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Warrior-Mentor
01-03-2008, 20:26
Baltimore Sun
January 2, 2008

Mirror Therapy Shown To Ease Pain
Mirror therapy eases ache of missing limb
By David Kohn, Sun reporter

On the morning of July 2, 2006, Sgt. Nick Paupore was driving the lead Humvee in a convoy near Kirkuk, in northern Iraq, when a roadside bomb blew off his right leg above the knee.

Within 48 hours, he was at Walter Reed Army Medical Center in Washington, where he has spent the past 18 months recovering. Soon after arriving, Paupore began to feel excruciating pain - in his missing leg.

"It felt like someone was shocking me, like someone was putting an electrode on the back of my ankle," says Paupore, 32.

He tried several painkillers, including methadone, but the pain didn't let up. Then a Navy neurologist, Dr. Jack W. Tsao, asked him to try a new approach that requires patients to move the intact limb while watching the action in a mirror.

Not surprisingly, Paupore was skeptical, and said no thanks.
He's not skeptical now.

Tsao eventually persuaded Paupore to try the therapy. After several weeks the shocks had almost disappeared.

"As soon as I started the treatment, I noticed a remarkable change," says Paupore, who has stopped taking painkillers. "I could see really big improvement, really fast."

No one quite understands how the therapy works, other than a suspicion that it reduces painful nerve impulses, probably in the brain.

Whatever it does, the treatment could revolutionize how doctors deal with phantom limb pain, as the problem is called. There are 2 million amputees in the United States, a number that has increased markedly in recent years with the rise in diabetes. More than 700 U.S. soldiers have lost limbs after being wounded in Iraq and Afghanistan.

Although there are no hard numbers, experts believe phantom limb pain afflicts from 10 percent to 50 percent of amputees. The ailment is often impervious to treatment. Many patients end up on drugs such as Oxycontin or Percocet; as powerful as the medicines are, they seldom work.

A few weeks ago, Tsao, 41, published his results in The New England Journal of Medicine. The study examined 18 veterans, all leg amputees suffering from phantom limb pain.

The soldiers were divided into three groups of six: One group received mirror treatment; another underwent treatment using a covered mirror, while the third didn't use a mirror, but visualized moving the amputated limb.

Those who used an uncovered mirror had significant pain relief. Few in the other groups got relief, and some actually got worse. When the covered-mirror and visualization patients tried the mirror, almost all improved.

"This is a beautifully designed study that shows, without a doubt, that patients are helped by the mirror," says Vilayanur Ramachandran, a neuroscientist at the University of California at San Diego, who invented mirror treatment 11 years ago.

Tsao's study is the first to test the mirror approach in such a rigorous way - a key step for establishing scientific proof.

"It amazes me that nobody ever did follow-up studies" on Ramachandran's work, says Tsao, an associate professor of neurology at the Uniformed Services University of the Health Sciences, the military's medical school in Bethesda. A key reason was the scarcity of amputees in any one place. But with a steady stream of injured veterans from the wars in Iraq and Afghanistan, Walter Reed had enough for a study, Tsao said.

Ramachandran says Tsao's research could increase the popularity of the treatment, which is not widely used.

"People are suffering needlessly because they're not getting this treatment," says Ramachandran. "Given how easy and inexpensive this is, it's worth trying."

Since the study appeared, Tsao has heard from doctors and therapists around the country interested in trying mirrors with their patients.

The technique is remarkably simple. The patient sits on a flat surface with his legs straight out. He puts a rectangular, 6-foot-long mirror lengthwise between his legs, with the reflective side facing the intact limb.

He then moves his good leg and watches the movement in the mirror. The reflection creates the illusion of two whole limbs moving in unison. As this is happening, the patient imagines moving the amputated leg in the same way as the uninjured one.

Patients go through this process for 15 minutes a day for a month, using a range of leg movements.

Sitting on an exercise bench in Walter Reed's rehabilitation center, Paupore says mirror therapy saved him.
"The pain wasn't something I could learn to live with," he says.
A gentle man with a crew cut, Paupore joined the Army in 2004 out of a sense of patriotism. Before enlisting, he worked in a wine and beer warehouse in Traverse City, Mich.; he hopes to find work as a civil servant for the federal government.

The mechanisms behind phantom limb pain remain mysterious. The problem could stem from a kind of cortical confusion. The brain has specific regions devoted to receiving sensory input from the body. In an uninjured person, this information - temperature, position in space, hardness and so on - flows steadily from nerve endings to cortex.

In amputees, the brain no longer receives information from the lost limb. But the receiving station still works, and without incoming data, it can go haywire.

