers, infections, and vascular disease, accounted for 40.7% of the amputations in this sample in total.

^d Data from the following studies were combined, due to use of the same dataset: Ehde et al. [5,6].

^e Additional data were provided by the author excluding foot, toes, and bilateral amputations.

^f Time since amputation: 0–10 years in 38% males and 29% females; 11–20 years in 19% males and 19% females; 21–30 years in 15% males and 23% females; >31 years in 25% males and 27% females.

^g Diabetes and vascular disease accounted for 37.2% of the amputations in this sample in total.

^h Data from the following studies were combined: Ebrahimzadeh et al. [22] and Ebrahimzadeh MH et al. Long-term outcomes of wartime transtibial amputations. Pain Pract. 2009;9:60.

ⁱ The total number also including other amputation levels at the lower limb, and persons with an upper limb amputation.

^j Additional data were substracted from the following study: Reiber GE et al. Service-members and veterans with major traumatic limb loss from Vietnam war and OIF/OEF conflicts: survey methods, participants, and summary findings. J Rehabil Res Dev. 2010;47(4):275–298.

^k Original number also including 70 persons with a unilateral upper limb amputation and 104 persons with multiple limb amputations.

^l Recalculated to fit the table: data from persons from the Vietnam and OIF/OEF war were combined.

^m Diabetes and vascular disease accounted for 22% of the amputations in this sample in total.

ⁿ Data from the following studies were combined, due to use of the same dataset: Ashraf et al. [21] and Rahimi et al. [20].

^o A proportion of the included persons might be represented in both included studies of Devan et al., published 2012 and 2017, respectively.

^p Data from this single study were divided in persons with a unilateral and bilateral amputation.

^q Fifty-one persons had had hip disarticulation, and 18 persons had had amputation through the intertrochanteric region (which was considered to be hip disarticulation). .

^r Sixty-eight percent routinely wear prostheses. Eleven percent never used any prostheses. Twenty-one percent abandoned prostheses.

^s Only data from the outpatient group were used in this study. In total, 92% unilateral persons with LLA; the percentage unilateral AK/BK was not specified, and therefore calculated using the available data.

^t Characteristics of the subjects having significant RLP only.

^u Highest level of amputation in either limb.

^v Data concerning patient groups 1 and 2 were combined and included, data concerning group 3 were excluded. Furthermore, only the RLP data 6 months post-amputation were included.

^w Only 366 amputation levels were reported. In total, 86.7% unilateral amputations, 13.0% bilateral amputations, and 0.3% three sided amputations were reported. Data concerning amputation levels were not specified according to unilateral or bilateral level. Percentages concerning amputation levels were used to estimate the proportion unilateral below knee versus above knee level of amputation. Furthermore, the data also included 50 Chopart amputations, 4 toe amputations, and 2 Pirogoff amputations.

^x Type of lower limb amputations not specified. Furthermore including 2 upper limb amputations. Finally, only the RLP data 12 months post-amp were included.

Table 2. Residual limb pain: prevalence, pain characteristics, and causes.

