Relieving phantom limp pain using mirror therapy is a presentation on a case study, where a clinical psychologist used mirror therapy to relieve phantom limp pain in a patient

1. Relieving phantom limb pain;
the use of mirror therapy

2. Science does not deal with subjective experience...
Well that's too bad because that is all any of us ever
have.
Terence McKenna

3. Outline
• Case presentation (Patient X)
• Phantom limb sensation & pain
• Mirror therapy
• Virtual Reality (VR) as new wave therapy
• Back to Patient X
• Before, During and After

4. Case Presentation
• Background: Client was seen by Lt Col Tenteh and his team prior to
amputation.
• 4 Post Operation management sessions for 32 y/o patient X.
• Client is married with 2 children.
• Lively, engaging during sessions.
• She had comminuted fracture of the mid Tib-Fib (Right leg) after a
RTA.
• Attempts were made towards saving the leg (Fasciotomy, wound
debridement) but was unsuccessful. Client’s gangrenous right foot
was amputated above the knee.

5. Case Presentation
• Presenting complaints from post op sessions:
• Client reported an incessant itch on her amputated leg.
• Fluids running down the amputated limb
• Eats well. Her sleep is usually disturbed because of the itch.
• She misses walking and would want the prosthetic leg as soon as possible.
• Family makes her sad because they cry when they visit her. Anxious to face the world of
gossip.
• Does not know how to face her children hanging on one leg and clutches.
(Goal of therapy was on supportive therapy and Body image perception)
• 2nd session:
• Appeared dull on account of loss of sleep from pain in the phantom limb.
• Pain in her phantom toe and calf and she does not know how to relax it.
• Complication adjusting to sleeping positions
• Visual Analogue Scale (VAS) of 7. Reported bothered about the pain and would hate to go
home with it. (The goal of therapy shifted to alleviating pain perception)

6. Phantom limb sensation and pain
• Majority of amputees can still feel it to its finest detail.
• In some cases people born without a limp can feel a phantom.
• Phantom limb pain:
• Perceive impression/continued sensation of pain from a limb that was lost/
amputated.
• Affects about 85% of amputees with 60% being affected for over a
year.
• First case: 18th century British admiral Lord Nelson; His view was that
phantom sensations were proof of the indestructible soul.

7. Phantom limb sensation and pain
• Others thought it was psychological- we cannot accept the loss of the
limb and we fantasize about it.
• Accuracy of sensations suggests that we are born with a map of the
body in our brains.
• Representations/systems responsible for various activities- automated.
• 2 theories :
• Inactive brain cell reassignment due to neuroplasticity; the amount of shift
directly relates to phantom limb pain.
• Cortical homunculus- representation based on proportion. Injured body parts
receive heightened sensation that alert danger.

8. Phantom limb sensation and pain
• Sensory residue: CNS and most sensory receptors outside the severed
limb.
• Neuroma: at the stamp of amputation, nerve endings thicken and
become more sensitive transmitting distress signals at the mildest
pressure. Normally curtailed by the dorsal horn of the spinal cord-losses
inhibitory control after amputation.
• Mismatch theory: visual and proprioception pathway mismatch.
• Basically we don’t know why phantom limb pain happens!
• Effects; tingling, cramping, heat/cold sensations, shooting sensations of
pain.
• Described as stepping on coal, puranas, leg on fire
• Typically people loss of sleep, cry, medicate, angry, afraid to catch things,
fall etc.

9. Treatment
• Time
• Physical therapy
• Pain medication
• Prosthesis (Pain when they take them off)
• Mirror therapy
• Virtual Reality

10. Mirror therapy
• Highly reliant on the mismatch theory. If we can trick the brain to see
the phantom limb, we can increase range of motion and treat pain
through relaxation.
• During Mirror Therapy, you watch a reflection of your intact limb in a
mirror, which creates the visual illusion that both limbs are moving
together.
• Client must be emotionally and mentally ready, willing to try and
persistent in the use of the mirror

12. VR as new wave therapy
• In recent times, VR is used to redesign mirror therapy. It relies on the
same concepts.
• Literature points that Mirror therapy and VR are both equally
efficacious in alleviating PLP, but neither is more effective than
the other.
• However, the ease of use and engagement of multiple senses
makes its results faster than conventional mirror therapy.
• However, mirror therapy offers clinicians an easy-to-use, low
cost therapeutic technique.

13. Back to Patient X
• Therapy was 15-30 mins sessions of mirror therapy 2x.
• Before session: an initial briefing session was conducted explaining
procedure and preparing client mentally ahead of the session.
• During: Client stirred pensively at the reflection of the leg for a while
and was supported and encouraged to go through the procedure. She
underwent box breathing (4/4/4/4) alongside exercises of larger slower
movements.
• After: After the session, client reported a Visual Analogue Scale (VAS) of
4. Client was excited about her achievement.
• In the second session (2 days apart), client reported better sleep. This
session was supervised by therapists and breathing exercises were
incorporated.

14. THANK YOU