Home Medicine Relief of phantom limb pain using mirror therapy: A bit more optimism from retrospective analysis of two studies
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Relief of phantom limb pain using mirror therapy: A bit more optimism from retrospective analysis of two studies

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Published/Copyright: April 1, 2017
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 15 Issue 1

In this issue of the Scandinavian Journal of Pain, Griffin and colleagues [1] have presented a rather unique analysis of data from two previous studies on mirror therapy for the treatment of phantom limb pain (PLP) of the lower extremity after amputation. One of the previous studies has been published [2], the other has been submitted for publication. The primary outcome of the Griffin et al. study was to assess the time to response and if the treatment response time was different with different levels of baseline pain.

1 Mirror therapy takes longer, up to 21 sessions, to work in patients with severe phantom pain

Indeed, those with less severe pain had a more rapid response, which was sustained over the course of treatment. The treatment paradigm consisted of five sessions (15 min long) per week for four weeks. Those amputees with the highest pain levels (VAS 6–10) had a slower response, not seen until the 21st session and, as with those in the other two groups, this effect persisted until therapy was completed at four weeks. These findings are important since many trials of mirror therapy are quite short and both patient and therapist may be discouraged with the lack of effect during a short course but had they persisted, perhaps there would have been a better outcome as seen here.

2 Throbbing, shooting, sharp, and tender pain components are relieved best by mirror therapy

A secondary outcome was to analyze which pain descriptors from the McGill Pain Questionnaire were improved in response to mirror therapy. Several showed a marked improvement, even with such a small cohort of subjects. Those with the strongest improvement were “throbbing”, “shooting”, “sharp” and “tender” (p = ≤ .0004) and these symptoms could function as predictors of a positive response to mirror therapy in the clinical setting.

3 Multiple varieties of protocols for mirror-therapy

Mirror therapy, although suggested by Ramachandran et al. in 1999 [3] for the treatment of PLP, has been poorly studied overall and the results have been variable [4]. For PLP, the poor results are possibly due to (1) the timing of the institution of the therapy, (2) the cause for amputation, (3) the age of the patients, (4) the severity of the baseline pain and (5) inconsistencies in treatment protocols.

4 Most therapies for phantom pain lack sufficient evidence of effect

Pharmacotherapy has been discouraging and a critique of the literature is available in the latest Cochrane Database Systemic Review [5]. The problem is with no evidence for effect for most medications for neuropathic pain and only short-term effects shown for analgesics. The studies are difficult to interpret because of small sample size and short follow up. It is evident that there is a need for other forms of therapy and mirror therapy has become popular. A recent review on mirror therapy for PLP is also discouraging and states “We cannot recommend MT as a first intention treatment for PLP. The level of evidence is insufficient” [4]. Again, poor studies are cited.

5 Mirror therapy may help and has no adverse effects: try it early and keep at it

However, the data in this study by Griffin et al. allows a bit more optimism. The two studies that their data are extracted from show a very high response rate with a minimal intervention for each session but with a rather long treatment period. In the first study, the response rate was well over 90%, a remarkable result [2]. The combined high rate of response – 87% – perhaps is due to this being an early intervention since most subjects entered the study at about one month after amputation. Early treatment presents two possible confounding variables. One is that there is often an early improvement in PLP [6] in most epidemiological studies but then an increase again after about a year [7]. In this present study data, over 50% of the participants were treated in the first two months after amputation and the end of the study period in the published study was just 8 weeks later. This would mean that treatment was during the early improvement phase of PLP and would miss the later rebound if the studies showing this time course are correct. Therefore, a part of the improvement could be due to the natural history of PLP. It is interesting to speculate that in some way, the cortical reorganization seen during the evolution of PLP could be altered to change the course of this process [8]. If this is so, early intervention with mirror therapy would be very important for the best outcome.

6 The younger patients have less phantom-pain after traumatic amputation

The age of the subjects might also influence the outcome and the majority were young individuals. Data on older individuals shows that the prevalence of PLP can be as high as 80% [9]. Data from children and teenagers show that this group has a much lower prevalence/incidence of PLP but there is no good data on stratification of the prevalence/incidence of PLP by age [10].

7 Will optimal perioperative pain management reduce risk of phantom pain?

There is also data that correlates the severity of PLP to preamputation pain and post-operative pain [11]. The once hopeful reports that perioperative epidural analgesia reduced stump and phantom pain, were not confirmed by Nikolajsen et al. [12], although in that study the control group also had prolonged epidural analgesia after amputation. We have no information concerning the pain state of the individuals in this study by Griffin et al. either pre- or post-operatively and if they had very good pain control in the perioperative period, this might be a factor in explaining the high success rate of the mirror therapy since one would expect a more rapid improvement in PLP based on good perioperative pain control.

8 “Irritable” pain phenotypes may be better pain candidates for mirror-therapy?