"We think the brain cells may be firing off randomly," says Tsao. The result: The amputee feels burning, throbbing, spasms or any number of other unpleasant sensations in the absent limb. One of Tsao's patients describes feeling as if a spike were being driven continuously through his foot.

Many researchers, including Tsao, suspect that mirror therapy eases these sensations by creating the illusion of two whole limbs.

Although patients know that the mirror does not reflect reality, other parts of the brain are not so savvy. These sensory input regions accept the mirror's evidence: The amputated limb reappears, provides the brain with sensory data and stops the random firing.

Tsao's research provides more evidence for an increasingly popular idea, that pain, particularly the chronic sort, is more a problem of brain than body.

"The key is not what happens in the body part; it's what the brain perceives is going on," says Oxford University neuroscientist Lorimer Moseley, who studies how the brain senses pain. "Any pain that anyone experiences is because the brain has constructed it."

Moseley expresses some skepticism about Tsao's results and says that larger studies are needed. He noted that mirror therapy sometimes loses effectiveness when used over longer periods.

Scientists believe that mirror treatment might help with other pain conditions. Dr. Eric Altschuler, a researcher at the University of Medicine and Dentistry of New Jersey, has used mirror therapy to help stroke patients. It not only reduces pain, but can restore use of paralyzed limbs.

"Mirror therapy is potentially a tremendous paradigm shift in therapy for many different problems," says Altschuler.
Tsao is starting two more mirror studies. One will examine whether mirrors can help arm amputees, while the other will use MRI scans to find out what happens in the brains of phantom limb pain patients before, during and after mirror treatment.

But even this work will likely leave many questions unanswered.
"Anybody who says they understand the brain," says Altschuler, "is a liar, a fool or both."

The Reaper
01-03-2008, 20:39
Saw that earlier this week.

Proof that if it sounds stupid, but it works, it wasn't stupid.

Good news for amputees.

TR

LeapingGnome
01-04-2008, 00:24
Can anyone validate this for me:

I was taught that if you use a pair of hemostats/etc. to crush/crimp the major nerve endings while performing an amputation it helps reduce the chances of the pt. experiencing the phantom limb phenomenon...

I did a google search but either my kung fu is weak or there isn't anything out there pertaining to the topic.

Firewolf
01-04-2008, 17:47
When I lost my hand, the surgeons told me they crimped/crushed and cauterized the nerve endings to prevent phantom pain and neuroma(sp) development. My phantom pain is slight at best. 2 out of 10 usually.

Hope that helps. At BAMC it sounds like what you describe is SOP.

swatsurgeon
01-07-2008, 14:51
Not to rain on anyones parade, but to cauterize a nerve is asking for a neuroma to form as well as crush technique.
We cut the nerve while putting traction on it, first ligate it with suture then cut and let it retract.
For the past 8-12 months we have used Lyrica on our amputees and massive nerve injuries with excellent success.
Some of the other techniques do work as we have also seen.

ss

Red Flag 1
01-07-2008, 17:28
As I understand, amputaions done under regional anesthesia, ie. spinal, with narcotic ( fentanly) added to the block has had some sucess in reducing phantom limb pain.

LeapingGnome
01-08-2008, 11:33
SwatSurgeon,

In addition to ligating the nerve while using traction what are the other techniques you mentioned?

Thank you for the information concerning cauterization/crushing causing a neuroma. I have learned a lot from your other posts and appreciate your input.

I am coming at this topic from an 18D point of view so the majority of amputations/amputees I would see are indig.

-gnome

swatsurgeon
01-10-2008, 12:48
L.G.,
sharp transection with knife ??may?? be best technique (not proven) vs. cutting with scissors which makes for a more imprecise (not even) cut of the nerve. There has been talk of actual nerve sheath issues causing the problems with the nerve it envelops but again, no scientific proof of this but it does in my mind go back to an even sharp cut to transect a nerve gives the least probability of post op nerve pain. The cautery issue is that the electical power is not point specific but travels a few mm and damages the nerve, partially in some areas, more or less in others.
The analogy is that limb crush injuries that do not result in amputation have worse dysesthesias (nerve pain) than operative amputations, all comers so with that said, traumatizing a major nerve (crush, clamp, oblique cut, etc) likely leads to the neuroma formation and the increased chances for pain.
I had a guy a few yearsd ago with a traumatic amputation (I had posted pictures) that the 1st operation I did was damage control, control the bleeding, clean it and no definitive nerve work, he woke up with terrible pain and once I brought him back and took care of the nerve as I described, he has no pain.
No guarantees with this one, just alot of cases and some science to back it up....sorry.

ss

Doc Dutch
01-12-2008, 19:54
All,

I have to agree 100% with SwatSurgeon. His posts are very sound advice to all who need to perform an amputation. Never crush tissue. Sharp excisions. Neuroma development is a bad complication of this operation and we do everything we can to avoid it.

