Mirror, virtual reality treatments for PLP more successful than traditional pharmaceuticals

Mirror Visual Feedback (MVF) discovered by Ramachandran and Altschuler in 1993 addresses "the issue of phantom pain by creating an illusion with a mirror in a box that was placed in front of the patient in such a way that the missing limb could be seen as a reflection of the remaining limb." (Hagenberg et al, 2013) Treatment plans throughout the world vary in materials, length, frequency, location, and more, but a consensus on some aspects was identified among practitioners. All agreed that "patient education and preparation, individual set up, face-to-face guidance, and reassessment", and most agreed on the importance of a quiet setting and familiarity with the patient's PLP triggers. A randomized, double-blind, active placebo controlled, crossover trial at Walter Reid Army Medical Center demonstrated dramatic success of MVF.  Although MVF seems to have provided a panacea for many PLP sufferers, there exists limited research about which percent of patients experience adverse effects. Those that have been identified are listed from most frequent to least and include "emotional reactions, pain increase, sensory changes, dizziness, nausea, telescoping, freezing of the phantom limb, overall sweating, sweating of the phantom limb, and spontaneous movements of the phantom limb". (Hagenberg, et al, 2013) Emotional reactions ranged from amazement to depression. If adverse effects can be tolerated, MVF may be an excellent option because it may help the patient enough to avoid the need for opioids and similar drugs with effects like sedation that may limit activity.

The use of mirror therapy demonstrated at Walter Reid Army Medical Center

https://www.youtube.com/watch?v=YL_6OMPywnQ

In our technology-driven world, the logical extension of mirror therapy is virtual reality therapy, which is shown below. No evidence shows that it works better than mirror therapy, and it requires expensive equipment that fewer people to which fewer patients have access. That being said, perhaps it has the potential to become even better than mirror therapy!

Virtual Reality for PLP

https://www.youtube.com/watch?v=0wp-SigTeLs

Opioids are the most frequently prescribed drug category to treat PLP, and while "morphine has shown to be effective in decreasing PLP in some instances", it comes with a high rate of undesirable side effects.  (Weeks, et al, 2010, 281) Treatment with anticonvulsants like Gabapentin shows conflicting results, as does treatment with tricyclic antidepressants. Drugs such as ketamine have shown promising initial results, but controlled trials have not been performed. Finally, treatment with transcutaneous electrical nerve stimulation (TENS) on the side of the remaining limb provided mild to moderate pain relief in some studies.

Sources:

Weeks, S. R., Anderson-Barnes, V. C., & Tsao, J. W. (2010, September). Phantom Limb Pain Theories and Therapies. The Neurologist, 16(5), 277-286.

Hagenberg, A., & Carpenter, C. (2014, August). Visual Feedback for Phantom Pain: International Experience on Modalities and Adverse Effects Discussed by an Expert Panel: A Delphi Study. PM&R, 6(8), 708-715.