Amputee
LITERATURE REVIEW
Mind-Body Interventions forTreatment of Phantom Limb Pain inPersons with Amputation
ABSTRACT
Moura VL, Faurot KR, Gaylord SA, Mann JD, Sill M, Lynch C, Lee MY: Mind-body
interventions for treatment of phantom limb pain in persons with amputation. Am J
Phys Med Rehabil 2012;91:00Y00.
Phantom limb pain (PLP) is a significant source of chronic pain in most per-
sons with amputation at some time in their clinical course. Pharmacologic therapies
for this condition are often only moderately effective and may produce unwanted
adverse effects. There is growing empirical evidence of the therapeutic effec-
tiveness of mind-body therapies for the relief of chronic pain; therefore, an ex-
ploration of their role in relieving amputation-related chronic pain is warranted.
We undertook a focused literature review on mind-body interventions for patients
with amputation who experience PLP. Because of study heterogeneity, only de-
scriptive presentations of the studies are presented. Only studies of hypnosis,
imagery, and biofeedback, including visual mirror feedback, were found; studies
on meditation, yoga, and tai chi/qigong were missing from the literature. Few
studies of specific mind-body therapies were dedicated to management of PLP,
with the exception of mirror visual therapy. Overall, studies were largely explora-
tory and reflect considerable variability in the application of mind-body techniques,
making definitive conclusions inadvisable. Nevertheless, the weight of existing
findings indicates that a mind-body approach to PLP pain management is prom-
ising and that specific methods may offer either temporary or long-term relief,
either alone or in combination with conventional therapies. The authors discuss
the potential for usefulness of specific mind-body therapies and the relevance of
their mechanisms of action to those of PLP, including targeting cortical reorgani-
zation, autonomic nervous system deregulation, stress management, coping ability,
and quality-of-life. The authors recommend more and better quality research ex-
ploring the efficacy and mechanisms of action.
Key Words: Amputation, Phantom Limb Pain, Visual Mirror Feedback, Mind-Body
Medicine
Authors:Vera Lucia Moura, MDKeturah R. Faurot, PA, MPHSusan A. Gaylord, PhDJ. Douglas Mann, MDMorgan Sill, MPHChanee Lynch, BAMichael Y. Lee, MD, MHA
Affiliations:From the Department of PhysicalMedicine and Rehabilitation (VLM,KRF, SAG, MS, CL, MYL), andDepartment of Neurology, University ofNorth Carolina at Chapel Hill (JDM).
Correspondence:All correspondence and requests forreprints should be addressed to:Vera Moura, MD, Department ofPhysical Medicine and Rehabilitation,Program for Integrative Medicine,CB #7200, UNC Hospitals,Chapel Hill, NC 27599-7200.
Disclosures:Financial disclosure statements havebeen obtained, and no conflicts ofinterest have been reported by theauthors or by any individuals in controlof the content of this article.
0894-9115/12/9103-0000/0American Journal of PhysicalMedicine & RehabilitationCopyright * 2012 by LippincottWilliams & Wilkins
DOI: 10.1097/PHM.0b013e3182466034
www.ajpmr.com Treatment of Phantom Limb Pain 1
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Currently, 1.6 million people in the UnitedStates live with a limb loss; by 2050, this numberwill likely double.1 Most persons undergo amputa-tion for peripheral vascular insufficiency, trauma,or malignancy, with greater numbers of lower thanupper limb loss (5:1 ratio).1,2 Individuals with limbamputation face physical and psychosocial chal-lenges during their adjustment process, including (1)impairment in physical functioning, (2) pain, (3)prosthesis use, (4) change in employment status, (5)alteration in body image and self-concept, and (6)poor psychosocial adjustment.3 Individuals with am-putation must often cope with chronic pain, includ-ing residual (stump) and phantom limb pain (PLP).
Current literature is divided on the impact ofPLP. PLP appears to be constant in only 18%Y25%of persons with amputation. In reported studies,the prevalence of PLP depends on how it is defined:Bany[ PLP ranges from 51% to 80%, whereas painexperienced at least a few times per week is reportedin 28%Y37% (Table 1).4,6,8Y11,13Y15 The incidenceand natural history of PLP is even more uncertain;only small, relatively brief longitudinal studies haveso far been reported.5,7,12,15 Longitudinal studiessuggest that PLP decreases in time,5,7,12,15 makinghigh prevalence estimates in populations several yearspost amputation even more notable and making theinterpretation of therapy efficacy very difficult. Painin other body locations as a result of prosthesis useis found in up to 45% of the population.16,17 PLP, achallenging source of chronic pain in this popula-tion, is the focus of this report.
Efficacious therapies to reduce the sufferingof persons with amputation are still elusive. Theliterature describes a variety of pharmaceutical, sur-gical, and other conventional therapeutic approachesto pain management in persons with amputation,includingmore than 30 types of therapy for PLP.18Y20
These procedures include the following modalities:(1) sympathectomy,21 (2) stump manipulation,21 (3)stump ultrasound,22 (4) injection with local anes-thetics and analgesics,21 (5) transcutaneous nervestimulation with discrimination training,23 (6) nerveblocks,24 (7) cordotomy,25 (8) pharmacologic ther-apies,20,26,27 and (9) myoelectric prosthesis.28 Theoverall findings of this literature conclude that thesevarious therapies range from ineffective to slightlyeffective. With conventional treatments for PLPhaving had mixed and often limited success,22,29
providers and the public have begun to examine anduse nonconventional approaches. However, clinicalstudies of nonconventional approaches reportingsome success in treating PLP are few in number, and
generally describe small numbers of subjects. Pub-lished studies on nonconventional or complementaryand alternative medicine approaches to treatmentof PLP have included acupuncture, energy healing,and mind-body therapies (e.g., hypnosis, biofeedback[including visual mirror feedback], eye movementdesensitization and reprocessing, guided imagery,and relaxation techniques).30Y33
Mind-body therapy approaches to pain man-agement are a small but growing area of investi-gation and use. The National Institutes of Healthstates that mind-body therapies focus on the in-teractions among the brain, mind, body, and be-havior, with the intent to use the mind to affectphysical functioning and promote health.34
Mind-body therapies use and enhance themind’s ability to be aware of and self-regulate symp-toms. Techniques include biofeedback, hypnosis,yoga, tai chi, qi gong, meditation, guided imagery,progressive relaxation, and deep breathing exercises.According to the 2007 National Health InterviewSurvey, 19.2% of adults reported using mind-bodytherapies in the past 12 mos.2,3
Research in mind-body medicine reveals thatthese therapies can enhance the ability to amelio-rate symptoms such as pain, stress, anxiety, depres-sion, and fatigue, often found in patients with chronicconditions, as well as improve coping ability andquality-of-life. For example, mindfulness meditationhas been shown to improve stress and mood35; yogawith controlled breathing and visualization has beenshown to decrease sleep disturbance,18 and hypno-sis has been found to reduce postsurgical pain anddistress.19,20
The prevalence of PLP among persons withamputation and its impact in terms of suffering andreduced quality-of-life, combined with the limita-tions of efficacy in conventional approaches, jus-tifies a continued search for alternative treatments.In particular, because mind-body therapies haveshown promise for self-regulation and ameliorationof various chronic painful conditions, an explora-tion of research on their application to PLPVa con-dition that exemplifies the complex interaction ofbody and mindVseems especially warranted. The pur-pose of this focused literature review was to evaluateexisting intervention studies of mind-body techniquesfor reducing PLP in persons with amputation.
