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Beth D. Darnall, PhD From the Department ofAnesthesiology and PerioperativeMedicine, Oregon Health and Science University, Portland, Oregon.
All correspondence and requests forreprints should be addressed to Beth Self-Delivered Home-Based Mirror
Darnall, PhD, Department ofAnesthesiology and Perioperative Therapy for Lower Limb Phantom
Medicine, Oregon Health and ScienceUniversity, 3181 Sam Jackson Park Road; UHN-2, Portland, OR 97239.
Supported by a grant from the Officeof Research on Women's Health Darnall BD: Self-delivered home-based mirror therapy for lower limb phantom pain. Am J Phys Med Rehabil 2009;88:78 – 81.
Home-based patient-delivered mirror therapy is a promising approach in the American Journal of Physical treatment of phantom limb pain. Previous studies and case reports of mirror Medicine & Rehabilitation therapy have used a therapist-guided, structured protocol of exercises. No case Copyright 2008 by Lippincott report has described treatment for either upper or lower limb phantom pain by Williams & Wilkins using home-based patient-delivered mirror therapy. The success of this case demonstrates that home-based patient-delivered mirror therapy may be an effi-cacious, low-cost treatment option that would eliminate many traditional barriersto care.
Key Words:
Mirror Therapy, Amputation, Phantom Limb Pain, Lower Limb Each year in the United States, ⬃158,000 persons undergo an amputation.1 Incidence of acquired amputation is increasing likely because of military con-flict injuries and the increasing prevalence of diabetes-related peripheral vas-cular disease. Prevalence of acquired amputation varies by region, sex, and typeof amputation. For first major amputations, United States data from 1992 to1997 range from almost 1 per 10,000 women in Alabama to 4.4 per 10,000 menin the Navajo Nation.2 A national survey of community dwelling persons withlimb loss (n ⫽ 914) reported a prevalence ratio of 8:1 for lower limb losscompared with upper limb loss.3 Phantom pain is a commonly experiencedcomorbid condition. Sixty-four percent of persons with limb loss reportedexperiencing phantom limb pain that was rated at least "bothersome" innature. Prevalence of "severely bothersome" phantom limb pain was 21%.3Eighty-seven percent of this limb loss sample was ⬎2 yrs after amputation,and 42.3% was ⬎6 yrs after amputation. These data speak to the chronicityof phantom limb pain, as well as the lack of efficacious and widely availabletreatments.
Ramachandran and Rogers-Ramachandran4 have described the use of mir- ror therapy to treat phantom limb pain. Persons with an amputated limb useeither a mirror or a mirror box to reflect an image of the intact limb; thisprovides the visual illusion that two intact limbs exist. Despite a greaterprevalence of lower limb amputation, mirror therapy for phantom limb pain haslargely focused on treatment for upper limb loss, and its efficacy in thispopulation has been demonstrated.4 It is hypothesized that the mechanism Am. J. Phys. Med. Rehabil. Vol. 88, No. 1

supporting the efficacy of mirror therapy for upper 1 mo after surgery. He was being treated for major limb phantom pain is cortical restructuring.5 Two depression that predated his amputation.
studies examining the efficacy of mirror therapy for Jonathan was referred to a tertiary academic lower limb phantom pain were found. The first was chronic pain clinic in September 2006 for medical a randomized, controlled trial for lower limb phan- evaluation. He was prescribed daily Effexor XR 150 tom pain that compared treatment effects between mg for pain and depression. He rated his pain as a group that viewed a computerized image of an 6/10. He was taking only Vicodin for pain. He was intact "virtual" limb to a group that received tra- treated by an inhouse pain psychologist and had a ditional mirror therapy.6 Persons in the virtual- modest response to a standard pain management limb mirror condition did not experience the ex- protocol that included relaxation techniques (dia- pected decreases in phantom limb pain associated phragmatic breathing and progressive muscle re- with traditional mirror therapy. The second report laxation). He returned to work on a part-time basis of lower limb mirror therapy involved randomiza- in the fall. Physical therapy was concluded in De- tion of 18 participants into three groups: the mir- cember 2006, and he had begun a home exercise ror group received traditional mirror therapy; the program that largely involved weight training. De- sham mirror group viewed a covered mirror and spite these treatments, his pain worsened in Janu- attempted to move both their intact and amputated ary 2007. He developed a rash to the subtherapeu- limbs in front of the covered mirror; and the men- tic dose of pregabalin 300 mg that was tried on tal visualization group closed their eyes and imag- him; this medication was discontinued. Gabapentin ined moving their amputated limb.7 The persons in (Neurontin) 600 mg thrice a day and oxcarbazepine the mirror group had direct supervision while per- (Trileptal 600 mg twice a day) were tried. Financial forming the mirror exercises for 15 mins daily.
limitations precluded optimal refitting of his pros- Every person in the mirror group (100%) evi- thesis, and this contributed to ongoing residual denced significant improvement in 4 wks (24-mm limb pain caused by friction generated by the ill- median decrease on the visual-analog scale) com- fitting device during ambulation.
