Mirror Therapy performed prior to amputation may prevent Phantom Limb Pain from developing

A study in the February 2010 issue of Anesthesia & Analgesia, official journal of the International Anesthesia Research Society (IARS), describes the successful use of mirror therapy by Dr. Steven R. Hanling and colleagues of Naval Medical Center, San Diego, to prevent phantom pains in soldiers with severe leg injuries requiring amputation. 

"Although it may sound like 'hocus pocus,' this is one of many recent reports about the use of mirror therapy in veterans with injured limbs," comments Dr. Steven L. Shafer of Columbia University, Editor-in-Chief of Anesthesia & Analgesia.

Phantom limb pains are a common and difficult problem after amputations—even though the injured limb is removed, the pain continues. "The pain pathways in the spinal cord and brain 'remember' the painful injury," says Dr. Shafer. "Because of this memory, the missing arm or leg continues to ache, sometimes severely so, long after the limb itself has been amputated."

Dr. Hanling and colleagues used mirror therapy in an attempt to prevent phantom pain in four soldiers requiring leg amputation because of combat injuries. In each case, amputation was necessary after extensive efforts to save the leg.

Before amputation surgery, the patients performed several sessions of mirror therapy. "In this form of therapy, patients sit with a mirror placed vertically between the legs and arms so that they are reflected in it," Dr. Shafer explains. The reflection in the mirror makes it look like the injured arm or leg is healthy and normal.

"Patients then observe and control their injured arm or leg in the mirror—but they are actually observing and controlling the reflected uninjured arm or leg," says Dr. Shafer. "The brain and spinal cord are visually tricked into believing that all of the arms and legs are intact and without pain."

None of the four soldiers had major problems with phantom pain after amputation. Any episodes of phantom limb pain were brief and mild. Importantly, all patients were able to fully participate in their postoperative physical therapy program.

Mirror therapy appears to re-program the brain's pain circuits into thinking that the painful injury is no longer present, according to Dr. Shafer. "Removing the source of the pain may not let the brain forget this memory, but by controlling, seeing, and reacting to a healthy limb, the brain can be tricked into believing the limb has healed, reducing the risk of phantom limb pain when the injured limb is eventually amputated."

Previous studies have reported the use of mirror therapy in patients with phantom pain that does not respond to other treatments. Although more research is needed, the new results suggest that mirror therapy performed before amputation may prevent disabling phantom limb pain from developing in the first place.

Read the full study in Anesthesia & Analgesia

End The Pain Project Ventures Into Vietnam

Friday, December 18, marks the beginning of End The Pain Project activity in Vietnam.  Co-Founder, Moira-Judith Mann arrives on that date to bring information about Mirror Therapy for amputees suffering Phantom Limb Pain to several Vietnamese organizations serving amputees in various capacities. First stop -Hanoi.  Mid-January, she will visit Phnom Penh, Cambodia to establish connections.

Mann will present the ETPP ToolKit; a newly developed unbreakable mirror system prototype and portable PrismGlasses, recently invented by Dr. Jonathan Bannister and Dr. Glyn Walsh of Scotland and marketed by Scottish Health Innovations Ltd., all as non-invasive interventions to reduce or end Phantom Limb Pain.

OHSU Clinical Trial: Home-based Self-delivered Mirror Therapy for Phantom Limb Pain

Beth D. Darnall, PhD, a psychologist at Oregon Health & Science University is conducting a pilot study of self-delivered home-based Mirror Therapy for Phantom Limb Pain.  The clinical trial started January 2009 and will continue through December 2010, and is currently recruiting participants.

In The Oregonian, December 2, 2009 article,  participant Gail Hillyer describes experiencing phantom limb pain soon after surgeons removed most of her right leg, a delayed consequence of damage caused by radiation therapy she underwent for bone cancer as a child.

"It was like someone taking my leg and shoving it on a bed of coals and holding it there," Hillyer says. Pain medications have helped minimize the pain, but she still experiences joint aches, shooting pains, itching and muscle cramps from the leg that is no longer there.

Hillyer decided to volunteer in a clinical trial at Oregon Health & Science University testing a treatment called Mirror Therapy. The technique is simple: She holds a mirror vertically alongside her left leg so that it hides the missing right leg, and what she sees is an image of two intact legs. She spends 25 minutes a day moving the intact limb in the mirror, exposing her brain to views of a functioning, pain-free limb.

The first time she sat down with the mirror, Hillyer experienced startling sensations from her phantom leg.

"When I pointed my toe, I felt a distinct sensation that my other heel was dragging across the bed covers," she says. While rotating her left foot in circles, her big toe accidentally touched the mirror. But instead of feeling cool glass, "it felt as if my two toes were touching," she says. "At some level, I know that didn't happen, but I would vouch for that sensation as being real."