Author, publication year	RLP prevalence by amputation level						Pain frequency/intensity/impact/cause in total group
	All levels	AK	KD	BK	BL	Timeframe reported RLP
Hoaglund et al., 1983 (trauma)^b		42%^c		43%^c	53%^c		Frequency 100% frequent/always present^a Intensity AK: 37% moderate; 18% severe. BK: 34% moderate; 18% severe. BL: 29% moderate; 29% severe
Hoaglund et al., 1983 (vascular)^b		67%^c		55%^c	45%^c		Frequency 100% frequent/always present^a Intensity AK: 22% moderate; 22% severe. BK: 55% moderate; 5% severe. BL: 27% moderate; 27% severe
Jensen et al., 1984	21–22%^d					0	Cause 3% neuroma
Pohjolainen, 1991		2%		8%		0	Intensity 1 year post-amp: 43% moderate^a
McCartney et al., 1999	68%^e						Duration 23% at least daily RLP, 40% variable 45% low disability – low intensity, 24% low disability – high intensity, 7% high disability – moderately/severely limiting^a^,^f
Smith et al., 1999	76%					4 weeks	Frequency 40% more than half of the time in the preceding 4 weeks Intensity 25% moderate, 38% severe^a
Ehde et al., 2000^g	76%					3 months	Frequency past 4 weeks: 72% intermittent; 41% ≤1/week, 30% >4–6 times. Duration > several hours in 34%, few minutes in 32%^a Intensity mean pain scale 5.4, SD 2.7^a^,^h Average bothersomeness (0–10) 5.2, SD 2.9: 27% moderately, 33% severely^a
Dillingham et al., 2001	36%^i					4 weeks	Frequency 39% constant, 61% occasional^a Intensity 100% extremely/very bothersome^a
Gallagher et al., 2001	48%					1 weeks	Frequency 48% pain last week: 13% 1–2 times, 41% 2–5, 13% continuous^a Duration 27% seconds, 25% minutes, 9% 30 minutes, 18% hours^a Intensity 48% discomforting, 26% distressing, 9% horrible, 4% excruciating^a Interference caused: 17% moderate, 13% quite a bit, 9% a lot^a
Hagberg and Branemark, 2001		TF 36–51%^j				4 weeks	Intensity when not wearing prosthesis: 36% moderate or worse, 15% considerable or worse severity/reduction QoL While standing/walking 51% moderate or worse, 20% considerable or worse severity/reduction QoL 11% ≥1 day no prosthesis use due to RLP
Ephraim et al., 2005	66%					4 weeks	Intensity 30% severe^a^,^k Mean pain scale 5.1, SD 2.4^a^,^h Bothersomeness 60% somewhat, 27% extremely bothersome^a^,^k
Kulkarni et al., 2005	57%						Frequency 27% occasionally, 17% often, 13% constant Intensity 32% moderate, 13% severe, 12% extreme
Richardson et al., 2006	52%					0
Ebrahimzadeh et al., 2007				44%^l
Hanley et al., 2007	57–66%^m					1 week	Intensity 6 months post-amp 31% pain scale >3, mean 2.5 (SD 2.6)^h 12 months post-amp 31% pain scale >3, mean 2.5 (SD2.9)^h 24 months post-amp 27% pain scale >3, mean 2.1 (SD 2.4)^h
Smith et al., 2007	56%					3 months	Frequency 83% intermittent, 15% constant. Frequency weekly: 33% <1, 35% 2–3, 13% 4–6, 18% >6^a Duration: 39% minutes, 30% up to 1 h, 11% >1 h, 21% >1 day^a Intensity mean pain scale 5.7, SD 2.3^a^,^h Interference (0–10) with ADL 2.9, SD 3.2^a Interference (0–10) with social life 2.8, SD 3.1^a Interference (0–10) with ability to work 3.9, SD 6.9^a Cause 52% a prosthetic problem
Raichle et al., 2008^g	77%					3 months	Intensity mean pain scale past 3 months 4.7, SD 2.7^a^,^h Cause 42% a prosthetic problem
Desmond et al., 2008	56%					–/1 weeks^n	Frequency past week: 33% 1–2 episodes, 24% 3–4, 11% 5–6, 31% ≥7^a. Duration: 73% 1–2 h, 9% 3–4 h, 2% 5–6 h, 13% ≥7 h^a Average pain intensity past week: 16% mild, 49% discomforting, 11% distressing, 18% horrible, 4% excruciating^a Interference with normal lifestyle during past week: 27% not at all, 33% a little bit, 20% moderate, 11% quite a bit, 7% a lot^a
Behr et al., 2009		TF 86%	71%	TT 86%		0/3 months^o	Intensity TF mean pain scale 2.0, SD 2.5^a^,^h. KD mean pain scale 1.7, SD 1.6^a^,^h. TT mean pain scale 3.0, SD 2.8^a^,^h Interference with daily activities past 3 months (0–10): TF 3.0, SD 3.4^a; KD 2.4, SD 2.2^a; TT 4.7, SD 3.5^a
Ebrahimzadeh et al., 2009		TF 65%		TT 42%			Cause TT 30% neuroma, 20% bone overgrowth, 20% ulcers and/or scar hypersensitivity, 2.5% foreign bodies, 27.5 % unknown/idiopathic Cause TF 50% neuroma, 20% bone overgrowth, 10% ulcers and/or scar hypersensitivity, 25% unknown/idiopathic
Taghipour et al., 2009	92%
Berke et al., 2010^p	57%^p
Sinha et al., 2011	28%^q	26%^r	26%^r	29%	21%		Intensity SF-36 bodily pain 85.6 SD 27.2
Sprunger, et al., 2012	59%						Frequency 19% RLP 7 days/week. Duration: 54% ≤2 h Intensity 41% discomforting, 30% distressing, 5% horrible, 5% excruciating^a Interference with normal daily activities: 76% some interference^a
Akarsu et al., 2013 (UL)^s	33%						Intensity SF-36 bodily pain: 51.6, SD 29.3–62.7
Akarsu et al., 2013 (BL)^s					20%		Intensity SF-36 bodily pain: 42.2, SD 29.3–62.7
Akyol et al., 2013	87%^t						Intensity Mean pain scale 4.1, SD 2.9^h. NHP subgroup pain: 34.8 SD3.5
Richardson, et al., 2015^u	48%
Buchheit et al., 2016^v	61%^v					1 week	Intensity 100% significant pain, NRS ≥ 3^a Cause 49% sensitized neuroma, 20% CRPS, 41% somatic pain, 11% either neuroma or CRPS
Morgan et al., 2016	35%	33%		37%	33%	1 week	Intensity 100% somewhat,” “quite a bit,” or “very much” a problem^a
Kelle, et al., 2017^w	29%	52%		15%			Intensity AK: mean VAS 3.46, SD 1.4. BK: mean VAS 4.20, SD 1.3
Yasar et al., 2017^x	38%
Esfandiari et al., 2018	49%
Larbig et al., 2019^y	39%					0
Allami et al., 2019				73%		0	Intensity at present mean NRS 3.2, SD 3.4; at worst mean NRS 7.9, SD 2.4