pared with only one person in the sham mirror He was referred to a second inhouse pain psy- group (17%) and three people in the visualization chologist for specialized treatment for phantom group (50%) reporting similar pain decreases. Fur- limb pain in February 2007. His phantom pain was thermore, more than half of the participants in the rated 4/10. He was taking 3– 4 Vicodin daily for nonmirror groups reported worsening pain after pain and reported feeling undesirable cognitive their treatments. Four weeks after crossover to "fuzziness" from the medication. At the time of the mirror therapy group, 89% of participants evaluation, he had been working full time for 2 formerly from the sham mirror and mental vi- mos; he was fearful of the negative impact opioid sualization groups reported significant phantom medication would have on his cognitive function- pain reduction. Finally, successful treatment for ing. In terms of other medications, he was still lower limb phantom pain using a structured, taking gabapentin 1200 mg and oxcarbazepine 600 clinical approach to exercising the phantom limb mg without benefit. He noted that mentally flexing has also been described.8,9 No case report has his phantom limb would gain him some temporary described treatment for either upper or lower relief; he initiated this imagery practice on his own limb phantom pain by using home-based, pa- and had been practicing for 20 mins at a time for tient-delivered mirror therapy.
the past 3 mos.
Jonathan was seen for a total of five 60-min psychology sessions during 3 mos for home-deliv-ered mirror therapy. The following list outlines his The patient gave consent to publish a descrip- progress with treatment.
tion of his case, but his name was changed tomaintain confidentiality. "Jonathan" is a 35-yr-old 1. I discussed the mirror therapy technique with man with acquired above-knee amputation of the him and provided him with educational mate- left lower limb. He suffered limb mangling and rial describing its application and efficacy for subsequent amputation after being struck by a upper limb amputees. He expressed interest in motor vehicle as a pedestrian in 2006. He began trying this form of therapy with the understand- experiencing phantom pain immediately after sur- ing that it was experimental and not well de- gery; he described it as having a "sharp, shooting"quality that felt as if the phantom foot had fallen scribed for lower limb amputees. We discussed asleep. Intensity varied from none to severe. His the goal of using the mirror technique while postoperative pain was managed with hydroc- mentally engaging the phantom limb; he was odone-acetaminophen (Vicodin 5/500 every 4 – 6 not given any structured exercise protocol. He hrs as needed). Physical therapy was initiated about was given a CD of guided diaphragmatic Self-Delivered Home-Based Mirror Therapy

breathing and progressive muscle relaxation continue with relaxation exercises and with his (25 mins), and I encouraged him to practice mirror therapy practice.
the relaxation skills several times daily, inde- 3. He reported having increased the frequency of pendent of his mirror therapy. Jonathan was self-delivered home-based mirror therapy in the already familiar with these relaxation skills past 2 wks to 30 mins daily. He experienced no from his treatment with his previous pain aversive sensations or memories while practic- ing the mirror therapy. Rather, he reported ex- 2. He purchased a simple full-length mirror (4 ft periencing decreased pain, increased control, long and 1.5 ft wide) from a discount store and a sense of enjoyment from the practice. In (approximate cost $10). He placed the mirror on the 3 days before this follow-up session, he its edge, longitudinally, against a coffee table in needed no Vicodin for pain control. He began his living room and positioned his intact limb in tapering off his gabapentin.
front of the mirror. The mirror image of his 4. He noted a direct correlation between the fre- quency of self-delivered mirror therapy practice intact limb provided the visual illusion that he and pain intensity. After practicing mirror ther- was viewing two intact limbs (Fig. 1). He fol- apy 20 mins daily for 1 mo, he reported that his lowed a largely unstructured protocol designed phantom limb pain was resolved (0/10). He con- by himself. During his mirror sessions, he ex- tinued to have some residual limb (stump) pain ercised his intact foot and watched the move- (3/10) that improved with exercise.
ments in the mirror. He tended to include the 5. Three months after the initial evaluation, his following movements: flexing his foot up and phantom limb pain was resolved, and nerve pain down at the ankle, rotating his ankle in circles, was very well managed. He reported his mood touching his big toe in the mirror, raising and was improved and anxiety was low; both were lowering his leg from the hip, and bending his assessed via clinical interview. He reported feel- leg at the knee. He self-delivered the mirror ing confident that he could self-manage his pain technique at home three times a week for 20 –30 symptoms. He was using Vicodin about once mins per session. He noted that his ongoing weekly as needed. He noted that if he missed his practice of the diaphragmatic breathing de- regular practice of mirror therapy, the phantom creased the tingling sensations and calmed his pain returned within 1–2 days. He was able to daily general anxiety. Because he was able to control any recurrence of pain by resuming practice the mirror therapy at home only, at regular mirror practice. He indicated that con- work he would visualize flexing his phantom sistent mirror practice was important for con- limb; doing so would allow him to "exercise" the trolling his phantom pain and for minimizing phantom limb at work and increase blood flow his reliance on pain medication.
to the residual limb. He was encouraged to Table 1 reflects the percent change in Jonathan's pain and pain-related interference on relevant lifedomains from pretreatment to posttreatment, mea-sured with the Brief Pain Inventory, a self-reportmeasure validated for use with noncancer pain.10Results show complete resolution of adversesymptoms (100% change) related to pain, mood,work, and sex. Investigators commonly use a50% change from baseline to post-treatment asthe criterion for treatment success. Jonathan'simprovements in all domains were sustained 4mos post-treatment.