This study brings up another point worth emphasizing [1]. In pain research, there is a new emphasis on focusing on pain phenotypes for research and therapy rather than diagnoses. This has been proposed formally by the IMMPACT group [13]. The evidence in this study offers an opportunity to select a phenotype for further research in mirror therapy, i.e. young, recent amputees with pain symptoms of “throbbing”, “shooting”, “sharp” and “tender” using the simple protocol from the two studies reanalyzed here.

9 There is much to be done!

There certainly is much to be done before we understand phantom limb pain. We lack consistent research in large populations on the demography of PLP. We lack consistency in protocols using mirror therapy for PLP and the protocols are many. We lack information on different phenotypes in the PLP population. There are perhaps a few bright spots in this picture, however. A study protocol addressing some of these issues has been proposed and will be used in the future [14]. There is hope that sufficient subjects can be recruited to make this a significant step forward. There has also been a DELPHI consensus meeting [15] that reviews the various treatment options and also presents a panel opinion on various aspects of mirror therapy that should be considered in research and treatment paradigms. The two studies that provided data for this article are promising since the response rate was so high. Both had control data similar to a placebo treatment that improved the quality of the studies. The small numbers of subjects in the studies is a weakness, however, that may be a source of bias seen in most of the published studies on PLP.

The present study by Griffin et al. published here adds important data on treatment trajectory and associated symptoms involved in the symptom improvement with mirror therapy for PLP that expands the present knowledge of this difficult problem [1].

10 Mirror therapy also for Complex Regional Pain Syndrome (CRPS)?

CRPS is another enigmatic pain condition that is difficult to treat. Pain modulator systems and limb representation appear to be disturbed in the CNS of patients with longstanding CRPS, and similar to phantom limb pain, CRPS has been miraculously improved with mirror therapy [16].

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2017.01.007.

Pain Center, Akademiska Sjukhuset, 751 85 Uppsala, Sweden. Fax: +46 18 503539.
stevmarg@telia.com

  1. Conflict of interest: None declared.

References

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Published Online: 2017-04-01
Published in Print: 2017-04-01

© 2017 Scandinavian Association for the Study of Pain

Articles in the same Issue

  2. Scandinavian Journal of Pain
  3. Editorial comment
  4. Cardiovascular risk reduction as a population strategy for preventing pain?
  5. Observational study
  6. Diabetes mellitus and hyperlipidaemia as risk factors for frequent pain in the back, neck and/or shoulders/arms among adults in Stockholm 2006 to 2010 – Results from the Stockholm Public Health Cohort
  7. Editorial comment
  8. Exercising non-painful muscles can induce hypoalgesia in individuals with chronic pain
  9. Clinical pain research
  10. Exercise induced hypoalgesia is elicited by isometric, but not aerobic exercise in individuals with chronic whiplash associated disorders
  11. Editorial comment
  12. Education of nurses and medical doctors is a sine qua non for improving pain management of hospitalized patients, but not enough
  13. Observational study
  14. Acute pain in the emergency department: Effect of an educational intervention
  15. Editorial comment
  16. Home training in sensorimotor discrimination reduces pain in complex regional pain syndrome (CRPS)
  17. Original experimental
  18. Pain reduction due to novel sensory-motor training in Complex Regional Pain Syndrome I – A pilot study
  19. Editorial comment
  20. How can pain management be improved in hospitalized patients?
  21. Original experimental
  22. Pain and pain management in hospitalized patients before and after an intervention
  23. Editorial comment
  24. Is musculoskeletal pain associated with work engagement?
  25. Clinical pain research
  26. Relationship of musculoskeletal pain and well-being at work – Does pain matter?
  27. Editorial comment
  28. Preoperative quantitative sensory testing (QST) predicting postoperative pain: Image or mirage?
  29. Systematic review
  30. Are preoperative experimental pain assessments correlated with clinical pain outcomes after surgery? A systematic review
  31. Editorial comment
  32. A possible biomarker of low back pain: 18F-FDeoxyGlucose uptake in PETscan and CT of the spinal cord
  33. Observational study
  34. Detection of nociceptive-related metabolic activity in the spinal cord of low back pain patients using 18F-FDG PET/CT
  35. Editorial comment
  36. Patients’ subjective acute pain rating scales (VAS, NRS) are fine; more elaborate evaluations needed for chronic pain, especially in the elderly and demented patients
  37. Clinical pain research
  38. How do medical students use and understand pain rating scales?
  39. Editorial comment
  40. Opioids and the gut; not only constipation and laxatives
  41. Observational study
  42. Healthcare resource use and costs of opioid-induced constipation among non-cancer and cancer patients on opioid therapy: A nationwide register-based cohort study in Denmark
  43. Editorial comment
  44. Relief of phantom limb pain using mirror therapy: A bit more optimism from retrospective analysis of two studies
  45. Clinical pain research
  46. Trajectory of phantom limb pain relief using mirror therapy: Retrospective analysis of two studies
  47. Editorial comment
  48. Qualitative pain research emphasizes that patients need true information and physicians and nurses need more knowledge of complex regional pain syndrome (CRPS)
  49. Clinical pain research
  50. Adolescents’ experience of complex persistent pain
  51. Editorial comment
  52. New knowledge reduces risk of damage to spinal cord from spinal haematoma after epidural- or spinal-analgesia and from spinal cord stimulator leads
  53. Review
  54. Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors
  55. Review
  56. Neuraxial blocks and spinal haematoma: Review of 166 cases published 1994 – 2015. Part 2: diagnosis, treatment, and outcome
  57. Editorial comment
  58. CNS–mechanisms contribute to chronification of pain
  59. Topical review
  60. A neurobiologist’s attempt to understand persistent pain
  61. Editorial Comment
  62. The triumvirate of co-morbid chronic pain, depression, and cognitive impairment: Attacking this “chicken-and-egg” in novel ways
  63. Observational study
  64. Pain and major depressive disorder: Associations with cognitive impairment as measured by the THINC-integrated tool (THINC-it)
https://doi.org/10.1016/j.sjpain.2017.01.005