ADL: activity of daily living; AK: above knee; BK: below knee; BL: bilateral; CRPS: complex regional pain syndrome; KD: knee disarticulation; NHP: Nottingham Health Profile; NRS: numeric rating scale; post-amp: postamputation; QoL: quality of life; RLP: residual limb pain; TF: transfemoral; TT: transtibial; UL: unilateral; VAS: visual analogue scale.

^a Containing data only from persons with pain, instead of the total patient group.

^b Data from this study were divided between persons with traumatic and vascular cause of LLA.

^c Data containing RLP frequent-always: data containing RLP seldom-never were left out.

^d Including data from 2 persons with upper limb amputation; RLP 22% 6 months post-amp, 21% 2 year post-amp. In the meta-analysis, the RLP percentage 2 year post-amp was included.

^e 67.5% RLP at some time following amputation (26% immediate onset, 30% within week-month, 44% after a month), 53% current RLP.

^f Including data from persons with phantom limb pain, and combined phantom limb pain and RLP.

^g Additional data were provided by the author excluding foot, toes, and bilateral amputations.

^h NRS or VAS used.

ⁱ Recalculated to fit the table: data containing constant and occasional RLP were combined. Including data from 2 persons with a foot amputation.

^j Thirty-six percent moderate or worse RLP when not wearing prosthesis, 51% moderate or worse RLP while standing/walking.

^k Including data from 100 persons with an upper limb amputation.

^l Persons with a Syme amputation, also including data from 7 persons with a foot amputation.

^m RLP 6 months post-amp 66%, 12 months post-amp 65%, and 24 months post-amp 57%. In the meta-analysis, the RLP percentage 24 months post-amp was included. Including data from 3 persons with a midfoot amputation and 2 persons with “other” amputation.

ⁿ No initial timeframe was given; when RLP was reported, pain frequency, intensity, and pain related interference during the last week were assessed.

^o Current pain was assessed; pain interference with daily activity was assessed over the past 3 months.

^p Recalculated to fit the table: data from the Vietnam and OIF/OEF war were combined.

^q Twenty percent RLP in 14 persons in “other” group(hip disarticulation, hemipelvectomy, foot amputation, or ankle amputation).

^r Data from AK and KD levels were presented as a single group in this study.

^s Data from this study were divided in persons with a unilateral and bilateral amputation.

^t Including data from 2 persons with a foot-ankle amputation.

^u Only data from the outpatient group were included in the study. In total, 92% persons with a unilateral amputation; percentage unilateral and bilateral AK/BK level was not specified.

^v Including data from 11 persons with an upper limb amputation. Concerning the cause of amputation: a selection of persons with significant RLP subtypes was made. Furthermore, somatic pain was not further specified in the study.

^w Data concerning groups 1 and 2 were combined and included, data concerning group 3 were excluded. Furthermore, only the RLP data 6 months post-amp were included.

^x Only 366 amputation levels were reported. In total, 86.7% unilateral amputations, 13.0% bilateral, and 0.3% three sided. Data concerning amputation levels were not specified according to unilateral or bilateral level. Percentages concerning amputation levels were used to estimate the proportion unilateral below knee versus above knee level of amputation. Pain data also including 50 Chopart amputations, 4 toe amputations, and 2 Pirogoff amputations.

^y Type of lower limb amputations not specified. Furthermore including 2 upper limb amputations. Finally, only the RLP data 12 months post-amp were included.