Jonathan's case elucidates several important A model demonstration of the mirror points. Although he was receiving multidisci- technique used by Jonathan. He practiced plinary care for his phantom limb pain (pain med- self-delivered home-based mirror therapy icine, physical therapy, and psychology), his results by placing a long mirror in front of hisresidual limb to create the image of two with standard care were unsatisfactory. The reso- intact limbs. lution of his phantom limb pain occurred after the Am. J. Phys. Med. Rehabil. Vol. 88, No. 1

cation. Self-delivered mirror therapy is likely to TABLE 1 Percent change from baseline to
gain importance as increasing numbers of veterans post-treatment for pain and other life return from conflict with an amputation. Previous domains. Pain was assessed using a data suggest persons who rate their phantom limb 0 –10 visual analog scale. Scores pain as "extremely bothersome" are at a 2.92-fold for mood, work, and sex were takenfrom the patient's brief pain inventory increased risk for experiencing a significant level of and reflect the impact of pain on the depressive symptoms (P ⬍ 0.001), compared with designated activity (0–10) those with no phantom limb pain.3 Thus, accessi-ble and efficacious treatment for phantom pain Impact of Pain
stands to provide patients with a significant im- on the Following
provement in overall quality of life.
(0–10 VAS) Mood
I acknowledge Jonathan's tenacity in overcom- ing significant obstacles associated with limb loss and his willingness to share his story in the hope that it will help other persons with limb loss experience similar success. I also express my gratitude to Tonya VAS, visual analog scale.
Palermo, PhD, for scientific advisement and to KathyGage for editorial review of the final manuscript.
initiation of self-delivered home-based mirror ther- 1. Dillingham TR, Pezzin LE, MacKenzie EJ: Limb am- apy. His strong and enduring favorable response to putation and limb deficiency: Epidemiology and re- the self-delivered mirror therapy above and beyond cent trends in the United States. South Med J 2002; all previous treatment modalities is noteworthy.
The mechanism of his response to mirror therapy 2. Ephraim PL, Dillingham TR, Sector M, et al: Epide- is unknown but may include a combination of miology of limb loss and congenital limb deficiency: neural restructuring, conditioning processes, and A review of the literature. Arch Phys Med Rehabil2003;84:747– 61 improved self-efficacy for pain and anxiety. Al-though continued practice was required for sus- 3. Darnall BD, Ephraim P, Wegener ST, et al: Depres- tained results, perhaps a treatment threshold can sive symptoms and mental health service utilizationamong persons with limb loss: Results of a national be reached in the long term, and mirror therapy survey. Arch Phys Med Rehabil 2005;86:650 – 8 can be discontinued.
4. Ramachandran VS, Rogers-Ramachandran D: Syn- This case report adds to the growing body of aesthesia in phantom limbs induced with mirrors.
literature describing successful treatment of lower Proc Biol Sci 1996;263:377– 86 limb phantom pain with mirror therapy. Further- 5. Flor H, Birbaumer N: Phantom limb pain: Cortical more, this case report is unique because Jonathan's plasticity and novel therapeutic approaches. Curr mirror therapy was self-delivered at home without Opin Anaesthesiol 2000;13:561– 4 the guidance of a structured exercise protocol. It is 6. Brodie EE, Whyte A, Niven CA: Analgesia through possible that other patients may benefit from sim- the looking glass? A randomized controlled trial ple educational brochures that describe how to investigating the effect of viewing a ‘virtual' limb self-deliver mirror therapy at home. MacLachlan et upon phantom limb pain, sensation and movement.
al.8 offer several exercises that may be useful to Eur J Pain 2007;11:428 –36 patients who require increased structure. How- 7. Chan BL, Wit R, Charrow AP, et al: Mirror therapy ever, the present case suggests that frequency for phantom limb pain. N Engl J Med 2007;357: and duration of practice may be variables of greater importance than following a structured 8. MacLachlan M, McDonald D, Waloch J: Mirror treat- protocol of exercises.
ment of lower limb phantom pain: A case study.
Among amputees, phantom limb pain is prev- Disabil Rehabil 2004;26:901– 4 alent and efficacious treatments have been lacking.
9. Brodie EE, Whyte A, Waller B: Increased motor The success of this case offers preliminary evidence control of a phantom leg in humans results from the that fully self-delivered mirror therapy in an at- visual feedback of a virtual leg. Neurosci Lett 2003; home setting can improve lower limb phantom pain. Mirror therapy may prove to be a low-cost 10. Keller S, Bann CM, Dodd SL, et al: Validity of the treatment that ameliorates pain, increases patients' Brief Pain Inventory for use in documenting the self-efficacy and sense of control regarding their outcomes of patients with noncancer pain. Clin J condition, and decreases reliance on opioid medi- Pain 2004;20:309 –18 Self-Delivered Home-Based Mirror Therapy

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