METHODS
Data SourcesSystematic searches were conducted on PubMed
(MEDLINE), Institute of Scientific Information Web
2 Moura et al. Am. J. Phys. Med. Rehabil. & Vol. 91, No. 3, March 2012
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TABLE
1Prevalence
ofphantom
limbpainacross
studies
First
Autho
r(Year)
Sherman
(198
4)4
Jensen
(198
5)5
Katz
(199
0)6
Nikolasjen
(199
7)7
Koo
ijman
(200
0)8
Ehd
e(200
0)9
Borsje
(200
4)10
Eph
raim
(200
5)11
Hun
ter
(200
8)12
Hanley
(200
9)13
Desmon
d(201
0)14
Bosmans
(201
0)15
Cou
ntry
UnitedStates
Denmark
Canada
Denmark
Netherlands
UnitedStates
Netherlands
UnitedStates
Canada
UnitedStates
Ireland
Netherlands
Stud
ytype
Cross-sectio
nal
Coh
orta
Cross-section
alRandomized
controlledtriala,b
Cross-sectio
nal
Cross-section
alCross-section
alCross-section
alCoh
orta
Cross-section
alCross-section
alCoh
orta
Metho
dSu
rvey
Interview
Interview
Interview
Survey
Survey
Survey
Interview
Interview
Survey
Survey
Survey
Response/
retentionrate
c55%
59%
91%
84%
80%
56%
30%
71%
78%
47%
49%
57%
N2694
3461
3672
255
468
914
11104
141
62Upper/lo
wer
Both
Both
Both
Lower
Upper
Lower
Both
Both
Upper
Upper
Upper
Both
Yearssince
ampu
tation
mean,
26Y3
02
mean,
5(0.1Y4
6)0.5
median,
19median,
7mean,
15Y1
8median,
4(G1Y
66)
2median,
7(0.2Y6
0)mean,
50(5Y63)
1.50
Popu
lation
Military
General
General
Non
traumatic
General
General
General
General
Traumatic
General
Traumad
General
Frequency
Anyvs.n
one
78%
59%
72%
75%
51%
72%
72%
80%
63%
79%
64%
Atleastfew
permon
th64%
44%
53%
59%
e68%
43%
Atleastfew
perweek
37%
33%
36%
32%
28%
Atleasta
fewperday
21%
25%
20%
21%
26%
18%
35%
a Percentages
reflect
incidence.
b Deathsexclud
edfrom
retentionrate
totalsreflect
item
respon
serate.
c Epidu
ralv
s.epidural
plus
generalanesthesia.
d 98%
asaresultof
trauma.
e BSo
metim
es.[
www.ajpmr.com Treatment of Phantom Limb Pain 3
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
of Knowledge, EMBASE, Cumulative Index to Nurs-ing and Allied Health, Cochrane libraries, and Alter-native Medicine Database electronic databases fromthe period of 1994 to 2010. Search terms includedthe following: amputee, amputation, psychologi-cal distress, phantom pain, depression, anxiety,stress management, mind-body medicine, medi-tation, guided imagery, imagery, hypnosis, bio-feedback, autogenic training, progressive musclerelaxation, yoga, breathing exercise, tai chi, andchi(qi) gong. A manual search of references fromretrieved articles was also conducted. Because ofthe paucity of intervention trials using mind-bodytechniques for amputation-related pain, both ran-domized-controlled clinical trials (RCTs) and studiesof lesser methodologic rigor were included, that is,simple clinical trials, case reports, and case series.Studies were excluded if they (1) lacked an inter-vention, (2) were not published in English, and (3)did not address PLP as the primary outcome amongpersons with limb amputation. Other than one dis-sertation, studies outside peer-reviewed journalswere not reviewed. Where overlapping reports werefound, only the most complete article was chosen.
Study SelectionOf 670 articles retrieved through search strat-
egies, 19 independent reports met the criteria andwere reviewed by two independent researchers. Ofthe 19 articles selected, 2 (including the dissertation)were randomized controlled clinical trials, 8 weresimple clinical trials, and 10 were case reports orseries. All studies addressed PLP. The studiesavailable for review reported results of interventionsin hypnosis, imagery, and biofeedback. No articlesthat met the review criteria were found for medi-tation, yoga, tai chi, or qigong as adjuvant therapiesfor pain and/or psychologic distress in amputees.
Data Extraction and Quality AssessmentInformation extracted from the studies in-
cluded descriptions of the following elements: (1)intervention technique, (2) sample size and com-position, (3) intervention duration, (4) follow-upperiod, and (5) detailed outcome assessments withstatistical analyses. The completeness of the de-scriptions of the above elements was used to judgethe quality of case reports and simple trials. RCTswere assessed with the quality criteria explicated byBalk et al.36
Non-RCTs and case studies are considered oflower methodologic quality because they do not ade-quately control for bias.37 Of the two RCTs reviewed,
TABLE
2Hypnosisforphantom
limbpainam
ongpersonswith
amputation
Case
Con
dition
Treatment
Results
P
Oakleyet
al.(20
02)30
case
review
PLPfor4yrs(AKA);
76-yr-oldwom
anEight
weekly25
-min
sessions
ofhypn
osis.
100%
pain
reliefa
ndcontinuedph
antom
sensations
n/a
Reviewof
11casesof
PLP
(duration,
0.5Y
25yrs)
(arm
,AKA,
BKA)
Hypno
sissessions
(3Y64)
ofvaryingleng
th.
Cases
includ
efive
ipsative-imageryY
andsixmovem
ent-im
ageryYbased
therapies.Five
includ
edrelaxation
training
;one,
cogn
itivetherapy;andon
e,mirrortherapy.
Reduction
inpain
frequencyor
intensity;
improvem
entin
physical
orpsycho
logicfunction
n/a
Bam
ford
(200
6)40;
uncontrolledtrial(n=25
)PL
P(m
eandu
ration
,7yrs)
(arm
,leg);10
wom
enand
15men
aged
27Y78yrs
Sixweeklysessions
+ho
mepractice
threetimes
daily
usinghypn
otic
analgesia,visualization
andmovem
entof
imaginarylim
b,psycho
logic
hypn
osis,and
self-hypn
osis
Sign
ificant
redu
ctionin
medianpain
after
intervention
,maintained6mos
later
(NRS,
8of
10to
3of
10);resultsno
tsensitive
toside
(right
vs.left)or
causeof
ampu
tation
(traum
avs.o
ther)(W
ilcoxon
)
G0.00
1
Rickard
(200
4)38
RCTn=20
PLPwith/witho
utstum
ppain
(arm
,AKA,
BKA;
0.5Y
63yrsago);
men
andwom
enaged
31Y70yrs
Threeindividu
alhypn
osissessions
vs.
waitlistedcontrol
Reduction
inpain
before
toafterintervention
.ByMPQ
-SP:
intervention
grou
p,mean(SD)
from
58.8
(26.02
)to
10.1
(6.28);con
trol,
from
49.5
(25.27
)to
46.4
(14.67
)(ANOVA
)
G0.00
1
AKA,
above-thekn
ee(transfemoral)ampu
tation
;ANOVA
,analysisofvariance;B
KA,
below-the-knee(transtibial)ampu
tation
;MPQ
-SP,
McG
illPain
Questionn
aire
Pain
IntensityScale;NRS,
numericrating
scale;
PLP,
phantom
limbpain;n
/a,n
otapplicable;R
CT,
rand
omized
controlledtrial.
4 Moura et al. Am. J. Phys. Med. Rehabil. & Vol. 91, No. 3, March 2012
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
neither met criteria for a high-quality clinical trial.Rickard’s38 study came closest to meeting criteria fora high-quality trial, but concealment of random al-location was unclear, and data regarding the com-parability of the groups at baseline was missing.38
In addition to these flaws, in the second RCT con-ducted by Chan et al.,19 the randomization methodwas inadequate, and it was unclear whether theassessments and analyses were blinded.19 Theauthors of this study also failed to report control ofother potentially confounding factors such as med-ication usage and other treatments being used by thepatients. Sample sizes of these studies were small(18Y20 subjects), and the studies were heteroge-neous in terms of both mind-body techniques andoutcomes. A third RCT was excluded because its pri-mary outcome was phantom limb sensation andawareness rather than PLP.39
Data SynthesisBecause of the small number of studies and
the heterogeneity of the mind-body techniques usedin the reports meeting our selection criteria, noquantitative synthesis of the findings was attempted.The following represents a summary of availablestudies examining mind-body techniques. To assistthe reader, the mind-body techniques are de-scribed briefly before the study reports. Tables 2Y5also present study elements for ease of comparisonacross studies.