Table 3. Back pain: prevalence, pain characteristics, and causes.

Author, publication year	Back pain prevalence by amputation level						Pain frequency/intensity/impact/cause in total group
	All levels	AK	KD	BK	BL	Timeframe reported back pain
Burke et al., 1978	48%						Intensity 40% moderate or severe^a
Kramer et al., 1979		TF 70%					Impact 65% in medical treatment, 20% (partly) disabled
Hoaglund et al., 1983 (trauma)^b		58%		66%	54%
Hoaglund et al., 1983 (vascular)^b		25%		35%	11%
Friberg, 1984	95%						Frequency 23% occasional and mild; 30% frequent/constant and severe. 20% chronic unilateral sciatica Cause: leg length discrepancy >10 mm in 66%, >20 mm in 34% of persons, adequate length (<10 mm) in 12% TT, in 24% TF. When low back pain significantly greater leg length discrepancies than without pain
Smith et al., 1999	71%^c					4 weeks	Frequency 33% more than half of the time in the preceding 4 weeks. 9% pain free last 4 weeks Intensity 25% moderate, 39% severe^a Cause: 24% osteoarthritis after radiological investigation, 53% postural and gait abnormalities
Ehde et al., 2000^d^,^e	50%					3 months	Frequency 72% intermittent (47% ≤1/week, 58% ≥several hours), 26% constant^a Mean 49, SD 36.43 days BP in last 3 months^a Intensity mean pain scale 5.2, SD 2.3^f: 25% moderate, 31% severe^a Average bothersomeness (0–10): 4.9, SD 3.4: 21% moderate, 31% severe^a Interference in ADL: mean (0–10) 3.9, SD 2.9: 20% moderate, 22% severe^a Interference in social activities: mean (0–10) 3.8, SD 3.1: 16% moderate, 23% severe^a Interference in work/housework: mean (0–10) 4.0, SD 3.4: 15% moderate, 28% severe^a
Hagberg and Branemark, 2001		TF 47%				4 weeks	Intensity 47% moderate or worse severity/reduction in QoL, 24% considerable or worse
Stam et al., 2004		TF 76%^g					Frequency 50% occasional, 18% frequent, 9% permanent^g
Ephraim et al., 2005	64%					4 weeks	Bothersomeness: 69% somewhat, 24% extremely^a^,^h
Friel et al., 2005	79%					1 week/1 months^i	Intensity mean pain scale 3.04, range 0.63–6.90^f: 5% moderate and 15% severe levels of pain
Kulkarni et al., 2005	63%	TF 81%		TT 62%			Frequency 26% occasional, 27% often, 9% constant Intensity in total group: 23% moderate, 27% severe, 11% extreme BP interfered significantly with lifestyle in 38% of persons Cause: no differences in lumbar range of motion, leg length, BMI and MRI-findings, comparing back pain and pain free persons
Kusljugic et al., 2006	89%^j
Ebrahimzadeh et al., 2007				44%^k
Smith et al., 2007	48%					3 months	Frequency 84% intermittent, 16% constant. Frequency weekly: 33% <1, 33% 2–3 times, 15% 4–6 times, 17% >6 times^a Duration: 29% minutes, 31% up to 1 h, 26% >1 h, 14% >1 day^a Mean duration: 7.7 years (SD 6.7)^a Intensity mean pain scale 5.3(SD 2.1)^a^,^f Interference (0–10) with ADL 3.5, SD 3.2^a; with social life 3, SD 3.4^a; with ability to work 3.4, SD 3.1^a
Behr et al., 2009		TF 50%	50%	TT 29%		0/3 months^l	Intensity TF mean pain scale 3.3, SD 3.7^a^,^f. KD mean pain scale 2.9, SD 3.1^a^,^f. TT mean pain scale 3.0, SD 2.2^a^,^f Interference with ADL past 3 months (0–10) TF 4.3, SD 3.0^a; KD 2.9, SD 3.4^a; TT 4.3, SD 3.1^a
Ebrahimzadeh et al., 2009		TF 61%		TT 44%
Taghipour et al., 2009	77%
Berke et al., 2010^m	47%^m
Hammarlund et al., 2011	87%	TF 89%	78%	TT 89%			TT frequency: 44% occasional, 22% few times/month, 11% several times/week, 11% daily. KD frequency: 11% occasionally, 11% few times/month, 33% several times/week, 22% daily. TF frequency 37% occasionally, 16% few times/month, 26% several times/week, 11% daily Intensity SF-36 bodily pain TT 51.5 SD 17.3; KD 70.9 SD 27.8; TF 63.3 SD 24.5. RMDQ scores: 7% severe disability, 20% moderate disability, 59% no/some disability
Ashraf et al., 2012^n					VCP 61%	6 months	Frequency 67% one area, 28% two areas, 5% three areas. VCP locations: 53% lumbosacral, 10% thoracic, 18% neck^a Intensity all pain bothersome and frequent. 52% bothersome pain >3 times/week. SF-36 bodily pain lumbosacral 45.4, SD 24; thoracic 41.9, SD 19.8; neck 41.2 SD, 22.7
Devan et al., 2012		TF 64%				4 weeks	Frequency 21% every day, 33% on most days, 47% on some days^a Duration last pain-free month: 28% <3 months, 18% 3–7 months, 11% 7 months to 3 years, 39% >3 years^a Intensity 27% moderate, 14% severe^a 39% interference BP with ADL^a
Ebrahimzadeh et al., 2013		VCP 87%^o					Frequency 45% cervical spine pain, 32% thoracic, 72% lumbar, 17% sacral
Morgan et al., 2016	39%	40%		39%	35%	1 week	Intensity 100% “somewhat,” “quite a bit,” or “very much” a problem^a
Yasar et al., 2017^p	39%
Devan et al., 2017^q	63%					4 weeks	Frequency 46% on some days, 29% on most days, 25% everyday^a Intensity 35% mild, 35% moderate, 31% severe^a Bothersomeness 5% not at all, 65% slightly, 29% extremely^a
Esfandiari et al., 2018	69%
Luetmer et al., 2019		TF 34%
Welke et al., 2019		TF 43%
Allami et al., 2019				78%		3 months	Intensity at present mean NRS 3.4, SD 2.9; at worst mean NRS 7.5, SD 2.5

