Open Journal of Orthopedics, 2013, 3, 300-305
Published Online November 2013 (http://www.scirp.org/journal/ojo)
Open Access OJO
Phantom Fighters: Coping Mechanisms of Amputee
Patients with Phantom Limb Pain: A Longitudinal Study
Daniella Margalit1,2*, Eyal Heled3, Corinne Berger4, Hod Katzir5
1Department of Orthopedic Rehabilitation, Sheba Medical Center, Ramat Gan, Israel; 2Department of Psychology, Ariel University,
Ariel, Israel; 3The Day Care Rehabilitation Unit, Sheba Medical Center, Ramat Gan, Israel; 4Pain Rehabilitation Department, Sheba
Medical Center, Ramat Gan, Israel; 5Department of Psychology, Bar-Ilan University, Ramat Gan, Israel.
Received October 8th, 2013; revised November 7th, 2013; accepted November 12th, 2013
Copyright © 2013 Daniella Margalit et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Phantom Limb Pain (PLP) is a phenomenon commonly observed in orthopedic rehabilitation units that can have detri-
mental effects on patients’ functioning. Psychological aspects of PLP have been widely investigated showing that some
coping mechanisms are advantageous at certain points but not at others. However, the mechanisms related to positive
adjustment to PLP during the course of rehabilitation have not been adequately examined. The aim of the study was to
investigate the relationship between PLP and coping mechanism at two points during the rehabilitation process. Thirty
one orthopedic inpatients, who had undergone lower-limb amputation following diabetic complications, rated their pain
levels and mental coping strategies. The Ways of Coping Checklist, Life Orientation Test, and the McGill Pain Ques-
tionnaire, 1 - 15 days post-surgery and six months post-surgery were used for evaluation. Denial was found to be nega-
tively correlated with PLP shortly after amputation. In contrast, optimism was found to be negatively correlated with
PLP six months after the surgery. Emotion-focused coping mechanisms were found to be positively correlated with PLP.
It is concluded that denial during the early stages of recuperation and optimism at later stages of rehabilitation is associ-
ated with reduced PLP. Awareness of these mental processes by both medical staff and family members may enable
acceptance of these processes and thus facilitate patients’ rehabilitation.
Keywords: Phantom Limb Pain; Mental Coping Mechanisms; Denial; Optimism
Phantom Limb Pain (PLP) refers to painful sensations in
an amputated or denervated part of the body . These
painful sensations are reported by 50% - 85% of limb
amputees beginning a short period after the procedure,
with the reported episodes ranging from a minimum of
several weeks per year to daily occurrences [2-4].
PLP is a challenge to caregivers and researchers in
multi-disciplinary fields, and is sometimes detrimental to
the sufferers. The occurrence of PLP can substantially
disrupt the rehabilitation process, and can have serious
consequences for the health and functioning of the pa-
tient . These consequences might be physical, emo-
tional or functional [5-12].
The perception of the etiology of PLP has changed
substantially over time. Initially, PLP was perceived as
primarily psychological, however later, physiological
explanations were proposed to explain the source of the
phenomenon [12,13]. Current views maintain that an
integrative bio-psycho-social approach is mandatory in
order to better understand PLP .
Research on psychological factors related to PLP ad-
justment revealed positive correlations between pain and
various psychiatric disorders, such as: depression, anxi-
ety, stress, post-traumatic stress disorder, which may
increase pain sensation. Cognitions have also been stud-
ied and catastrophizing was associated with pain. How-
ever, perceived control was found to be negatively cor-
related with pain sensations [4,11,15-21].
Various coping mechanisms help amputee patients
deal with pain . Moreover, coping styles were found
to be important predictors of psychosocial adjustment.
For example, the psychosocial functioning of adults with
acquired limb amputations was shown to be significantly
Phantom Fighters: Coping Mechanisms of Amputee Patients with Phantom Limb Pain: A Longitudinal Study 301
related to the use of coping strategies . Folkman and
Lazarus  identified two main coping mechanisms:
emotion-focused coping and problem-focused coping.