RESULTS
HypnosisThe American Society of Clinical Hypnosis de-
fines hypnosis as Ba state of inner absorption, con-centration and focused attention.[52 Hypnosis isa form of information processing in which periph-eral awareness and critical analytic cognition aresuspended, readily leading to apparently involun-tary changes in perception, memory, and moodthat have profound behavioral and biologic con-sequences.53 Hypnosis has been used for more thana century as a therapeutic approach for a variety ofphysical and mental health conditions and is fre-quently cited in the literature as an effective mind-body intervention for pain.54 Numerous studiessuggest that hypnosis is effective as a primary oradjunctive treatment of acute pain related to med-ical and surgical procedures such as bone marrowaspiration, burn wound dressing changes, laborpain, and for chronic pain under conditions suchas fibromyalgia and headache.55 A review of con-trolled trials of hypnotic analgesia indicates that
hypnosis reduces pain better than no treatment atall for conditions such as headache, cancer-relatedpain, fibromyalgia, osteoarthritis, low back pain, anddisability-related pain.56 In 1996, the National In-stitutes of Health assembled a Technology Assess-ment Panel on the integration of behavioral andrelaxation approaches into the treatment of chronicpain and insomnia, which reported that relaxationand hypnosis are effective in reducing chronic pain.57
We identified a case report and review of casereports, one RCT, and one non-RCT in the use ofhypnosis as an adjuvant therapy for PLP. Reportsof cases indicate substantial improvement in PLPwith hypnosis training Table 2).30,38,40 In the smallclinical trial, patients 6 mos postamputation withPLP were randomized to either three individualsessions of hypnosis for PLP or the waitlisted con-trol group. Repeated-measures analysis of varianceshowed statistically significant time-by-group effects(P G 0.001) in the McGill Pain Questionnaire PainIntensity Rating and the Daily Pain Rating Scale. Inaddition, in the treatment group, prehypnotic paindecreased during the course of the three hypnosissessions.
In the only uncontrolled trial, a multifacetedintervention was used, including hypnotic analge-sia, visualization and movement of an imaginarylimb, psychologic hypnosis, and self-hypnosis.40 Inaddition to improvements in immediate presessionto postsession pain via Visual Analogue Scale, me-dian pain scores by nonparametric paired-sampletesting fell significantly. In his review of case re-ports, Oakley et al.30 proposed two types of hypnoticapproach to PLP using imageryVipsative/imageryand movement/imagery. The first one uses imagesto modify a patient’s representation of and to im-prove their pain; the second one uses suggestionsto make the patient move the phantom limb and tobe able to control the pain. In general, the studiesreduced pain frequency or intensity. Oakley et al.30
found no evidence that either form of hypnosis wassuperior to the other. As a whole, these case reportsand studies are suggestive of support for the use ofhypnosis as an effective intervention for PLP (andresidual stump pain) in the short term. Additionalwell-controlled randomized studies are needed be-fore conclusions can be made. It is particularly un-clear whether the positive effects of hypnosis onpain control are persistent.
Guided ImageryImagery is described as a thought process that
invokes and uses the senses: vision, audition, smelland taste, senses of movement, position, and touch.
www.ajpmr.com Treatment of Phantom Limb Pain 5
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
It is considered a communication mechanism be-tween perception, emotion, and bodily change andis defined as using one’s imagination to createmental images that involve all senses to assist thebody in healing, maintaining health, or reducingstress and promoting relaxation.58Y60 A recent na-tional survey found that guided imagery was theninth most commonly used complementary andalternative medicine therapy (2.2%) by adults 18 yrsor older in the United States in 2007.61 InteractiveGuided Imagery is a unique form of guided im-agery created in a therapeutic setting as a resultof (1) patient/therapist interaction, (2) interactionbetween the patient and his or her images, and (3)interaction among the patient’s images.62 Duringan Interactive Guided Imagery session, initially,the patient was guided to a state of relaxation andencouraged to describe the spontaneous imagerythat happens at that particular moment. The ther-apist elicits the patient’s imagery and responds inan appropriate way. The Interactive Guided Im-agery session continues in an interactive and per-sonalized manner. It mobilizes the latent, innatehealing abilities of the patient to promote pain con-trol and accelerate rehabilitation, recovery, andhealth enrichment.62 The Interactive Guided Im-agery approach is eclectic, holistic, humanistic, andnondogmatic, incorporating skills from many re-lated disciplines including hypnosis, Jungian psy-chology, psychosynthesis, self-actualization, andego-state psychology.62
Imagery is thought to be helpful in a numberof conditions, including chronic pain, psychologicdistress, sleep disturbance, cancer, and cardiovas-cular disease.31,63,64 Our review identified fourstudies on imagery for persons with amputationexperiencing PLP: one case series and three un-controlled trials (Table 3).33,65Y67 These studiesused a variety of models of mental imagery in thetreatment of PLP in persons with amputation.Zuckweiler64 and Zuckweiler and Kaas67 used anovel imaging technique to increase the experienceof movement of the phantom limb. All patients inthe case series were free of pain at 6 mos after theconclusion of treatment. In the uncontrolled trial,PLP frequency diminished after treatment and at6 mos. In a second trial focused on central nervoussystem mechanisms, MacIver et al.33 used sensa-tion and movement imagery in combination withpsychotherapy and relaxation techniques. In addi-tion to demonstrating improvements in pain in-tensity, the investigators reported reductions incortical reorganization, a central nervous systemmechanism thought to cause PLP.33,68Y70 Instead
TABLE
3Mentalimagery
trainingforphantom
limbpainam
ongpersonswith
amputation
Case
Con
dition
Treatment
Results
P
McAvinu
eand
Rob
ertson
(201
1)65
case
series
(n=4)
PLP(AKA,
BKA1.7
to19
yrspreviously)on
40-yr-oldman,4
5-yr-old
man,
66-yr-oldman,and
25-yr-oldwom
an
Four
weeklysessions
ofmovem
entim
agerytraining
follo
wed
by6wks
training
onincreasing
the
awarenessof
theph
antom
andin
movem
ent
ofthestum
pandim
agined
movem
entof
the
phantom;d
aily
practice
andpain
diaries
Allp
articipantsim
proved
inim
ageryaftertraining
,althou
ghtwomorethan
theothers.T
hrou
ghinterrup
tedtimeseries
analysis,o
neof
the
four
participants
notedan
improvem
entin
PLP.
n/a
Zuckweiler(200
5)64
uncontrolledtrial
(n=14
)
PLP(leg,h
and,
finger1Y21
yrs
previously);71
%male,
aged
30Y80yrs
5to
15im
agerysessions
usingZIPS
over
4Y20
wks;
ZIPS
encourages
precisebo
dyim
ageandim
proved
mind-bo
dysensorymessaging
.
Sign
ificant
redu
ctionin
PLPfrequencyat
end
ofintervention
andat
6mos
(7-point
scale,W2 )
G0.00
1
MacIver
etal.(20
08)33
uncontrolledtrial
(n=13
)
PLPfor3Y51
yrs(arm
);11
men,3
wom
enSixtraining
sessions:g
uidedbo
dyscan
forrelaxation
follo
wed
bysensoryandmotor
imagerytraining
;participants
wereencouraged
topractice
daily
witha40
-min
CDanddo
a10
-min
exercise
tousewitho
utaCD.