ADL: activity of daily living; AK: above knee; BK: below knee; BL: bilateral; BP: back pain; KD: knee disarticulation; NRS: numeric rating scale; Post-amp: post-amputation; QoL: quality of life; RMDQ: Roland Morris Disability Questionnaire; TF: transfemoral; TT: transtibial; VAS: visual analogue scale; VCP: vertebral column pain.

^a Containing data only from persons with pain, instead of the total patient group.

^b Data from this study were divided between persons with a traumatic and vascular cause of LLA.

^c Painful sensations in the back, which could include low, mid, and upper back pain.

^d Data from the following studies were combined, due to use of the same dataset: Ehde et al. [5,6].

^e Additional data were provided by the author excluding foot, toes and bilateral amputations.

^f NRS or VAS used.

^g Recalculated to fit the table: male and female data were combined.

^h Including data from 100 persons with an upper limb amputation.

ⁱ Back pain disability was calculated during the month preceding study participation.

^j Including data from 5 persons with a foot amputation.

^k Persons with a Syme amputation, also including data from 7 persons with a foot amputation.

^l Current pain was assessed; pain interference with daily activity was assessed over the past 3 months.

^m Recalculated to fit the table: data from the Vietnam and OIF/OEF war were combined.

ⁿ Data from the following studies were combined, due to use of the same dataset: Ashraf et al. [21] and Rahimi et al. [20].

^o Persons with a hemipelvectomy or hip disarticulation.

^p Only 366 amputation levels were reported. In total 86.7% unilateral amputations, 13.0% bilateral and 0.3% three sided. Data concerning amputation levels were not specified according to unilateral or bilateral level. Percentages concerning amputation levels were used to estimate the proportion unilateral below knee versus above knee level of amputation. Pain data also including 50 Chopart amputations, 4 toe amputations, and 2 Pirogoff amputations.

^q Additional data were provided by the author concerning back pain frequency and intensity.

Figure 2. Forest plot residual limb pain.

Table 4. Results of meta-regression to explore which study characteristics are associated with the logit of RLP and logit of back pain: random effects model.