According to this model, coping refers to the cognitive,
emotional, and behavioral efforts aimed at keeping a
balance between the person and the environment. Coping
has two main functions: to regulate distress (emotion-
focused coping) and to take actions to change and im-
prove the situation (problem-focused coping). Problem-
focused coping is related to a special form of emotion-
focused coping, namely, “emphasizing the positive”
which facilitates problem-focused coping . Studies
have shown emotion-focused coping to be associated
with poor psychosocial outcomes [25-27].
Optimism (defined as a generalized expectation that
future outcomes will be positive) was also found to be
correlated with coping in patients with amputation
[28,29]. Dunn  showed that having an optimistic
disposition was associated with lower levels of depres-
sion and higher levels of self-esteem during the rehabili-
tation process after lower-limb amputation. Horgan and
MacLachlan  demonstrated that respondents with
high levels of optimism were more likely to search for
positive meanings for their amputations. Furthermore,
additional research showed a correlation between opti-
mism and good rehabilitation outcomes [32,33].
A broadly acknowledged coping mechanism specifi-
cally found to be a common defense mechanism in the
etiology of PLP is denial, that is, the refusal to believe
that the stressor exists or the attempt to act as though the
stressor is not real . People who experience the loss
of a limb have been shown to go through the five stages
of grief also experienced by people who are dying: denial,
anger, bargaining, depression, and acceptance [8,35].
Research shows that denial of the implications of an
amputation (as a type of emotion-focused coping) is a
positive short-term coping style following amputation
. However, in the long term, denial is associated with
higher levels of depression and hostility and poor ad-
While coping mechanisms and psychosocial adjust-
ment in amputees have been studied, little is known
about the psychological processes associated with PLP
reduction during rehabilitation of lower-limb loss. Elabo-
rating on the psychological aspects of this phenomenon
may add an additional perspective to caregivers’ under-
standing of coping with PLP.
Therefore, the aim of this study was to examine the
correlation between coping mechanisms adopted by pa-
tients and PLP at two different points in time, following
lower-limb amputation: a few days after the procedure,
and six months later: a point in time when stump pain
should have been resolved and when PLP would be
deemed to be chronic , indicating a different stage in
coping with pain.
We hypothesize that the coping mechanisms for pain
management that are more prevalent a few days after sur-
gery (such as denial and other emotion-focused strategies)
would be negatively correlated with pain sensations .
However, these same coping mechanisms would be posi-
tively correlated with PLP six months later.
2.1. Ethics Statement
All participants received written and oral instructions of
the research aims and procedures and gave informed
written consent. This study was approved by the local
ethic committee of Sheba Medical Center and Bar-Ilan
University and performed in accordance with the De-
claration of Helsinki.
The study sample consisted of 31 lower-limb amputee
patients suffering from diabetes (28 men and 3 women)
who were hospitalized in the orthopedic department of
the Sheba Medical Center. All patients with reported PLP
(as opposed to those reported as having stump pain or
phantom sensations), as detailed in their medical records
were enrolled in the study. No patients approached were
subsequently excluded from the study. Of the partici-
pants, 21 were below-knee amputees, 4 were above-the-
knee amputees, and 6 were foot amputees. The selection
criteria for the group were as follows: 1. Patients who
suffered from diabetes and had above- or below-knee
amputation surgery; 2. Patients who experienced phan-
tom limb pain; 3. Patients for whom a maximum of fif-
teen days had elapsed since the operation; and 4. Patients
with no chronic pain complaints other than those associ-
ated with the amputation.
The use of drugs, including painkillers, major and mi-
nor tranquilizers, and muscle relaxants was prevalent,
with 71% of the patients reporting drug use. Table 1
provides a demographic breakdown of the sample.
Table 1. Demographic and clinical data of the patients (n =
Maximum Minimum Mean (SD)
Age (years) 55 (7.12) 75 45
Education (years) 11.34 (3.12) 17 5
Time since amputation
(days) 9.29 (3.23) 15 4
Present Pain Intensity
At present 1.64 (0.52) 5 1
Minimum level 1.29 (0.52) 3 1
Maximum level 4.03 (1.01) 5 2
Open Access OJO
Phantom Fighters: Coping Mechanisms of Amputee Patients with Phantom Limb Pain: A Longitudinal Study
The Ways of Coping Checklist (WOCC) is a measure
that operationalizes and quantifies coping capabilities
. This checklist was administered in its translated and
validated Hebrew version [39,40]. The instrument is a
42-item measure, utilizing a 5-point scale format, with
responses ranging from 0 (not appropriate) to 4 (regu-
larly used). The scores of the WOCC are produced by
calculating the means of the responses.
