Amputation Adaptations

How Massage Therapy Can Help

By Ruth Werner
[Pathology Perspectives]

About one in every 155 Americans is missing some part of an extremity due to surgical removal. The chance of massage therapists having amputee clients is reasonably high, yet almost none of us get any training to prepare to work with this special population. Here, we will review some basic information about the situations that can lead to amputation, and what kinds of long-term consequences these surgeries can involve. We will also hear from several massage therapists who have generously shared their stories about some of their clients who are amputees.

Bodywork Story #1
Buddy was a Vietnam veteran and a double amputee. He came to our school clinic almost every week for nine years until he passed away. He volunteered for class as a demonstration model, and said it did wonders for his soul and self-esteem.
He encouraged people to pretend to massage the legs that were not there. He also had this horrible itching [perceived as coming from] his left big toe that he was unable to reach, of course. One day we were working, and he was suddenly startled and said, “Do that again.” I did. I was just working the stump. Seems that right behind his knee, it felt like I was touching his left big toe. He sat up and scratched the spot, and sighed happily.

Definition and Reasons
The definition of an amputation is fairly straightforward: some part of an extremity is surgically removed because it is too damaged to function, and not removing it could put the patient at risk for dangerous consequences.
Some people consider amputation to reflect a failure in treatment; after all, these surgeries only occur when other interventions could not save the damaged tissue. But in many cases, amputation can be considered a “successful failure”: the person with the amputation can live a healthy and fulfilling life, in spite of missing part of a limb.
In the United States, circulatory dysfunction is the cause of the vast majority of amputations. If the circulatory system cannot deliver adequate nutrients to cells, nor remove adequate wastes, then tissue degenerates and becomes vulnerable to infection with potentially life-threatening pathogens.
Diabetes mellitus, especially type 2 diabetes, is the leading cause of amputations in this country. While treatments for diabetes are more successful than in the past, the increasing number of patients causes the number of diabetes-related amputations to rise, while the numbers of amputations due to other causes are generally falling.
One exception to this trend is amputations among injured military personnel. These have risen significantly since 2007. This is a direct outcome of the wars in Afghanistan and Iraq, which have led to amputation surgeries for approximately 1,500 American servicepeople.

Long-Term Consequences of Amputation
Many postsurgical complications are common among amputees. Some, like bleeding, deep vein thrombosis, and pulmonary embolism, are outside the reach of massage therapy, but many other issues are within our scope.
As with many surgeries, postoperative pain is a major issue. The pain can be related to many sources, and the nature of the amputation procedure introduces some factors that raise the risk of long-term, sometimes practically intractable, problems.
Depression and anxiety frequently accompany amputation surgery. These conditions have also been seen to exacerbate pain sensation. Fortunately, the evidence on massage therapy for mood improvement is strong: this is a place where we can have a profound influence on a person’s quality of life. And if massage therapy can help manage depression and anxiety, it is possible then that a person with an amputation might have the capacity to invest more energy into self-care and well-being.
One major source of postsurgical pain is muscle spasms in the remaining part of the limb. Because these are triggered by external stimuli instead of central nervous system damage, massage therapy with stretching can be a useful intervention.
The joint nearest to the amputation may also be vulnerable to progressive muscle tightening, along with painful permanent contractures and thickening of tendons and ligaments.
As the patient begins to adapt to the new limitations, it is inevitable that compensatory patterns emerge in the rest of the body. This is self-evident for someone who has lost a foot or a portion of a leg, but losing part of an arm can change the gait and shift the center of gravity, leading to musculoskeletal pain. Even losing a toe or two alters how weight is transferred through the leg—consequent torque on the knee, twisting at the hip, and low-back pain that reverberates into headaches may result.
One of the most common sources of pain for amputation patients is poor wound healing at the site of the amputation scar, or irritation of that scar tissue from the use of a prosthetic. It is critical that the scar tissue on the stump be able to move with some freedom over the underlying tissues. Otherwise it is vulnerable to shearing injury, pressure sores, and other lesions that make using a prosthetic all but impossible.
Because peripheral nerves are among the traumatized tissue in these surgeries, the endoneurium around them may develop hypertrophy and grow into neuromas: clumps of connective tissue that compress and irritate nerves. A similar situation is seen in Morton’s neuroma (see “Morton’s Neuroma,” Massage & Bodywork, May/June 2009, page 110).
Finally, phantom limb sensation is the hallmark of post-amputation complications. This is a phenomenon that most amputees experience, even months or years after surgery. In this situation, the severed nerves of the amputated limb continue to transmit messages to the brain, which interprets them as coming from a part of the body that no longer exists. When those transmissions relay pain, it is often described as extreme burning, stabbing, twisting, or crushing pain. And of course because the source of the pain (the amputated limb) is no longer there, relief seems impossible.
Pain is not the only sensation that amputation patients “feel” in their missing limbs. Cold, heat, itching, and pressure changes may all be perceived through nerves that are no longer connected to the source of these sensations in a normal way. Amazingly, neuroplasticity allows us to build new connections in the central nervous system. Sometimes this can happen in very unexpected ways: in one case study, a neurologist was able to map in great detail the sensory stimulus for the missing arm and hand of a patient by tracing a pattern on the patient’s face. Her brain had remapped the source of sensation in such a way that touching her face allowed her to “scratch” the itch on her missing limb.