Outcome Predictor	Coefficient (95% CI)	p Value
Logit RLP
BP total	3.43 (0.09–6.77)	0.0439
Time since amputation	0.04 (–0.05 to 0.12)	0.4419
Mean age	0.02 (–0.09 to 0.14)	0.6964
Male gender	2.33 (–1.21 to 5.87)	0.1974
Cause trauma	1.37 (–0.83 to 3.56)	0.2225
Prosthesis use	–0.29 (–7.16 to 6.58)	0.9348
Above knee amputation	–0.15 (–1.93 to 1.62)	0.8659
Below knee amputation	0.50 (–1.30 to 2.29)	0.5876
Bilateral amputation	–2.72 (–5.62 to 0.18)	0.0662
Study publication year	0.00 (–0.05 to 0.05)	0.9752
Logit BP
RLP total	2.06 (–0.00 to 4.12)	0.0502
Time since amputation	0.09 (0.05–0.13)	0.0000
Mean age	–0.03 (–0.11 to 0.05)	0.4543
Male gender	2.82 (0.82–4.83)	0.0058
Cause trauma	1.94 (0.95–2.93)	0.0001
Prosthesis use	–0.90 (–6.11 to 4.32)	0.7366
Above knee amputation	–0.01 (–1.45 to 1.44)	0.9934
Below knee amputation	0.15 (–0.61 to 0.91)	0.6978
Bilateral amputation	–4.25 (–9.30 to 0.80)	0.0988
Study publication year	0.02 (–0.03 to 0.07)	0.4152

BP: back pain; CI: confidence interval; Logit: natural logarithm of prevalence/(1 – prevalence); RLP: residual limb pain.

The significant and borderline significant values are highlighted in bold.

Figure 3. Forest plot back pain.

Figure 4. Bubble plot showing the association between back pain and time since amputation.

Burke MJ, Roman V, Wright V. Bone and joint changes in lower limb amputees. Ann Rheum Dis. 1978;37(3):252–254.

 PubMed Web of Science ®Google Scholar

Kramer J, Heisel JM, Ullrich CH. Late results of patients with amputation of the thigh (author’s transl). Z Orthop Ihre Grenzgeb. 1979;117(5):801–807.

 PubMed Web of Science ®Google Scholar

Hoaglund FT, Jergesen HE, Wilson L, et al. Evaluation of problems and needs of veteran lower-limb amputees in the San Francisco Bay Area during the period 1977–1980. J Rehabil Res Dev. 1983;20:57–71.

 Google Scholar

Friberg O. Biomechanical significance of the correct length of lower limb prostheses: a clinical and radiological study. Prosthet Orthot Int. 1984;8(3):124–129.

 PubMed Web of Science ®Google Scholar

Jensen TS, Krebs B, Nielsen J, et al. Immediate and long-term phantom limb pain in amputees: incidence, clinical characteristics and relationship to pre-amputation limb pain. Pain. 1985;21(3):267–278.

 PubMed Web of Science ®Google Scholar

Pohjolainen T. A clinical evaluation of stumps in lower limb amputees. Prosthet Orthot Int. 1991;15(3):178–184.

 PubMed Web of Science ®Google Scholar

McCartney CJL, Charles DHM, Cooper GG, et al. Pain and disability following lower limb amputation – a quantitative and qualitative study. Pain Clin. 1999;11(4):293–300.

 Google Scholar

Smith DG, Ehde DM, Legro MW, et al. Phantom limb, residual limb, and back pain after lower extremity amputations. Clin Orthop Relat Res. 1999;361:29–38.

 PubMed Web of Science ®Google Scholar

Ehde DM, Czerniecki JM, Smith DG, et al. Chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after lower limb amputation. Arch Phys Med Rehabil. 2000;81(8):1039–1044.

 PubMed Web of Science ®Google Scholar

Ehde DM, Smith DG, Czerniecki JM, et al. Back pain as a secondary disability in persons with lower limb amputations. Arch Phys Med Rehabil. 2001;82(6):731–734.

 PubMed Web of Science ®Google Scholar

Dillingham TR, Pezzin LE, MacKenzie EJ, et al. Use and satisfaction with prosthetic devices among persons with trauma-related amputations: a long-term outcome study. Am J Phys Med Rehabil. 2001;80(8):563–571.

 PubMed Web of Science ®Google Scholar

Gallagher P, Allen D, Maclachlan M. Phantom limb pain and residual limb pain following lower limb amputation: a descriptive analysis. Disabil Rehabil. 2001;23(12):522–530.

 PubMed Web of Science ®Google Scholar

Hagberg K, Branemark R. Consequences of non-vascular trans-femoral amputation: a survey of quality of life, prosthetic use and problems. Prosthet Orthot Int. 2001;25(3):186–194.

 PubMed Web of Science ®Google Scholar

Stam HJ, Dommisse AM, Bussmann HJ. Prevalence of low back pain after transfemoral amputation related to physical activity and other prosthesis-related parameters. Disabil Rehabil. 2004;26(13):794–797.

 PubMed Web of Science ®Google Scholar

Ephraim PL, Wegener ST, MacKenzie EJ, et al. Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. Arch Phys Med Rehabil. 2005;86(10):1910–1919.