The questionnaire consists of four subscales: a prob-
lem-focused coping strategy (PF; e.g., “I planned a
course of action and followed it”), an emotion-focused
coping strategy (EF; e.g., “I wish I had the ability to
change the way I feel”), a seeking-social-support coping
strategy (SSS; e.g., “I accept sympathy and understand-
ing from others”), and denial (e.g., “I tried to forget the
whole thing”) . A high score on a specific subscale
indicates greater use of the coping strategy measured by
the subscale. The internal reliability of the WOCC was
tested using Cronbach’s alpha coefficient; the coefficient
confirmed satisfactory internal reliability of the subscales
(PF = 0.88, EF = 0.82, SSS = 0.86, denial = 0.74).
The Life Orientation Test (LOT) measures generalized
optimism ; that is, it tests individuals’ sense of the
probability that hopeful expectations will indeed materi-
alize. The Hebrew version of the questionnaire was ad-
ministered to the patients . The LOT scale is com-
prised of twelve items: four positive items (e.g., “I am
always optimistic about the future”), four negative items
(e.g., “Things never work out the way I want them to”),
and four distracters (e.g., “I find it important to keep
busy”). The LOT is rated on a 4-point scale ranging from
1 (I agree very much) to 4 (I disagree very much). A high
score on this scale indicates a high level of optimism.
The McGill Pain Questionnaire (MPQ), compiled by
Melzack , was used in its validated Hebrew transla-
tion form [43-45]. The MPQ assesses qualitative com-
ponents of pain and differentiates among different as-
pects of pain. Although the scale is made up of four parts,
we made use of the Present Pain Intensity (PPI) scale,
which consists of six items, rated from 1 (mild) to 5 (ex-
cruciating). When presented with this questionnaire, re-
spondents were asked to rate how well a statement
matches their PLP sensation at present, at its minimum
level, at its maximum level, and when experiencing other
types of pain (toothache, headache, and stomachache).
We used the values of the three initial items.
Personal data on the patients were obtained from their
medical records. Patients who met inclusion criteria were
approached in their room a few days after the amputation
procedure. The researcher introduced himself and ex-
plained the research and its goals while emphasizing the
two-stage procedure. If the patient agreed to proceed, he
or she was given the informed consent form and, after
signing, was asked to complete the questionnaire. Six
months later, the patients were contacted via telephone
and the questionnaires were re-administered.
2.5. Analytic Strategy
All analyses were conducted using SPSS (SPSS-15 Inc.,
Chicago, Illinois). One-way analysis of variance (ANOVA)
was used to compare WOCC indices of patients in the
hospitalization stage, followed by Tukey post-hoc test. In
order to test the correlation between the mental variables
and Present Pain Intensity in both time periods, Pearson
correlation coefficient was employed. Significance was
set at α < 0.05.
Comparison of WOCC indices in the hospitalization
phase, revealed a significant difference between the dif-
ferent indices shortly after the amputation procedure
(F(3,28) = 91.69, p < 0.001). Tukey post hoc test re-
vealed that denial of life-long implications of the surgery
was the most commonly employed coping mechanism,
whereas seeking social support was the least common
(see Table 2 for the data).
Table 3 presents correlation coefficients between op-
timism and coping abilities, and Present Pain Intensity at
the first administration and at the second phase of the
study. That is, the scores on the same questionnaires re-
Table 2. Means (standard deviations) and ranges of the
WOCC (n = 31).