Sign
ificant
decrease
inpain
intensity(NRS,
7.5
of10
to4.0of
10)andexacerbation
s(6.0
to3.0);
training
resulted
inredu
cedmotor
andsensory
cortical
reorganization
(inapp
ropriate
activation
ofcontralateralhand
/arm
cortical
area)by
fMRI
G0.00
1
Beaum
ontet
al.(20
11)66
uncontrolledtrial
(n=6)
PLPfor0.6Y
28yrs(arm
,AKA,
BKA);
allm
en,aged32Y65yrs
Participants
chose10
of48
movem
ents
from
avideoto
practice
withtheph
antom.T
raining
(30mins,twiceweekly)
over
4wks
added
twomovem
ents
perweekto
theinitial4.
Atho
me,participants
practiced30
minswith
avideoforan
addition
al4wks.
Imageryability
improved
inallb
uton
e.Fo
urparticipants
notedat
least30
%redu
ctionin
pain
aftertheintervention
,but
only
oneno
ted
persistenceof
theim
provem
entat
6mos
(witho
utpractice).Psycho
logichealth
appeared
tobe
afactor
indegree
ofim
provem
ent.
n/a
AKA,
above-thekn
ee(transfemoral)am
putation
;BKA,
below-the-knee(transtibial)am
putation
;fMRI,function
almagneticresonanceim
aging;
NRS,
numeric
rating
scale;PL
P,ph
antom
limbpain;n
/a,n
otapplicable;Z
IPS,
Zuckweiler’sIm
ageIm
printing
.
6 Moura et al. Am. J. Phys. Med. Rehabil. & Vol. 91, No. 3, March 2012
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
of cortical reorganization, Beaumont et al.66 mea-sured psychologic variables in investigating mech-anisms of reduction in PLP. The locus of control,social support, and general psychologic distresswerenegatively correlated with reductions in pain.66
Finally, in a study of visual mirror feedback, theinvestigators used mental imagery as a control con-dition.19 In the mental imagery condition, partici-pants in the study were instructed to imaginemovingtheir phantom rather than viewing the unaffectedlimb in a mirror. Visual stimulation with the mir-ror was superior in reducing PLP.19
BiofeedbackBiofeedback is a self-regulatory technique that
has been used for decades to help individuals learncontrol of autonomic physiologic processes, suchas heart rate, muscle tension, blood pressure, andvasoconstriction.71 The hypothesis is that the painexperience is maintained or exacerbated by auto-nomic nervous system deregulation.71 Biofeedbacksignals, which can be visual or auditory analogs ofthe physiologic changes, focus self-regulatory ef-forts. Biofeedback methods used to treat phantompain are many and include (1) electromyography, (2)muscle tension biofeedback, (3) thermal (periph-eral skin temperature) biofeedback, (4) visual mirrorfeedback, and (5) auditory biofeedback.71
Studies have shown that people experiencingPLP, especially those complaining of burning pain,present lower skin temperature at the stump distalend than at a corresponding point on the intactlimb.72Y74 Thermal biofeedback therapy, as pro-
mulgated by Sherman et al.,74 teaches PLP patientsto increase skin temperature at the stump distalend.74 In addition, patients with PLP presenting withspontaneous muscular hyperactivity in the stump,including involuntary spontaneous jerking, seemto benefit from electromyography biofeedback.75,76
Physiologically, when one autonomic nervous sys-tem function is regulated, such as skin temperature,it positively impacts other functions. For exam-ple, cold limbs indicate arteriolar vasoconstrictioncaused by increased sympathetic activation; in con-trast, warm limbs are a sign of arteriolar vasodila-tion as a result of decreased sympathetic drive andincreased parasympathetic activation. Sympatheticactivation, a common feature of anxiety and hyper-vigilance, is seen in a variety of chronic healthconditions, including chronic pain.71 Thermal bio-feedback, combined with simple relaxation tech-niques, trains PLP patients to both increase thetemperature of the stump and to relax.71 In time,repeated use of thermal biofeedback provides pa-tients with an increased ability to deal with stressand reduce pain.71
Two studies on traditional biofeedback treat-ment of PLP, a case report and an uncontrolledclinical trial, met our selection criteria (includingpublications after 1994) (Table 4).77,78 In the casereport, pain was completely resolved through acombination of electromyography and thermal bio-feedback.77 Despite earlier reports on the effec-tiveness of thermal biofeedback in some forms ofPLP, the uncontrolled trial did not show signifi-cant reductions in the primary outcome variable(McGill Pain Questionnaire Pain Intensity), but
TABLE 4 Biofeedback for phantom limb pain among persons with amputation
Case Condition Treatment Results P
Belleggia andBirbaumer (2001)77
case report (n = 1)
PLP (arm 3 yrspreviously);69-yr-old man
Six weekly EMG and thermalbiofeedback/relaxationsessions (1 hr), thensix weekly thermalbiofeedback sessions
Elimination of pain (VAS)at end of treatment,maintained at 3- and12-mo follow-ups, withdecreased differencesin EMG and temperaturebetween the stumpand the contralateral arm
n/a
Harden et al. (2005)78
uncontrolled trial(n = 9)
PLP (arm, leg); fivemen, four womenwith mean ageof 57.6 yrs
Six weeks of thermalautogenic biofeedbacksessions; follow-upat 12 mos
Only sensory MPQ-SPsignificantly differentbefore and after treatment;daily painintensity (VAS)reduced by mean of 39%
0.05
EMG, electromyography; MPQ-SP, McGill Pain Questionnaire Pain Intensity Scale; PLP, phantom limb pain; n/a, not appli-cable; VAS, Visual Analogue Scale.
www.ajpmr.com Treatment of Phantom Limb Pain 7
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TABLE
5Visualmirrorfeedbackandassociatedtechniquesforphantom
limbpainforpersonswith
amputation
Case
Con
dition
Treatment
Results
P
Ram
achand
ran(199
3)41
andRam
achand
ranand
Rog
ers-Ram
achand
ran
(199
6)42
case
series
(n=10
)
PLP(arm
andhand
ampu
tation
s19
days
to9yrspreviously);
men
andwom
enaged
23Y73yrs
Individu
alized
exploratoryprotocol
ofVM
Ffor5to
15minsdaily
forafewweeks;
explorationinclud
edbo
thmotor
and
sensorystim
ulation
Self-repo
rted
redu
ctionin
orcomplete
resolution
ofpain
andability
tomove
theph
antom
limb
n/a
Darnall(200
9)43
case
repo
rt(n
=1)
PLP(BKA3yrspreviously);
35-yr-oldman
Hom
e-basedmirrortherapy,
relaxation
,and
psycho
therapy
After3mos,the
man
was
completelyfree
ofpain.
n/a
MacLachlanet
al.(20
04)44
case
repo
rt(n
=1)
PLP(AKA);3
2-yr-old
man
Twoto
threesessions
perdayfor3wks
Reduction
inph
antom
pain
(100
%)and
stum
ppain
(50%
)(NRS)
aftertreatm
ent.
After3mos,P
LPcontrol,30
%.
n/a
Murrayet
al.(20
06)45,46
case
series
(n=5)
PLP(arm
,AKA,
BKA1Y40
yrs
previously);threemen
aged
56Y63yrsandtwowom
enaged
61Y65yrs
Immersive
virtualrealitysystem
was
used
totransposethemovem
entof
theexisting
limbinto
thespaceof
themissing
limb.
30-m
insessions:fou
rmovem
enttasks
ofthevirtuallim
b;nu
mberof
sessions
notspecified.
Transientim
provem
entin
PLP,
decaying
withtime.Patientwithrecent
(1yr)
ampu
tation
notedthemostbenefit.