 PubMed Web of Science ®Google Scholar

Friel K, Domholdt E, Smith DG. Physical and functional measures related to low back pain in individuals with lower-limb amputation: an exploratory pilot study. J Rehabil Res Dev. 2005;42(2):155–166.

 PubMedGoogle Scholar

Kulkarni J, Gaine WJ, Buckley JG, et al. Chronic low back pain in traumatic lower limb amputees. Clin Rehabil. 2005;19(1):81–86.

 PubMed Web of Science ®Google Scholar

Norvell DC, Czerniecki JM, Reiber GE, et al. The prevalence of knee pain and symptomatic knee osteoarthritis among veteran traumatic amputees and nonamputees. Arch Phys Med Rehabil. 2005;86(3):487–493.

 PubMed Web of Science ®Google Scholar

Kusljugic A, Kapidzic-Durakovic S, Kudumovic Z, et al. Chronic low back pain in individuals with lower-limb amputation. Bosn J Basic Med Sci. 2006;6:67–70.

 PubMedGoogle Scholar

Richardson C, Glenn S, Nurmikko T, et al. Incidence of phantom phenomena including phantom limb pain 6 months after major lower limb amputation in patients with peripheral vascular disease. Clin J Pain. 2006;22(4):353–358.

 PubMed Web of Science ®Google Scholar

Ebrahimzadeh MH, Rajabi MT. Long-term outcomes of patients undergoing war-related amputations of the foot and ankle. J Foot Ankle Surg. 2007;46(6):429–433.

 PubMedGoogle Scholar

Hanley MA, Jensen MP, Smith DG, et al. Preamputation pain and acute pain predict chronic pain after lower extremity amputation. J Pain. 2007;8(2):102–109.

 PubMed Web of Science ®Google Scholar

Smith E, Comiskey C, Ryall N. Prevalence and patterns of back pain and residual limb pain in lower limb amputees at the National Rehabilitation Hospital. Ir J Med Sci. 2008;177(1):53–57.

 PubMed Web of Science ®Google Scholar

Raichle KA, Hanley MA, Molton I, et al. Prosthesis use in persons with lower- and upper-limb amputation. J Rehabil Res Dev. 2008;45(7):961–972.

 PubMedGoogle Scholar

Desmond D, Gallagher P, Henderson-Slater D, et al. Pain and psychosocial adjustment to lower limb amputation amongst prosthesis users. Prosthet Orthot Int. 2008;32(2):244–252.

 PubMed Web of Science ®Google Scholar

Behr J, Friedly J, Molton I, et al. Pain and pain-related interference in adults with lower-limb amputation: comparison of knee-disarticulation, transtibial, and transfemoral surgical sites. J Rehabil Res Dev. 2009;46(7):963–972.

 PubMedGoogle Scholar

Ebrahimzadeh MH, Fattahi AS. Long-term clinical outcomes of Iranian veterans with unilateral transfemoral amputation. Disabil Rehabil. 2009;31(22):1873–1877.

 PubMed Web of Science ®Google Scholar

Ebrahimzadeh MH, Hariri S. Long-term outcomes of unilateral transtibial amputations. Mil Med. 2009;174(6):593–597.

 PubMed Web of Science ®Google Scholar

Taghipour H, Moharamzad Y, Mafi AR, et al. Quality of life among veterans with war-related unilateral lower extremity amputation: a long-term survey in a prosthesis center in Iran. J Orthop Trauma. 2009;23:525–530.

 PubMed Web of Science ®Google Scholar

Berke GM, Fergason J, Milani JR, et al. Comparison of satisfaction with current prosthetic care in veterans and servicemembers from Vietnam and OIF/OEF conflicts with major traumatic limb loss. J Rehabil Res Dev. 2010;47(4):361–371.

 PubMedGoogle Scholar

Hammarlund CS, Carlstrom M, Melchior R, et al. Prevalence of back pain, its effect on functional ability and health-related quality of life in lower limb amputees secondary to trauma or tumour: a comparison across three levels of amputation. Prosthet Orthot Int. 2011;35(1):97–105.

 PubMed Web of Science ®Google Scholar

Sinha R, van den Heuvel WJ, Arokiasamy P. Factors affecting quality of life in lower limb amputees. Prosthet Orthot Int. 2011;35(1):90–96.

 PubMed Web of Science ®Google Scholar

Rahimi A, Mousavi B, Soroush M, et al. Pain and health-related quality of life in war veterans with bilateral lower limb amputations. Trauma Mon. 2012;17(2):282–286.

