How To Use Mirror Therapy for Phantom Limb Pain: Instructions for Upper and Lower Limb Loss Patients

Tripartite Mirror Apparatus

Tripartite Mirror Apparatus

A mirror has been used previously to reduce or eliminate phantom limb pain in amputees and to generate phantom sensations (e.g., tingling) in normal subjects (Ramachandran & Rogers-Ramachandran, 1996).  I have developed a new apparatus that has generated intense phantom sensations in pilot participants (missing left arms) who experienced little relief following standard mirror treatment (missing limb behind a single mirror held at an angle).  The Tripartite Mirror Apparatus (TMA) uses three vertical mirrors, with panes oriented at angles and the use of a single mirror held at ninety degrees facing the mirrors.  The TMA enable viewers to see unusual multiple images of themselves from the side and the illusion of the missing limb intact (see below).  When both the individuals moved their remaining arms and hands while viewing the modified images, they experienced sensations and a sense of movement in the missing limb. This author is one of those individuals who have experienced complete and permanent cessation of phantom pain following use of the TMA.  The method induces sensations of tingling, movement, and temperature change in the hands and arms of some normal individuals (Peterzell, Cone, McQuaid, & Ramachandran, 2006).  The theory proposes that when a patient gets visual feedback that the phantom is obeying the brain’s commands; the learned paralysis is sometimes “unlearned.”  This suggests that a remarkably simple, inexpensive, and portable pain management program that uses visual input may be an effective and rapid-acting phantom limb pain treatment (Ramachandran, 2004).

Instructions: Mirror Practice – Protocol for Upper Limb Amputees Using a Three-panel Mirror

Instruction for using this simple pain management instrument for upper limb loss is as follows.  Select a comfortable standing/sitting position with your prosthesis off.  Close your eyes and focus your attention on your breathing.  Notice each breath as you inhale and exhale.  Notice the feeling of the air going into your lungs, your lungs expanding.  Notice the feeling of the air going out of your mouth or nose, with your lungs deflating.  Systematically relax the muscles in your body.  Relax your forehead, jaw, and tongue, feel your body relaxing, letting oxygen flow in and out of your lungs.  Continue to scan your body as you relax your shoulders, chest, stomach, legs and feet. When you are in a relaxed state, stand facing the center pane, place the amputated limb behind the angled mirror and open and close/move the surviving hand while viewing the reflections.  Your amputated limb should be hidden behind one of the side mirrors, as shown.  While facing the mirror, raise the intact arm and hand, as if to take an oath.  Without changing posture, look into the side pane, as shown, and adjust the angle of the hinged mirror until you see a rotated image of yourself.  When the mirror is viewed this way, it creates the illusion that your missing limb is intact, and that you can see it from the side.  Concentrate on the multiple visual images in the mirror appearing as if your amputated limb is in fact intact and moving freely.  To the best of your ability do not look at or focus on the moving of your actual intact limb.  Focus your visual attention on the illusion in the mirror.  Spend 15 minutes per day viewing the image and especially at any time you are experiencing a phantom limb pain episode.

Instructions: Mirror Practice – Protocol for Lower Limb Amputees Using a Three-panel Mirror

Select a comfortable sitting position with your prosthesis off.  Close your eyes and focus your attention on your breathing.  Notice each breath as you inhale and exhale.  Notice the feeling of the air going into your lungs, your lungs expanding.  Notice the feeling of the air going out of your mouth or nose, with your lungs deflating.  Systematically relax the muscles in your body.  Relax your forehead, jaw, and tongue, feel your body relaxing, letting oxygen flow in and out of your lungs. Continue to scan your body as you relax your shoulders, chest, stomach, legs and feet. When you are in a relaxed state sit facing the center pane, place the amputated limb behind the angled mirror Your amputated limb should be hidden behind one of the side mirrors, as shown.

While facing the mirror, raise your intact leg and foot, noticing the movement of your reflected leg.  Without changing posture, look into the side pane, as shown, and adjust the angle of the hinged mirror until you see a rotated image of yourself. When the mirror is viewed this way, it creates the illusion that your missing limb is intact, and that you can see it from the side.  Your task is to view the reflection of your intact leg and foot in the mirror, and imagine that the reflection that you see is, in fact, your missing limb.  Move your intact leg by bending your joints (e.g., toes, ankle, knee and thigh) in various ways.  You may want to imagine that you are telling both legs to move together, moving them as you did before the amputation.  Concentrate on the multiple visual images in the mirror appearing as if your amputated limb is in fact intact and moving freely.  To the best of your ability do not look at or focus on the moving of your actual intact limb.  Focus your visual attention on the illusion in the mirror.  Spends 15 minutes viewing the image per day and especially at any time you are experiencing a phantom limb pain episode.

For more mirror pictures you can read my article, Limb Loss: Seeking Relief Through the Looking Glass in InMotion magazine by clinking this link: http://www.amputee-coalition.org/inmotion_online/inmotion-22-06-web/#/1/

FOR INDIVIDUALS WITH LIMB LOSS, PLEASE CLICK ON  THIS LINK FOR RESOURCES AND SUPPORT FROM THE AMPUTEE COALITION http://www.amputee-coalition.org/

Dr. Cone is the developer of the Tripartite Mirror Apparatus (TMA) for the treatment of phantom limb pain.  A clinical trial has recently been completed with a cognitive behavioral intervention integrated with the TMA to treat phantom limb pain and psychosocial disability at the Veterans Administration Healthcare System. Published study results are expected in 2013. 

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2 thoughts on “How To Use Mirror Therapy for Phantom Limb Pain: Instructions for Upper and Lower Limb Loss Patients

  1. Dear Dr. Cone,
    my grandfather recently had a transfemoral amputation, and is suffering from PLP.
    I haven’t been able to find a health care professional in his home town who could provide mirror treatment, so I’m writing to you for help.
    In the videos I’ve seen on mirror therapy with a single mirror, the patient has been sitting on a bed with their remaining leg stretched out in front of them, and the mirror between their legs. I’m wondering about the three-panel mirror, should the patient be sitting on the edge of the bed with their remaining foot on the floor, and the mirror standing in the same position as with the patient in your pictures with the amputated arm?
    Thank you for your articles, they contain the clearest instructions I’ve been able to find!
    Gratefully yours,
    Sara K
    Turku, Finland

    • Sara,
      Thank you for writing to me. Your grandfather can sit forward in a chair or on the edge of his bed. A chair will be more supportive and maybe safer. The mirror needs to be close enough to his body so his amputated limb is hidden behind one of the side mirrors. Then he can follow the suggested movements mentioned in the post. I will be sure to add a picture for the lower limb loss person. Thank you for bringing it to my attention.
      Best Regards,
      Roberta

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