Variable Mean (SD) Minimum Maximum
Problem-focused 2.59 (0.57) 1.5 3.7
Emotion-focused 2.57 (0.55) 1.4 3.5
Seeking social support2.52 (0.64) 1.3 3.7
Denial 2.65 (0.79) 1.2 4
Table 3. Pearson correlations between scores on the WOCC,
LOT, and PPI indices of recently amputated respondents
Level At present
Optimism −0.02 −0.06 −0.19 −0.44*
Problem-focused0 −0.05 0 0.01
Emotion-focused0.01 −0.02 0.23 0.45*
support 0.22 0.09 0.2 0.03
Denial −0.31* −0.25 0.17 0.33
*p < 0.05.
Open Access OJO
Phantom Fighters: Coping Mechanisms of Amputee Patients with Phantom Limb Pain: A Longitudinal Study 303
administered six months after amputation.
The current study examined the mental coping mecha-
nisms that are associated with PLP at two points in time.
In the first stage, a few days post-amputation, the most
employed defense mechanism reported by PLP patients,
was denial, whereas seeking social support was the least
employed. In addition, we found denial to be negatively
correlated with PLP a few days after the operation, while
six months after surgery, optimism was found to be nega-
tively correlated with PLP. Finally, a positive correlation
was found between emotion-focused mechanisms and
PLP at six months post surgery, showing that this mecha-
nism is associated with PLP a considerable period of
time following the surgical intervention.
Our results complement findings by Pucher et al. 
who concluded that patients’ coping strategies affect
their experience of pain, denial, in particular, was found
to be associated with less reported pain in the initial
phase of trauma following surgery [36,37]. By disre-
garding the implications of the disability, denial may
enable other mental resources to surface in order to cope
with the physical aspects of the amputation. Hence, de-
nial aids in focusing on regaining bodily capabilities .
The correlation between denial and lower pain levels
demonstrates the tendencies of patients post lower limb
amputation to “favor” this self focused coping mecha-
nism over the interpersonal coping mechanism “seeking
Furthermore, studies have shown that consistent use of
emotion-focused coping mechanisms is associated with
depression in lower limb amputation patients, while for
example, denial, long after the surgery might also even-
tually result in high levels of depression and hostility
[47,36]. Our results add to this, by showing that use of
emotion-focused coping mechanisms in general, six
months after surgery is correlated with higher phantom
limb pain sensation, indicating that this strategy is nega-
tively associated with some aspects of rehabilitation.
On the other hand, it appears that adopting an optimis-
tic view six months post amputation is associated with
low levels of PLP. Optimism may instill meaning in the
amputation, providing one with a greater sense of control
over the event, as well as over the resulting disability
This study has several limitations. Although there are
numerous coping mechanisms and emotional constructs
that most likely influence coping with PLP, we chose to
explore a number of specific ones. Had we included ad-
ditional constructs, we may have obtained a broader and
clearer picture of the factors associated with this phe-
nomenon. In addition, our sample included patients with
lower-limb amputations at various sites, constituting a
diverse population. More homogenous samples in terms
of the physical location of the amputation may aid in
further clarifying interactions between coping mecha-
nisms and PLP.
Furthermore, future studies should examine other as-
pects associated with lower-limb PLP to expand our
grasp of this phenomenon, and should focus on patients
who have undergone upper-limb amputation as well. The
work presented here focuses on the psychological do-
main in relation to pain prediction. However, in light of
the need for a comprehensive perspective, future re-
searchers should study the interaction of physical, social,
and psychological variables together on long-term post-
In conclusion, from a psychological standpoint, those
who deny the consequences of the amputation shortly
after it has occurred may suffer less from PLP. Moreover,
optimism is also associated with lower PLP six months
after surgery, whereas emotion-focused coping mecha-
nisms are associated with higher levels of PLP. In con-
sequence, it seems that the relation between PLP and
coping mechanisms indicates the six months post-am-
putation as a relevant time frame for rehabilitation which
patients and caregivers of which caregivers should be
The implications of this study lie in the importance of
understanding the underlying mental processes experi-
enced by patients shortly and six months after surgery.
Caregivers such as physicians, rehabilitative therapists,
and family members can be educated regarding these
mental processes and the emotional manifestations they
should expect to see in patients following amputation.
They can then be directed to be accepting of coping me-
chanisms positively associated with rehabilitation such as
denial of disability in early stages of rehabilitation, al-
lowing patients to utilize this coping mechanism at that
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