 PubMedGoogle Scholar

Ashraf A, Shojaee H, Mousavi B, et al. Impact of pain in vertebral column on activities of daily living in the Iranian amputees with bilateral lower limb amputation. Disabil Rehabil. 2012;34(10):869–872.

 PubMed Web of Science ®Google Scholar

Devan H, Tumilty S, Smith C. Physical activity and lower-back pain in persons with traumatic transfemoral amputation: a national cross-sectional survey. J Rehabil Res Dev. 2012;49(10):1457–1466.

 PubMedGoogle Scholar

Sprunger NM, Laferrier JF, Collins DP, et al. Utilization of prostheses and mobility-related assistive technology among service members and veterans from Vietnam and Operation Iraqi Freedom/Operation Enduring Freedom. J Prosthet Orthot. 2012;24:144–152.

 Google Scholar

Akarsu S, Tekin L, Safaz I, et al. Quality of life and functionality after lower limb amputations: comparison between uni- vs. bilateral amputee patients. Prosthet Orthot Int. 2013;37(1):9–13.

 PubMed Web of Science ®Google Scholar

Akyol Y, Tander B, Goktepe AS, et al. Quality of life in patients with lower limb amputation: does it affect post-amputation pain, functional status, emotional status and perception of body image? J Musculoskelet Pain. 2013;21(4):334–340.

 Web of Science ®Google Scholar

Ebrahimzadeh MH, Kachooei AR, Soroush MR, et al. Long-term clinical outcomes of war-related hip disarticulation and transpelvic amputation. J Bone Joint Surg Am. 2013;95:e114.

 PubMedGoogle Scholar

Richardson C, Crawford K, Milnes K, et al. A clinical evaluation of postamputation phenomena including phantom limb pain after lower limb amputation in dysvascular patients. Pain Manag Nurs. 2015;16(4):561–569.

 PubMed Web of Science ®Google Scholar

Buchheit T, Van de Ven T, Hsia HL, et al. Pain phenotypes and associated clinical risk factors following traumatic amputation: results from Veterans Integrated Pain Evaluation Research (VIPER). Pain Med. 2016;17(1):149–161.

 PubMed Web of Science ®Google Scholar

George J, Newman JM, Caravella JW, et al. Predicting functional outcomes after above knee amputation for infected total knee arthroplasty. J Arthroplasty. 2017;32(2):532–536.

 PubMed Web of Science ®Google Scholar

Morgan SJ, Friedly JL, Amtmann D, et al. Cross-sectional assessment of factors related to pain intensity and pain interference in lower limb prosthesis users. Arch Phys Med Rehabil. 2017;98(1):105–113.

 PubMed Web of Science ®Google Scholar

Kelle B, Kozanoğlu E, Biçer ÖS, et al. Association between phantom limb complex and the level of amputation in lower limb amputee. Acta Orthop Traumatol Turc. 2017;51(2):142–145.

 PubMed Web of Science ®Google Scholar

Yaşar E, Tok F, Kesikburun S, et al. Epidemiologic data of trauma-related lower limb amputees: a single center 10-year experience. Injury. 2017;48(2):349–352.

 PubMed Web of Science ®Google Scholar

Devan H, Hendrick P, Hale L, et al. Exploring factors influencing low back pain in people with nondysvascular lower limb amputation: a national survey. Pm R. 2017;9(10):949–959.

 PubMedGoogle Scholar

Esfandiari E, Yavari A, Karimi A, et al. Long-term symptoms and function after war-related lower limb amputation: a national cross-sectional study. Acta Orthop Traumatol Turc. 2018;52(5):348–351.

 PubMed Web of Science ®Google Scholar

Larbig W, Andoh J, Huse E, et al. Pre- and postoperative predictors of phantom limb pain. Neurosci Lett. 2019;702:44–50.

 PubMed Web of Science ®Google Scholar

Luetmer M, Mundell B, Kremers HM, et al. Low back pain in adults with transfemoral amputation: a retrospective population-based study. Pm R. 2019;11(9):926–933.

 PubMedGoogle Scholar

Welke B, Jakubowitz E, Seehaus F, et al. The prevalence of osteoarthritis: higher risk after transfemoral amputation? A database analysis with 1,569 amputees and matched controls. PLoS One. 2019;14(1):e0210868.

 PubMed Web of Science ®Google Scholar

Allami M, Faraji E, Mohammadzadeh F, et al. Chronic musculoskeletal pain, phantom sensation, phantom and stump pain in veterans with unilateral below-knee amputation. Scand J Pain. 2019;19(4):779–787.

 Google Scholar

Data availability statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.