Allh
advividsensations
ofmovingph
antom.
n/a
Hanlin
get
al.(20
10)47
case
series
(n=4)
PLP(BKA);three
22-yr-old
men,o
ne27
-yr-oldman
Daily
mirrortherapyfor30
mins
for5Y6days
before
ampu
tation
Mod
eratestum
ppain
buton
lymild
occasion
alPL
P1moafteram
putation
.n/a
Wilcheret
al.(20
11)48
case
repo
rt(n
=1)
PLP(arm
andshou
lder
ampu
tation
G1mopreviously);
24-yr-oldman
PLP,
refractory
tomedical
managem
ent,
treatedwithtwice-daily
VMFaccompanied
byauditory
stim
uli(handclaps)
Reduction
inPL
Pfrom
averageor
8/10
tomax
of6/10
withwithd
rawal
ofmostmedications
n/a
Mercier
andSirigu
(200
9)49
uncontrolledtrial(n
=8)
PLP(arm
ampu
tation
1Y16
yrs
previously);allmen
aged
19Y54yrs
Virtualvisual
feedback
therapytwiceweekly
for8wks.Intactlim
bfilmed
performing
tenmovem
ents;images
digitally
inverted;
participantfollo
wed
imagewith
phantom
limbs
Meandecrease
inpain
by38
%(VAS
).Five
ofeigh
trepo
rted
30%
ormoreim
provem
ent.
Pretreatment-po
sttreatm
entpaired-sam
ple
ttest
sign
ificant
at1and4wks.
0.02
(1wk);
0.04
(4wks)
Sumitaniet
al.(20
08)50
uncontrolledclinical
trial
(n=22
;11witham
putation
)
PLPandsensation(six
arm
and
fivelower-lim
bam
putation
s3Y90
0wks
previously);
nine
men
andtwowom
enaged
32Y74yrs
Mirrortherapy:individu
alsessions
of10
minson
cedaily
forweeks:m
ean
(SD)of
20.4
(23.8);p
articipantsmoved
intact
limbwithob
servationin
themirror
andim
agined
movem
entof
theph
antom.
All:decrease
inpain
(NRS)-meanpretreatment,
6.6(1.7);po
sttreatm
ent,4.2(2.8);
participants
withgreaterim
ageryshow
edmoredecrease
than
patients
witho
ut:
51.4%
(31.8%
)vs.1
2.5%
(21.7%
).Im
agery
correlated
withdeep
pain
descriptors.
G0.00
2
Coleet
al.(20
09)51un
controlled
clinical
trial(n
=14
)PL
P(half-arm,h
alf-leg
ampu
tation
s5mos
to10
yrspreviously);tenmen
andfour
wom
enaged
27to
83yrs
Virtualrealityim
aging(avatar)
withmotor
task
activatedby
movem
entof
theresidu
allim
b;sessions
lasted
60Y90mins
Four
ofsevenwitharm
andfour
ofseven
withlegam
putation
srepo
rted
redu
ctions
inpain
930
%(VAS
).Pain
relieftendedto
betransient.
Chanet
al.(20
07)19
rand
omized/sham-con
trolled
trialo
fmirrortherapyvs.
imagerytherapy
(n=22
;18completers)
PLP(low
erlim
b)Fo
ur-week15
-min
daily
practice;u
sed
different
visual
mirrorfeedback
techniqu
es:(1)
VMF,
(2)view
edCM,
or(3)trainedin
MV.
Pain
intensity(VAS
)po
stintervention
decreased:
VMF,
100%
;CM,1
7%;M
V,33
%.9
50%
ofCM
andMVsubjects
repo
rted
increasesin
pain
intensity.89
%of
thosewho
switched
toVM
Ftherapyrepo
rted
decreasedpain.
0.04
(VMFvs.
CM);0.002
(VMFvs.M
V)
AKA,
above-thekn
ee(transfemoral)am
putation
;BKA,
below-the-knee(transtibial)am
putation
;CM,coveredmirror;n/a,
notapplicable;NRS,
numeric
rating
scale;
PLP,
phantom
limbpain;VA
S,Visual
Analogue
Scale;VM
F,visual
mirrorfeedback;M
V,mentalv
isualization.
8 Moura et al. Am. J. Phys. Med. Rehabil. & Vol. 91, No. 3, March 2012
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
McGill Pain Questionnaire sensory pain was signifi-cantly reduced.78
Visual Mirror Feedback and AssociatedTechniques
In the last 15 yrs, a novel approach to thetreatment of PLPVvisual mirror feedback (VMF)Vhas gained the attention of researchers in the fieldof rehabilitation medicine, with a proliferation ofclinical trials to study its effect on PLP in personswith amputation as well as its mechanism of ac-tion. Studies involving VMF are not limited to PLP;they also include complex regional pain syndrometherapy and stroke rehabilitation.63,79,80 In addition,new refined devices that use the same principles ofthe original cardboard visual mirror feedback box(virtual reality technology and left/right reversingprisms) have been developed.45,46,49,51
VMF is a technique introduced by Ramachandranand Altschuler81 in 1992 to treat pain of central ori-gin such as PLP. The VMF procedure requires the useof a rectangular box made of wood or cardboard. Amirror is placed vertically in the middle of the box,dividing it into two compartments, with the top andfront of the box removed. A patient places his/heraffected limb in one side of the box and the intactlimb in the other side. By looking at the intact limband its reflection on the mirror, patients observethat the intact limb visually takes the place of thephantom limb, creating an illusion that the phan-tom has been revived.41
In 1993, during his first experiment with VMF,Ramachandran and Altschuler81 observed that whilefacing a mirror box with open eyes and followingthe commanded movement of the intact limb, hispatient was able to see and feel the phantom limbmoving. During the course of the intervention, hispatient also had amarked reduction in pain intensity.The results of this experiment marked the beginningof a series of studies that contributed to advances inneurosciences’ Bnew view of brain functions[ andits Bstrong inter-sensory interaction as well as plas-ticity of the brain modules[ (p. 1693). Seven articleson VMF as an intervention for phantom pain metourselection criteria, along with three articlesusing virtual reality technology (Table 5).19,42Y51
The first set of investigations was carried out byRamachandran and Rogers-Ramachandran42 in1996 and reported again in 2009.81 Ramachandrandescribed a goal: to Bresurrect the phantom visuallyand study the inter-sensory effects of visual inputon phantom sensations[ (p. 377).42 Ten patientswith upper limb amputation, phantom limb sensa-
tion, and pain were treated with VMF followingan individualized protocol. The length of treatmentvaried from six single sessions of 5 mins to 15 minsa day for a few weeks. During and after the inter-vention, participants reported a reduction in pain,ability to move the frozen limb in the cases that thissensation was present, disappearance of the phan-tom arm in one of the patients, relief from spasmin the phantom arm, and touch perception in thephantom limb when the intact limb was touched.These experiments Bsuggest that there is an amountof latent plasticity even in adult human brain,[whereby Bprecisely organized new pathways, bridg-ing the two hemispheres, can emerge in less thanthree weeks.[(p. 386).42 As a result of his experi-ments, Ramachandran recommended imaging stud-ies such as functional magnetic resonance imagingand positron emission tomography scan to elucidatenew pathways of sensory interactions.
Three additional case reports were consistentwith Ramachandran’s initial findings. The resultsof the uncontrolled clinical trial of VMF were lessimpressive, demonstrating a 36% reduction in PLP.In the one small randomized trial, those who wereassigned to VMF achieved complete PLP resolutionas compared with 17% in the sham-mirror ther-apy and 33% in the Bmental visualization[ group.The virtual reality studies used an avatar createdby sensors either on the intact limb or the residuallimb. Improvements in pain control were similarto those reported using VMF therapy, althoughimprovement tended to decrease with time sincetreatment.45,49,51
DISCUSSIONAlthough more research is needed on specific
mind-body therapies to supply definitive evidenceof their usefulness for PLP, the weight of existingfindings indicates that a mind-body approach toPLP pain management is promising and that specificmethods may offer either temporary or long-termrelief, alone or in combination with conventionaltherapies. In particular, because conventional treat-ments are not always successful22,29,78 and may pro-duce unwanted adverse effects, it is important toconsider how mind-body therapies may enhancecare of PLP patients.