The goal is quite often to get the limb off as result of a trauma secondary to massive hemorrhage (life over limb) or to treat the infection that could consume the patient's life (sepsis due to pus or necrotizing fasciitis). Many times in the older diabetic patient or the patient that has had prolonged ischema to the foot (diminished blood flow) has also developed neural pathways, we believe , in the brain that must be overcome so that after amputation, the phantom pain is eliminated or diminished. This is why a spinal or epidural catheter that takes away the pain for hours to several days prior to an amputation can be important. The problem is that most traumatic amputations or massive forefoot / diabetic foot infection require an amputation emergently or urgently. If the pain has occurred for weeks to months, and the pain neural pathways have matured, the results is post-op phantom pain. For traumatic injuires, many times patients are dying so, we do what we need to do emergently (again, life over limb). Nerve blocks and epidurals are excellent modalities but if you are dying, we need to get you into the OR and asleep to get the work at hand completed.

Now, as for technique, use a scapel and sharply cut the nerve. Do not use a scissors. Suture ligation of the end of the nerve which is key prior to the cut. Make sure that the nerve retracts up into the muscle. You do not want a nerve below the level of the amputated bone as the nerve wil be crushed by the weight between the cut stump and the muscle when the prosthesis is eventually used. I add a mixture of 1/4 percent Marcaine with 2% lidocaine to the area around the cut nerve. I do not inject straight into the nerve, just the tissue around the cut end. Neuromas are the enemy which is why we ligate the end and sharply incise the nerve.

Think about an epidural, however, that is if the patient is stable, and not in severe ARDS so they can be up on their side to place an epidural, and not on anticioagulation such as heparin, low-molecular weight heaprin, asparin, plavix or coumadin in the immediate post-operative period. Most patients should not be on these medications or should have had their coags corrected with fresh frozen plasma pre-op. If in an ICu or even in a theater of war, lovenox subcutaneous may be started for DVT's if indicated, and if that occurs, I would not place an epidural as there is the risk of spinal cord hematoma and paralysis. Coagulation studies should be normal before an epidural is placed. Now, as an adjunct, I have found neurontin to be effective with many pain syndromes, especially post-operative pain in burns, trauma and in my vascular patients after amputations. This is also true for our phantom pain patients.

I am going to ask our Rehab physician what he uses in the prosthetic clinic for phantom pain. I will ask him on Monday and get back to all of you as this is an important topic and is often poorly understood and many physicians either do not know what to do or get angry when this happens and blame their patients (this is why the vascular surgeons, pain specialists, and rehab physicians are the best to discuss this as they see so much of it). However, it has been my experience that the best way to treat phantom pain is before it even starts and that is why epidurals for a few days pre-op can be beneficial for patients, to re-educate the brain and deny it the (painful) neural input it had been dealing with previously. However, for the soldier, sailor or marine in the field with a severely mangled extremity, this would not be possible For more information, I might recommend Rutherford's textbook in Vascular Surgery. The chapter on causalgia is quite good when I read it several years ago.

More to follow . . .

Dutch

LeapingGnome
01-20-2008, 16:17
Just getting back to this thread but I appreciate the input gentlemen. As opposed to other issues encountered by the 18D this is low on the probability scale as far as i understand but one of those loose ends I would like to tie up in my trauma education. As the primary provider for both indig and team guys I want to be able to put it in my mental Rolodex so when it comes up I can grab it and remember the lessons learned. For example, one of the key lessons i remember from amputations is that debridement and bone removal should be done as distal as possible to preserve the joints and tissue for follow on surgeries in order to preserve as many prosthetic options as possible.

I have read several anecdotal interviews concerning phantom nerve pain and anything an 18D can do initially to prevent this condition is important as Doc D said. Obviously there are life/limb priorities but in the process of addressing those priorities if technique can prevent future complications it is desirable. Especially when the difference is lack of knowledge. This is one of those areas where I do not want to be reaching for the bookshelf or the MAR07 issue of JAMA to learn the finer points.

Doc Dutch
01-21-2008, 22:29
All,

I apologize that this is late in getting back to you.