In the OHSU trial, Darnall hopes to show that amputees can use mirror therapy to treat themselves at home without the expense and inconvenience of having to visit a therapist for each session.

How it works remains "a great mystery," says University of Oregon neuroscientist Scott Frey. His group used functional MRI to scan brain activity in people with amputations as they viewed mirror images that appeared to restore the missing limb.

"When you give this visual feedback with the mirror, you tend to see a boost in activity in the brain that would have been used in moving the hand that the person no longer has," Frey says.

Targeted Muscle Reinnervation

Excerpted from The New York Times article, 2/11/09, New Artificial Arm Listens to the Brain.

Man controlled robotic hand with thoughts

AP reported from Rome on December 2, that a group of European scientists say they have successfully connected a robotic hand to a man who had lost an arm, allowing him to feel sensations in the artificial hand and control it with his thoughts.

The experiment lasted a month. Scientists say it was the first time an amputee has been able to make complex movements using his mind to control a biomechanic hand connected to his nervous system.
The Italian-led team said at a news conference Wednesday in Rome that last year they implanted electrodes into the arm of the patient, who had lost his left hand and forearm in a car accident.

The electrodes were removed after a month, during which the man learned to wiggle the robotic fingers and make other movements.

Virtual massage could relieve phantom limb pain for amputees

The Daily Mail of London, England, reported that amputees who experience phantom limb pain could find relief in a surprisingly simple way - by watching someone else rub their hands together.

The treatment seems to fool the brain that it is their missing hand being massaged, according to the American researchers, who worked with combat veterans. Phantom limbs occur when an amputee feels the often painful sensation of touch arising from a limb that is no longer present.

Lead researcher Vilayanur Ramachandran from the Centre for Brain and Cognition at the University of California, used newly discovered properties of mirror neurons to soothe the ache. Mirror neurons fire when a person performs an intentional action - such as waving - and also when they observe someone else performing the same action. They are thought to help us predict the intentions of others by creating a "virtual reality" simulation of the action in our minds.

"You also find cells like this for touch," says Ramachandran. "They fire when you touch yourself and when you watch someone else being touched in the same location."

Ramachandran and his colleague and wife Diane Rogers-Ramachandran used a "mirror box" - a tool that creates the visual illusion of two hands for people who actually only have one. By placing an amputee's arms either side of a mirror - with the missing limb on the non-reflective side, the amputee sees the reflection of their normal hand superimposed on the location of their missing hand.

Two amputees watched their normal hand being prodded, and both felt the remarkable sensation of "being prodded" in their missing hand. In another experiment, when the amputees watched a volunteer's hand being stroked, they too began to experience a stroking sensation arising from their missing limb.
The amputees "felt" the actions of others because their missing limb provided no feedback to partially inhibit their mirror neurons, no longer telling them that they were not "literally" being touched, says Ramachandran.

One woman reported that watching a volunteer rubbing her hand caused the cramping sensation within the phantom limb to cease for 10 to 15 minutes. "If you do it often enough perhaps this pain will go away for good," suggests Ramachandran. "If an amputee experiences pain in their missing limb, they could watch a friend or partner rub their hand to get rid of it."

Massaging the skin helps relieve a painful sensation by restoring blood flow and activating sensory fibres, which inhibit pain messages to the brain. By watching another person rubbing their hand, these amputees are apparently tapping into this latter mechanism, says Ramachandran.

"If performed early enough, this type of therapy may also be used to help stroke patients regain movements by watching others perform their lost actions," he concluded.

New Study Shows Amputees Can Mentally Move Missing Limbs In Impossible Ways

Excerpted from the Science News article: An experiment explores the connections between brain and body By Stephen Ornes, Web edition : Thursday, November 19th, 2009

“Phantom” pain is like a ghost in the body — but it’s anything but imaginary. People who have had an arm or leg amputated can often still feel sensations of the missing limb, even though it’s no longer there. These sensations can be painful, and scientists are always looking for new ways to help relieve this phantom pain for amputees. Treatment often involves using mirrors to visually trick the person’s brain. The thinking is that, if a person can “see” his own body in a new way, his brain may stop sending pain messages.
In a new study, a team of neuroscientists have made another surprising discovery about amputees: They can be taught to mentally move their missing limbs in ways that are impossible in the real, physical world. It’s impossible for a person to bend his wrist down and then twist his hand around in a full circle.
Seven people who had had their arms amputated above the elbow participated in the experiment. After extensive mental training, four of the seven were able to feel the sensation of this impossible act, and describe it in detail.
“It is very surprising that anybody — amputees or not — can learn impossible movements just by thinking about it,” Henrik Ehrsson of the Karolinska Institutet in Stockholm, told Science News. Ehrsson is a neuroscientist, which is a scientist who studies the brain and nervous system.