Relevance of Mind-Body Therapies toMechanisms of Action of PLP
To better understand the possible roles thatmind-body therapies may play in PLP management,it may be helpful to review the mechanisms of PLP.
www.ajpmr.com Treatment of Phantom Limb Pain 9
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Although answers regarding the causes of PLP haveremained elusive, much progress has been maderecently. It is now understood that multiple factorsinvolving both the central and peripheral nervoussystem contribute to PLP.82 Central factors involveboth the spinal cord and the brain. They includecentral sensitization in the spinal cord, character-ized by increased excitability, and expansion of re-ceptive fields into adjacent sensory areas.83 Inaddition, changes in input into the neural matrix-anetwork of neurons in several brain regions in-cluding the thalamus, somatosensory cortex, retic-ular formation, and limbic system together form ananatomical representation of self.84 Perhaps mostsignificantly, changes in the functional structuralarchitecture of the primary somatosensory cortexresult in phantom sensations arising from adjacentareas.81 For example, pursing of the lips resultedin activation of primary motor and sensory cor-tices corresponding to the phantom by functionalmagnetic resonance imaging,33 and greater corticalreorganization was associated with increased PLP.82
Peripheral nervous system changes includenociceptive input from the residual limb, as whena neuroma forms in the stump and peripheralneuropathy may contribute to worsening of pain.85
Paradoxically, stimulation of the stump throughdiscrimination training or myoelectric prosthesistends to reduce PLP.28 In addition, emotional fac-tors, including anger and stress, are known to ex-acerbate pain sensations in PLP, with both central(e.g., increased sympathetic nervous system activ-ity) and peripheral (e.g., muscle tensing and regionalsympathetic stimulation) factors being involved.78,86
Cognitive factors such as coping ability are also as-sociated with pain modification in PLP.83 It has alsobeen hypothesized that pain memories and proprio-ceptive memory may play a role in the character anddegree of PLP.33,87,88
In her first review, Flor83 stated that Bso far, fewmechanism-based treatments for PLP have beenproposed[ (p. 182). However, recent research in-dicates the potential for usefulness of several spe-cific mind-body therapies based on the relevanceof their mechanisms of action to those of PLP.For example, one of the most successful and well-studied therapies, Mirror Visual Feedback, appearsto target cortical reorganization,81 including changesin the somatosensory cortex and the neural matrix.Other therapies that use guided mental imagery,including therapeutic uses of hypnosis, may alsotarget reduction of cortical reorganization. For ex-ample, MacIver et al.33 found that motor imagerystimulated the contralateral cortex and reduced cor-
tical reorganization. Anderson et al.89 found thatmotor imagery was associated with activation ofthe thalamic sensory nuclei. Biofeedback mecha-nisms use the mind-body’s ability to self-regulate andrestore autonomic nervous system deregulation,71
as in the use of electromyography and thermalbiofeedback to decrease muscle tension and in-crease temperature of the stump, resulting in painmodification.77,78,90
Need for High-Quality Studiesof Mind-Body Therapies
A surprising finding in this literature reviewwas the paucity of research studies available inthe English language on mind-body therapies forphantom pain in persons with amputation. Onlystudies of hypnosis, imagery, and biofeedback, in-cluding visual mirror feedback, were found. Al-though the available findings are promising for therole of mind-body therapies, the articles reviewedhere have shortcomings that limit our ability togeneralize the findings, including small numbersof participants, uncontrolled experimental designs,and lack of study replication. There is a need forRCTs with well-defined and clearly reported treat-ment protocols to evaluate the efficacy of the vari-ous approaches that have been suggested, whetherthose approaches be hypnosis, imagery, or bio-feedback. Moreover, in this review, not all therapieswere used in a consistent and standard manner,which also affected the generalizability acrossstudies of the mind-body therapies. There is also aneed for standardized measures of the PLP to betaken preintervention and postintervention, alongwith other measures of psychologic and social ad-justment. With these caveats in mind, there is anoverall need for replication and validation of prom-ising findings in hypnosis, guided imagery, and bio-feedback. In addition, extended follow-up to measurechanges in quality and intensity of pain over time,as well as in-depth interviews of study participantsfor qualitative analysis of their experience, areadvisable.
One exception, in terms of volume of stud-ies, is those on VMF. The growing exploration andpromising findings for VMF lend support for its usein rehabilitation centers, either alone or in combi-nation with other mind-body therapies. Moreover,the value of VMF cannot be separated from thecontext in which it was developed and has con-tributed to the expansion of the new understandingof brain functions and advances in neuroscience.Because early experiments in the late 1970s on the
10 Moura et al. Am. J. Phys. Med. Rehabil. & Vol. 91, No. 3, March 2012
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
effects of amputation on somatosensory maps inadult mammals, the resurgence of interest in theclinical phenomena of phantom limbs and the de-velopment of the VMF device and therapy in theearly 1990s, many advances have been made in neu-roscience with evident benefit for many people withchronic neurologic disorders including PLP in per-sons with amputation.
Additional research investigating the useful-ness of other mind-body therapies for PLP shouldalso be explored. Specifically, mindfulness medita-tion, a cognitive and behavioral technique involv-ing the intentional self-regulation of attention topresent-moment experience91 has already shown tosignificantly lower stressVwell known to exacer-bate pain phenomenaVas well as ameliorate de-pression and anxiety, also associated with increasedpain.92 Moreover, mindfulness has been shown toreduce pain in specific conditions and to enhancecoping ability.92Y94 To our knowledge, there are nostudies of mindfulness for persons with amputa-tion, including those experiencing PLP. Additionalresearch using existing therapies not found in thisreview include possible sympathetic blocks usinghypnotic analgesia. Hypnotic analgesia may operateat the spinal cord level and may be compared withregional anesthesia.95
Overall, one major advantage of mind-bodytherapies as part of a comprehensive pain manage-ment program is the ability to enhance capacity forself-regulation and self-efficacy, which can increasequality-of-life. Offering techniques known to ex-pand these capabilities for those with disabilities iscritically important to the well-being of this popu-lation and their reintegration into society.
The understanding of the phenomena of phan-tom pain and sensations is now being articulated inthe science of rehabilitation, and the important roleplayed by mind-body therapies in the treatment ofthis condition is only now beginning to be appreci-ated. More and better research on mind-body thera-pies for PLP, including studies of mechanisms ofaction, will extend the frontiers of research in theneurosciences on interactions of brain, body, andbehavior and enhance health care and quality-of-lifefor this deserving population.
ACKNOWLEDGMENTS
We thank Dr. Kyu Hoon Lee for his invaluablecontributions to the literature review.