I meet with our Physical Medicine and Rehab Specialist who comes to our institution with many years of rehab experience (he runs his own prosthetic clinic as well). He wanted me to pass on the following information from an e-mail he sent me. He was very happy to be of help to America's finest and here is what he had to say. He included some background followed by the signs and symptoms, and some medications that may be of use, followed by some adjuncts. As this field is growing, things will change over time, so please check with your physician if you are having any such issues with phantom limb pain/sensations.


"Phantom limb sensation was first described by Pare in 1551. Weir Mitchell introduced the concept of phantom limb sensation from Civil War amputees.

Introduction

Neuropathic pain develops after tissue trauma from surgical procedures. After peripheral nerve injury, changes such as sprouting spontaneous activity in nerve endings, and peripheral sensitization occur. With the loss of somatosensory input from distal nerves, the increased activity from damaged nerves leads to spontaneous pain and hyperalgesia. (This basic mechanism usually underlies most postoperative pain syndromes.)

Phantom sensation may occur in any appendage but most describe the extremities. Phantom sensation of the tongue, nose, penis, rectum, teeth, and breast have all been described. Phantom limb sensation is the perception of the continued presence of the amputated limb. The sensation is non-painful.

Phantom limb pain is painful sensations that are perceived to come from the amputated part of the limb. In the first month after amputation, 85 to 97% of patients experience phantom limb pain to some extent. At one year after amputation approximately 60% continue to have phantom limb pain. Less than 30% of amputees have phantom pain greater than 20 days of the month and greater than 15 hours per day. Phantom limb pain may occur months to years after an amputation, however, pain beginning greater than one year after amputation occurs in less than 10% of these cases.

Signs and symptoms

Burning, aching, cramping, crushing, twisting, tingling, drawing, grinding, and knife-like or shock-like pain can occur. Pain may vary with emotional stimulation or depression. Greater than 50% of phantom limb pain is provoked by emotional distress, urination, cough, defecation or even sexual activity. Pain may vary with emotional stimulation or depression, just as it may with chronic-pain syndromes.


Treatments

1) Medications

Tegretol
Chlorpromazine
Propanolol
Calcitonin (salmon) administered IV
Neurontin or Lyrica have also been used with success
Antidepressant medications
Tramadol
Ketamine may reduce spinal sensation via N-methyl D-aspartate receptor antagonism

Neuromodulation has been successful with implanted spinal stimulators as well as intrathecal pumps. Lastly, deep brain stimulation with electrodes have been described.

2) Nerve blocks with epidural blocks have been described. Also direct injections into the nerve ending as in a nerve block have been helpful.

3) Augmentative techniques such as hypnotherapy

These are just some of the things that would help . . . "

So, there you have it. I believe that the mirror technique described in the e-mail string above falls into the augmentative category.

I hope this helps.

Dutch

Red Flag 1
02-14-2008, 10:39
This is really a great thread!! I think we are seeing a huge step ahead for folks with phantom limb pain. The article presented by Warrior-Mentor (W-M) is just spot-on, and gathering credability. This is worth a HARD second look! A news article in the 18FEB08 Air Force Times has picked this up and is reporting on a USAF asset.

Historically, reasearch in "mirroring" started, as Warrior-Mentor pointed out, @ UCSD in the mid 1990s. The study was stopped when civillian amputees and funding stopped. Research was not picked up until JAN 06 by Tsao as described in W-M's presented article. Tsao reported that in the first study group all using the mirror improved. Further reasearch is being conducted for bilateral amputees. Research assistants Katie Hughes and Lindsay Hussey are using their limbs to recreate missing limbs.

My training and experience in anesthesia has, for the most part, been in the operating room. With the exception of a smattering of pain management issues, I have little clinical experience with phantom limb pain. I have noted, however, events that to me, help explain why mirroring works. During my practice, I was a proponent of block anesthesia. I have done many spinals and epidurals. For those who had spinal anesthesia, I generally used Lidocaine which would "set up" rather rapidly. Most spinals I did were done with the patient in a sitting position with hips and knees flexed. Once the block was in, I would reposition them supine ( on their back). While I do not have a % figure in my head, probably 50-60% would ask me if their legs were bent or out straight. Some would take my word and some I would sit up a bit so they could see their legs, and then they were satisfied.

I believed then and now, that their brains "froze" in on the last properceptive "snap shot". Without further evidence, their nervous system could not move on to the next believable frame. In the case of traumatic amputations, or amputations because of trauma, the properceptive snap shot is more burned in and harder to advance through.