Treatment Options for Amputation Pain
Pain treatments in conventional medicine typically focus on pharmacologic interventions for these patients. Nonsteroidal anti-inflammatory drugs can reduce irritation at the nerve endings in the peripheral tissues, while opiates and anti-seizure drugs work on pain transmission and modulation within the central nervous system. All of these drugs carry significant risks of negative side effects, and many doctors and patients are invested in finding alternative methods to manage pain in the long term.
Follow-up surgeries are sometimes performed to correct neuromas or even to address pain centers within the brain, but these are seldom satisfactory in the long run. This leaves amputation patients with limited options, so many turn to complementary and alternative therapies for relief.

Bodywork Story #2
We had a gentleman come in to our school clinic who had his lower leg amputated. He spoke of phantom limb pain, and the student massaged the missing leg and foot as if it were still there—practicing the techniques she knew in the air of the missing limb. He swore that her massage gave him the most relief.

Massage Therapy for Amputation Patients
The pain-related complications discussed here fall well within the scope of practice for massage therapists. Indeed, our ability to identify specific soft-tissue injuries and address issues of anxiety and depression make massage therapy an excellent choice for many people with amputations.
Further, with good guidance from the client, a massage therapist can work directly on the amputated stump to help control edema, deal with neuromas, improve skin health, and loosen local scar tissue. Some specialists specifically recommend massage for recent surgeries:
“Massage is effective at many levels of pain—tissue level, cognitive level, and nerve level (pain gate). It increases sensory input from the residual limb, and may override the brain’s perception of pain. Early massage can help develop tolerance of the residual limb to touch
and pressure.”1
Many people, massage therapists and clients alike, marvel at how effective massage therapy can be to help deal with the nerve pain associated with amputation. Working directly on the stump to access irritated nerve endings makes physiological sense, but how is it that clients find relief when a massage therapist literally “goes through the motions” over the missing limb?
One explanation may be held in some specialized structures in the brain called mirror neurons. These help us process what we see (and consequently believe) into a perception of sensation. In some protocols, a person with one missing upper or lower limb puts the healthy limb into a specially designed mirror box so it looks as if there is a limb on the other side of the body. When the healthy limb is stimulated in a mirror box, the patient perceives touch to the missing limb. A whole field of mirror therapy has developed to help people with phantom sensation, but also for people with complex regional pain syndrome, stroke, trigeminal neuralgia, and other intractable pain problems. Conceivably, massage therapy could have application here, too; look for a future article on this topic.
The takeaway message is that massage therapy has a lot to offer clients who have had amputations. Story #3 is a great synopsis of what massage therapy can do:

Bodywork Story #3
I worked with a man whose arm had been torn off at the elbow in a log-rolling machine. We had two huge issues: severe nerve pain at the amputation site, and phantom nerve pain in the missing limb.
I found it very helpful to work on his arm as if it were intact. Using pillows, I made an “arm” and continued my long strokes as if the arm were there, while he watched. That helped dramatically with the phantom pain.
For the actual nerve pain associated with the amputation surgery, we found that light massage over the stump, although somewhat painful, was especially soothing. He felt that it calmed the nerves after a few minutes.
After he received a prosthetic, we had to spend a lot of time on the muscle soreness he developed from the use of the new device.
The client reported that in every way possible, massage helped him. He especially appreciated being touched by someone who did not find the amputation to be offensive. 

What do you need to know to work safely with this special population? Find out what led to the surgery: circulatory dysfunction, congenital problem, or trauma. Find out what drugs your clients are taking, especially pain management drugs. To gauge clients’ adaptability, you need to know their level of general activity, and whether they have experienced contractures, cramps, or other limitations at the affected limb. And most of all, you need to find out what your client’s highest priorities are for the time you spend together. Massage therapy is unique among healthcare options with its ability to decrease pain and promote a sense of well-being. Let’s use that capacity to improve the life of all our clients, especially those who are amputees.

1.    Tony Fitzsimons et al., “Physiotherapy Following Lower Limb Amputation: Protocols and Reference Material,” Sydney West Area Health Service, Western Cluster hospitals, physiotherapy departments. Accessed September 2014,

Ruth Werner is a former massage therapist, a writer, and an NCTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2013), now in its fifth edition, which is used in massage schools worldwide. Werner is available at or

Amputee Coalition. “Limb Loss Statistics.” 2014. Accessed September 2014.
Bloomquist, T. “Amputation and Phantom Limb Pain: A Pain Prevention Model.” AANA Journal 69, no. 3 (June, 2001). Accessed September 2014.
Brigham and Women’s Hospital Department of Rehabilitation Services. “Standard of Care: Lower Extremity Amputation.” 2011. Accessed September 2014.
Ertl, J. P., and J. H. Calhoun. “Amputations of the Lower Extremity.” WebMD, 2011. Accessed September 2014.
Foell, J. et al. “Mirror Therapy for Phantom Limb Pain: Brain Changes and the Role of Body Representation.” European Journal of Pain 18, no. 5 (May, 2014): 729–39. Accessed September 2014.
Kania, A. “Integration of Massage Therapy into Amputee Rehabilitation and Care.” inMotion 14, no. 4 (July/August, 2004). Accessed September 2014.
Ramachandran, V. S., and E. L. Altschuler. “The Use of Visual Feedback, in Particular Mirror Visual Feedback, in Restoring Brain Function.” Brain 132 (2009): 1,693–1,710. Accessed September 2014.
Sydney West Area Health Service, Western Cluster hospitals, physiotherapy departments. “Physiotherapy Following Lower Limb Amputation: Protocols and Reference Material.” 2006. Accessed September 2014.