REFERENCES
1. Ziegler-Graham K, MacKenzie EJ, Ephraim PL, et al:Estimating the prevalence of limb loss in the United
States: 2005 to 2050. Arch Phys Med Rehabil 2008;89:422Y9
2. Darnall BD, Ephraim P, Wegener ST, et al: Depres-sive symptoms and mental health service utilizationamong persons with limb loss: Results of a nationalsurvey. Arch Phys Med Rehabil 2005;86:650Y8
3. Esquenazi A: Amputation rehabilitation and pros-thetic restoration. From surgery to communityreintegration. Disabil Rehabil 2004;26:831Y6
4. Sherman RA, Sherman CJ, Parker L: Chronic phan-tom and stump pain among American veterans:Results of a survey. Pain 1984;18:83Y95
5. Jensen TS, Krebs B, Nielsen J, et al: Immediate andlong-term phantom limb pain in amputees: Inci-dence, clinical characteristics and relationship to pre-amputation limb pain. Pain 1985;21:267Y78
6. Katz J, Melzack R: Pain Fmemories_ in phantomlimbs: Review and clinical observations. Pain 1990;43:319Y36
7. Nikolajsen L, Ilkjaer S, Christensen JH: Randomisedtrial of epidural bupivacaine and morphine in pre-vention of stump and phantom pain in lower-limbamputation. Lancet 1997;350:1353Y7
8. Kooijman CM, Dijkstra PU, Geertzen JH, et al:Phantom pain and phantom sensations in upper limbamputees: An epidemiological study. Pain 2000;87:33Y41
9. Ehde DM, Czerniecki JM, Smith DG, et al: Chronicphantom sensations, phantom pain, residual limbpain, and other regional pain after lower limb am-putation. Arch Phys Med Rehabil 2000;81:1039Y44
10. Borsje S, Bosmans JC, van der Schans CP, et al:Phantom pain: A sensitivity analysis. Disabil Rehabil2004;26:905Y10
11. Ephraim PL, Wegener ST, MacKenzie EJ, et al:Phantom pain, residual limb pain, and back pain inamputees: Results of a national survey. Arch PhysMed Rehabil 2005;86:1910Y9
12. Hunter JP, Katz J, Davis KD: Stability of phantomlimb phenomena after upper limb amputation: Alongitudinal study. Neuroscience 2008;156:939Y49
13. Hanley MA, Ehde DM, Jensen M, et al: Chronic painassociated with upper-limb loss. Am J Phys MedRehabil 2009;88:742Y51; quiz 752, 779
14. Desmond DM, Maclachlan M: Prevalence and char-acteristics of phantom limb pain and residual limbpain in the long term after upper limb amputation.Int J Rehabil Res 2010;33:279Y82
15. Bosmans JC, Geertzen JH, Post WJ, et al: Factorsassociated with phantom limb pain: A 31/2-yearprospective study. Clin Rehabil 2010;24:444Y53
16. Gallagher P, Maclachlan M: The Trinity Amputationand Prosthesis Experience Scales and quality of life inpeople with lower-limb amputation. Arch Phys MedRehabil 2004;85:730Y6
17. Asano M, Rushton P, Miller WC, et al: Predictors ofquality of life among individuals who have a lower
www.ajpmr.com Treatment of Phantom Limb Pain 11
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
limb amputation. Prosthet Orthot Int 2008;32:231Y43
18. Horgan O, MacLachlan M: Psychosocial adjustmentto lower-limb amputation: A review. Disabil Rehabil2004;26:837Y50
19. Chan BL, Witt R, Charrow AP, et al: Mirror ther-apy for phantom limb pain. N Engl J Med 2007;357:2206Y7
20. Black LM, Persons RK, Jamieson B: Clinical inquiries.What is the best way to manage phantom limb pain?J Fam Pract 2009;58:155Y8
21. Mailis A, Furlan A: Sympathectomy for neuropathicpain. Cochrane Database Syst Rev 2003:CD002918
22. Sherman RA, Sherman CJ, Gall NG: A survey ofcurrent phantom limb pain treatment in the UnitedStates. Pain 1980;8:85Y99
23. Flor H, Denke C, Schaefer M, et al: Effect of sensorydiscrimination training on cortical reorganisationand phantom limb pain. Lancet 2001;357:1763Y4
24. Birbaumer N, Lutzenberger W, Montoya P, et al:Effects of regional anesthesia on phantom limb painare mirrored in changes in cortical reorganization.J Neurosci 1997;17:5503Y8
25. Pool JL: Posterior cordotomy for relief of phantomlimb pain. Ann Surg 1946;124:386Y91
26. Huse E, Larbig W, Flor H, et al: The effect of opioidson phantom limb pain and cortical reorganization.Pain 2001;90:47Y55
27. Muraoka M, Komiyama H, Hosoi M, et al: Psychoso-matic treatment of phantom limb pain with post-traumatic stress disorder: A case report. Pain 1996;66:385Y8
28. Lotze M, Grodd W, Birbaumer N, et al: Does use of amyoelectric prosthesis prevent cortical reorganiza-tion and phantom limb pain? Nat Neurosci 1999;2:501Y2
29. Halbert J, Crotty M, Cameron ID: Evidence for theoptimal management of acute and chronic phantompain: a systematic review. Clinical J Pain 2002;18:84Y92
30. Oakley DA, Whitman LG, Halligan PW: Hypnoticimagery as a treatment for phantom limb pain: Twocase reports and a review. Clin Rehabil 2002;16:368Y77
31. Benn R, Moura V, Sill M: Mind-Body Skills Group forWomen with History of Abuse: A Pilot Study. AnnArbor, MI, University of Michigan, 2009
32. Schneider J, Hofmann A, Rost C, et al: EMDR in thetreatment of chronic phantom limb pain. Pain Med2008;9:76Y82
33. MacIver K, Lloyd DM, Kelly S, et al: Phantom limbpain, cortical reorganization and the therapeutic ef-fect of mental imagery. Brain 2008;131:2181Y91
34. National Center for Complementary and AlternativeMedicine. What Is Complementary and AlternativeMedicine? 2010. Available at: http://nccam.nih.gov/
health/whatiscam/#mindbody. Accessed on October4, 2011
35. Gallagher P, Allen D, Maclachlan M: Phantom limbpain and residual limb pain following lower limbamputation: A descriptive analysis. Disabil Rehabil2001;23:522Y30
36. Balk EM, Raman G, Tatsioni A, et al: Vitamin B6, B12,and folic acid supplementation and cognitive func-tion: a systematic review of randomized trials. ArchIntern Med 2007;167:21Y30
37. Deeks JJ, Dinnes J, D’Amico R, et al: Evaluating non-randomised intervention studies. Health TechnolAssess 2003;7:iiiYx, 1Y173
38. Rickard JA. Effects of Hypnosis in the Treatment ofResidual Stump and Phantom Limb Pain [disserta-tion]. Pullman, WA: Washington State University,2004
39. Brodie EE, Whyte A, Waller B: Increased motorcontrol of a phantom leg in humans results from thevisual feedback of a virtual leg. Neurosci Lett 2003;341:167Y9
40. Bamford C: A multifaceted approach to the treatmentof phantom limb pain using hypnosis. ContempHypnosis 2006;23:115Y26
41. Ramachandran VS: Behavioral and magnetoence-phalographic correlates of plasticity in the adulthuman brain. Proc Natl Acad Sci U S A 1993;90:10413Y20
42. Ramachandran VS, Rogers-Ramachandran D: Syn-aesthesia in phantom limbs induced with mirrors.Proc Biol Sci 1996;263:377Y86
43. Darnall BD: Self-delivered home-based mirror ther-apy for lower limb phantom pain. Am J Phys MedRehabil 2009;88:78Y81
44. MacLachlan M, McDonald D, Waloch J: Mirrortreatment of lower limb phantom pain: A case study.Disabil Rehabil 2004;26:901Y4
45. Murray CD, Patchick E, Pettifer S, et al: Immer-sive virtual reality as a rehabilitative technology forphantom limb experience: A protocol. CyberpsycholBehav 2006;9:167Y70
46. Murray CD, Patchick EL, Caillette F, et al: Canimmersive virtual reality reduce phantom limb pain?Stud Health Technol Inform 2006;119:407Y12
47. Hanling SR, Wallace SC, Hollenbeck KJ, et al: Pre-amputation mirror therapy may prevent developmentof phantom limb pain: a case series. Anesth Analg2010;110:611Y4
48. Wilcher DG, Chernev I, Yan K: Combined mirror vi-sual and auditory feedback therapy for upper limbphantom pain: a case report. J Med Case Reports2011;5:41