We in the medical community are, from time to time, accused of using smoke, mirrors, snake oil, and crystals held over the head. In this case, it seems the mirror is working witrhout the other stuff. Now maybe some one is holding a crystal over my head that I don't know about but, this is beginning to make sense to me.

RF 1

rltipton
07-25-2008, 21:23
Thanks for a bunch of great info on this thread! I'm not a medic, but I am an amputee.

I never tried the mirror because I didn't know about it, but I accidentally discovered something that worked for me most of the time and that is to squeeze one of those anti-stress balls or some Silly Putty. It sounds ridiculous, but it diminished my phantom pain 95% of the time. It is worth a try if you have a patient having a lot of phantom pain and it's cheap and non-addictive.

Thankfully I am 98% pain-free now, but I wish I had known that mirror trick two months ago. The phantom pains were the worst part of the whole amputation ordeal for me. Hopefully word of the mirror trick will get around and help out more folks. Good info...thanks!

Be safe,
Randy

Red Flag 1
07-26-2008, 08:32
rltipton,

Glad to hear you are in the 98% pain free position.

Thanks for the feed back.

RF 1

gl092180
12-12-2008, 10:49
Thanks for posting the mirror technique, I spent a month in WR in 2005--only lost a couple of fingers, my best friend lost his leg, just above the knee. He suffered more than anyone I have ever seen, no medication seemed to work. He recently went thru mirror therapy and seems to be helping him out quite a bit.

Longstreet
12-12-2008, 11:35
This is a little off-topic, but is great news for amputees - in particular those who have lost an arm or arms. I read about it in the Economist and did a websearch to find this. Have a read.

http://blogs.spectrum.ieee.org/automaton/2008/02/01/dean_kamen_luke_skywalker_bionic_arm.html

Looks like we may be getting close to becoming cyborgs.

Red Flag 1
12-12-2008, 17:36
In every war, there are huge medical advances. Rapid access to high level medical care has been saving lives since the days of " Dust Off" missions. Advances in technology, and interface with medical needs have provided great steps foreward in the field of prosthetic applications.

Fox news this morning reported on a prosthetic hand fitted to a patient injured over a decade ago. Up to now, the best a prostetic hand could offer was bringing the thumb, first and second fingers together. Now a hand prosthetic can bring the thumb and all four fingers into play for better grip, and more "normal" hand motions.

This post seems to acurately reflect the world of advances in prosthetics today.

RF 1

rltipton
05-15-2009, 10:36
Northwestern is doing a pain study. Let any of your amputee bros know in case they are interested. Might get some relief and make a nickel.

http://www.ric.org/research/clinicaltrials/detail.aspx?trialID=194

Be safe,
Randy

500 Proof
11-01-2010, 01:57
The mechanisms behind phantom limb pain remain mysterious. The problem could stem from a kind of cortical confusion. The brain has specific regions devoted to receiving sensory input from the body. In an uninjured person, this information - temperature, position in space, hardness and so on - flows steadily from nerve endings to cortex.

In amputees, the brain no longer receives information from the lost limb. But the receiving station still works, and without incoming data, it can go haywire.

Sounds a bit like tinnitus.

Red Flag 1
11-04-2010, 14:52
Sounds a bit like tinnitus.

I've somehow missed the "Medical Pearl" here. Comedy Zone is 29 items down on the forum list.

RF 1

greenberetTFS
11-04-2010, 17:20
I've somehow missed the "Medical Pearl" here. Comedy Zone is 29 items down on the forum list.

RF 1

LMAO.........:D The medical pearls of wisdom by some of these "medical wannabes" got to make me laugh..........;)

Big Teddy :munchin

500 Proof
11-26-2010, 22:14
I've somehow missed the "Medical Pearl" here.
Because there wasn't one.

I'll remember where the comedy section is next time.

Shredder
07-21-2011, 14:05
The sensations that DD described in his excellent reply are truly spot on.
It's phenomenal what pain the brain can conjure up when you don't realise you're putting your mind to it.
As for the mirror box therapy, for me it gives short term relief.
I'd recommend it to anyone who asks.
Might not work for all but as a drug free option I'll stick with it.

Red Flag 1
07-21-2011, 14:25
The sensations that DD described in his excellent reply are truly spot on.
It's phenomenal what pain the brain can conjure up when you don't realise you're putting your mind to it.
As for the mirror box therapy, for me it gives short term relief.
I'd recommend it to anyone who asks.
Might not work for all but as a drug free option I'll stick with it.

Great to hear from you, and that mirror therapy continues to provide relief.

Take a moment if you would, and drop us an introduction. Give us all a chance to know you are here, and to know who you are.

Be well.

RF 1