Articles in the same Issue

  2. Scandinavian Journal of Pain
  3. Editorial comment
  4. Cardiovascular risk reduction as a population strategy for preventing pain?
  5. Observational study
  6. Diabetes mellitus and hyperlipidaemia as risk factors for frequent pain in the back, neck and/or shoulders/arms among adults in Stockholm 2006 to 2010 – Results from the Stockholm Public Health Cohort
  7. Editorial comment
  8. Exercising non-painful muscles can induce hypoalgesia in individuals with chronic pain
  9. Clinical pain research
  10. Exercise induced hypoalgesia is elicited by isometric, but not aerobic exercise in individuals with chronic whiplash associated disorders
  11. Editorial comment
  12. Education of nurses and medical doctors is a sine qua non for improving pain management of hospitalized patients, but not enough
  13. Observational study
  14. Acute pain in the emergency department: Effect of an educational intervention
  15. Editorial comment
  16. Home training in sensorimotor discrimination reduces pain in complex regional pain syndrome (CRPS)
  17. Original experimental
  18. Pain reduction due to novel sensory-motor training in Complex Regional Pain Syndrome I – A pilot study
  19. Editorial comment
  20. How can pain management be improved in hospitalized patients?
  21. Original experimental
  22. Pain and pain management in hospitalized patients before and after an intervention
  23. Editorial comment
  24. Is musculoskeletal pain associated with work engagement?
  25. Clinical pain research
  26. Relationship of musculoskeletal pain and well-being at work – Does pain matter?
  27. Editorial comment
  28. Preoperative quantitative sensory testing (QST) predicting postoperative pain: Image or mirage?
  29. Systematic review
  30. Are preoperative experimental pain assessments correlated with clinical pain outcomes after surgery? A systematic review
  31. Editorial comment
  32. A possible biomarker of low back pain: 18F-FDeoxyGlucose uptake in PETscan and CT of the spinal cord
  33. Observational study
  34. Detection of nociceptive-related metabolic activity in the spinal cord of low back pain patients using 18F-FDG PET/CT
  35. Editorial comment
  36. Patients’ subjective acute pain rating scales (VAS, NRS) are fine; more elaborate evaluations needed for chronic pain, especially in the elderly and demented patients
  37. Clinical pain research
  38. How do medical students use and understand pain rating scales?
  39. Editorial comment
  40. Opioids and the gut; not only constipation and laxatives
  41. Observational study
  42. Healthcare resource use and costs of opioid-induced constipation among non-cancer and cancer patients on opioid therapy: A nationwide register-based cohort study in Denmark
  43. Editorial comment
  44. Relief of phantom limb pain using mirror therapy: A bit more optimism from retrospective analysis of two studies
  45. Clinical pain research
  46. Trajectory of phantom limb pain relief using mirror therapy: Retrospective analysis of two studies
  47. Editorial comment
  48. Qualitative pain research emphasizes that patients need true information and physicians and nurses need more knowledge of complex regional pain syndrome (CRPS)
  49. Clinical pain research
  50. Adolescents’ experience of complex persistent pain
  51. Editorial comment
  52. New knowledge reduces risk of damage to spinal cord from spinal haematoma after epidural- or spinal-analgesia and from spinal cord stimulator leads
  53. Review
  54. Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors
  55. Review
  56. Neuraxial blocks and spinal haematoma: Review of 166 cases published 1994 – 2015. Part 2: diagnosis, treatment, and outcome
  57. Editorial comment
  58. CNS–mechanisms contribute to chronification of pain
  59. Topical review
  60. A neurobiologist’s attempt to understand persistent pain
  61. Editorial Comment
  62. The triumvirate of co-morbid chronic pain, depression, and cognitive impairment: Attacking this “chicken-and-egg” in novel ways
  63. Observational study
  64. Pain and major depressive disorder: Associations with cognitive impairment as measured by the THINC-integrated tool (THINC-it)
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