49. Mercier C, Sirigu A: Training with virtual visualfeedback to alleviate phantom limb pain. Neuro-rehabil Neural Repair 2009;23:587Y94
50. Sumitani M, Miyauchi S, McCabe CS, et al: Mir-ror visual feedback alleviates deafferentation pain,
12 Moura et al. Am. J. Phys. Med. Rehabil. & Vol. 91, No. 3, March 2012
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
depending on qualitative aspects of the pain: A pre-liminary report. Rheumatology (Oxford) 2008;47:1038Y43
51. Cole J, Crowle S, Austwick G, et al: Exploratoryfindings with virtual reality for phantom limb pain;from stump motion to agency and analgesia. DisabilRehabil 2009;31:846Y54
52. American Society of Clinical Hypnosis: Definition ofhypnosis. 2010; Available at: http://www.asch.net/Public/GeneralInfoonHypnosis/DefinitionofHypnosis/tabid/134/Default.aspx. Accessed September 20, 2011
53. Wickramaskera I: Hypnotherapy, in: Moss D, McGradyA, Davies TC, et al (eds): Handbook for Mind-BodyMedicine for Primary Care. Thousand Oaks, CA: SagePublications, Inc, 2003, pp. 151Y66
54. Montgomery GH, DuHamel KN, Redd WH: A meta-analysis of hypnotically induced analgesia: How ef-fective is hypnosis? Int J Clin Exp Hypn 2000;48:138Y53
55. Patterson DR, Jensen MP: Hypnosis and clinical pain.Psychol Bull 2003;129:495Y521
56. Jensen M, Patterson DR: Hypnotic treatment ofchronic pain. J Behav Med 2006;29:95Y124
57. Integration of behavioral and relaxation approachesinto the treatment of chronic pain and insomnia. NIHTechnology Assessment Panel on Integration of Be-havioral and Relaxation Approaches into the Treat-ment of Chronic Pain and Insomnia. JAMA 1996;276:313Y8
58. Achterberg J, Lawlis F: Imagery and health inter-vention. Top Clin Nurs 1982;3:55Y600
59. Lyon DE, Taylor AG: Nursing education for mind-body nursing, in: Moss D, McGrady A, Davies TC,Wickramasekera J (eds): Handbook of Mind-BodyMedicine for Primary Care. Thousand Oaks, CA:Sage, 2003, pp. 449Y56
60. Bresler DE, Rossman ML: History of guided im-agery. 2003; Available at: http://www.healthyroads.com/mylibrary/dala/ash_rel/htm/arl_historyofguidedimagery.asp. Accessed September 7, 2009
61. Barnes PM, Bloom B, Nahin RL: Complementary andalternative medicine use among adults and children:United States, 2007. Natl Health Stat Report 2008;4:1Y23
62. Heinschel JA: A descriptive study of the interactiveguided imagery experience. J Holist Nurs 2002;20:325Y46; quiz 347-51
63. Moseley GL: Graded motor imagery for pathologicpain: A randomized controlled trial. Neurology 2006;67:2129Y34
64. Zuckweiler RL: Zuckweiler’s Image Imprinting in thetreatment of phantom pain: Case reports. J ProsthetOrthot 2005;17:113Y8
65. McAvinue LP, Robertson IH: Individual differences inresponse to phantom limb movement therapy. Dis-abil Rehabil 2011;33:2186Y95
66. Beaumont G, Mercier C, Michon PE, et al: Decreasing
phantom limb pain through observation of actionand imagery: A case series. Pain Med 2011;12:289Y99
67. Zuckweiler RL, Kaas MJ: Treating phantom painand sensation with Zuckweiler’s Image Imprinting.J Prosthet Orthot 2005;17:103Y12
68. Flor H: The modification of cortical reorganizationand chronic pain by sensory feedback. Appl Psycho-physiol Biofeedback 2002;27:215Y27
69. Nikolajsen L, Jensen TS: Phantom limb pain. Br JAnaesth 2001;87:107Y16
70. Weeks SR, Anderson-Barnes VC, Tsao JW: Phantomlimb pain: Theories and therapies. Neurologist 2010;16:277Y86
71. Shaffer F, Moss D: Biofeedback, in Yuan C, Bieber EJ,Bauer JA (eds): Textbook of Complementary andAlternative Medicine. London, UK, Informa Health-care, 2006, pp.291Y311
72. Katz J: Psychophysical correlates of phantom limbexperience. J Neurol Neurosurg Psychiatry 1992;55:811Y21
73. Wahren LK: Changes in thermal and mechanical painthresholds in hand amputees. A clinical and physio-logical long-term follow-up. Pain 1990;42:269Y77
74. Sherman RA, Ernst JL, Markowski J: Relationshipsbetween near surface blood flow and altered sensa-tions among spinal cord injured veterans. Am J PhysMed 1986;65:281Y97
75. Cronholm B: Phantom limbs in amputees; a study ofchanges in the integration of centripetal impulseswith special reference to referred sensations. ActaPsychiatr Neurol Scand Suppl 1951;72:1Y310
76. Sherman RA, Gall N, Gormly J: Treatment of phan-tom limb pain with muscular relaxation training todisrupt the painYanxietyYtension cycle. Pain 1979;6:47Y55
77. Belleggia G, Birbaumer N: Treatment of phantomlimb pain with combined EMG and thermal biofeed-back: A case report. Appl Psychophysiol Biofeedback2001;26:141Y6
78. Harden RN, Houle TT, Green S, et al: Biofeedback inthe treatment of phantom limb pain: A time-seriesanalysis. Appl Psychophysiol Biofeedback 2005;30:83Y93
79. McCabe C: Mirror visual feedback therapy. A practicalapproach. J Hand Ther 2011;24:170Y8; quiz 179
80. de Vries S, Mulder T: Motor imagery and stroke re-habilitation: A critical discussion. J Rehabil Med2007;39:5Y13
81. Ramachandran VS, Altschuler EL: The use of visualfeedback, in particular mirror visual feedback, inrestoring brain function. Brain 2009;132:1693Y710
82. Flor H, Nikolajsen L, Staehelin Jensen T: Phantomlimb pain: A case of maladaptive CNS plasticity? NatRev Neurosci 2006;7:873Y81
83. Flor H: Phantom-limb pain: Characteristics, causes,and treatment. Lancet Neurol 2002;1:182Y9
www.ajpmr.com Treatment of Phantom Limb Pain 13
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
84. Melzack R: Phantom limbs and the concept of aneuromatrix. Trends Neurosci 1990;13:88Y92
85. Harden RN, Gagnon CM, Khan A, et al: Hypoesthesiain the distal residual limb of amputees. PM R 2010;2:607Y11
86. Dougherty J: Relief of phantom limb pain after EMGbiofeedback-assisted relaxation: A case report. BehavRes Ther 1980;18:355Y7
87. Gagne M, Reilly KT, Hetu S, et al: Motor control overthe phantom limb in above-elbow amputees and itsrelationship with phantom limb pain. Neuroscience2009;162:78Y86
88. Raffin E, Giraux P, Reilly KT: The moving phantom:Motor execution or motor imagery? Cortex 2011
89. Anderson WS, Weiss N, Lawson HC, et al: Demon-stration of motor imagery movement and phantommovement-related neuronal activity in human thal-amus. Neuroreport 2011;22:88Y92
90. Sherman RA, Bruno GM: Concurrent variation ofburning phantom limb and stump pain with near
surface blood flow in the stump. Orthopedics 1987;10:1395Y1402
91. Ludwig DS, Kabat-Zinn J: Mindfulness in medicine.JAMA 2008;300:1350Y2
92. Teixeira ME: Meditation as an intervention forchronic pain: an integrative review. Holist Nurs Pract2008;22:225Y34
93. Kabat-Zinn J: An outpatient program in behavioralmedicine for chronic pain patients based on thepractice of mindfulness meditation: Theoreticalconsiderations and preliminary results. Gen HospPsychiatry 1982;4:33Y47
94. Ospina MB, Bond K, Karkhaneh M, et al: Clinicaltrials of meditation practices in health care: char-acteristics and quality. J Altern Complement Med2008;14:1199Y213
95. Jensen MP, Barber J, Hanley MA, et al: Long-termoutcome of hypnotic-analgesia treatment for chronicpain in persons with disabilities. Int J Clin Exp Hypn2008;56:156Y69
14 Moura et al. Am. J. Phys. Med. Rehabil. & Vol. 91, No. 3, March 2012
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.