Mirror Therapy

***image1***Army Sgt. Nicholas Paupore is using a large mirror to help adjust to the loss of his leg after suffering injuries in an explosion while on duty in Iraq.

His right leg was destroyed when an explosively-formed penetrator ripped through his Humvee just south of Kirkuk, Iraq. By using the mirror, his leg suddenly reappears before his eyes, reflecting the left leg that remains.

Sergeant Paupore was skeptical when Navy Cmdr. (Dr.) Jack Tsao suggested using a mirror to help him deal with the excruciating pain he continued to feel in his missing right leg.

The phenomenon − called “phantom limb pain” − plagues as many as half of all amputees, likely the result of a faulty signal between the brain and the missing appendage, Commander Tsao said. Neurons in the brain continue sending out signals to a limb that’s no longer there. As a result, amputees can feel discomfort or pain and, in some cases, the sense that their missing limb is stuck in an uncomfortable position.

For Sergeant Paupore, a 101st Airborne Division artilleryman who was serving on a military transition team training Iraqi troops when he was wounded in July 2006, the pain felt like electric shocks or knives stabbing into his missing leg.
“It felt like someone was putting an electrode on the back of my ankle,” he said.
Sergeant Paupore tried several different painkillers, including morphine, but none gave him relief.

Commander Tsao, associate professor of neurology at the Uniformed Services University of the Health Sciences in Bethesda, Md., thought he was onto something when he revisited literature he’d first seen while in graduate school. Vilayanur Ramachandran, a neuroscientist at the University of California, San Diego, had come up with mirror therapy to treat phantom limb pain in upper extremities.

Mr. Ramachandran used mirrors so amputees could “see” and “move” their missing limbs to relieve the discomfort. Funding restrictions and lack of a steady stream of amputees prevented Mr. Ramachandran from testing his research through clinical trials.

Commander Tsao, who treats military amputees wounded in Iraq and Afghanistan at Walter Reed Army Medical Center in Washington, D.C., had no such restrictions. With huge Defense Department interest in caring for combat-wounded amputees, he had little trouble selling a treatment that involved little more than a $20 mirror.
He set up a clinical trial and recruited 18 combat-wounded amputees suffering from phantom limb pain to participate.

“I was really skeptical,” Sergeant Paupore said. “But I figured ‘I’m not going anywhere,’ so I’ll try it.”

Commander Tsao randomly assigned the participants into three groups. One group received mirror therapy as advocated by Mr. Ramachandran. One went through the same therapy, but with the mirror covered by a sheet so it didn’t reflect the limb. The third group got no mirror and simply visualized seeing the missing limb in a mirror.

Sergeant Paupore began the trial in the second group, with a covered mirror. After four weeks, he felt little change. But when Commander Tsao switched him to the group using an uncovered mirror so he was able to “see” his missing leg, Sergeant Paupore saw immediate improvement.

Sitting on a hospital bed with his legs fully extended, Sergeant Paupore demonstrated the therapy. He put a standard six-foot-long mirror lengthwise between his left leg and the residual stump on his right side, with the mirror reflecting the intact leg. He moved the leg, watching the movement in the mirror and imagining that his missing leg was making the movements.
The very first time he tried it, he felt something.

“The stump started firing off right away,” Sergeant Paupore said. “It got a little uncomfortable.”

Participants in the trial used the mirror therapy technique 15 minutes a day, five days a week, for four weeks.

“Pain levels seemed to come down after the first week and kept diminishing,” Commander Tsao said.

Every person who used the mirror experienced relief and some reported that their phantom pain disappeared altogether.

Commander Tsao increased the therapy up to eight weeks and saw more success in patients. Many were able to get off their pain medicine altogether or bring their pain levels down to a point where it was manageable with low dosages of drugs, he said.
“The mirror works for most people who have tried it,” Commander Tsao said. “It doesn’t work fully for everyone. Some people are left with some residual pain, but it is better than when they started. For the most part, if you talk to the amputees here, they have actually been able to get off the medications, some sooner than others.”

Those who used the covered mirror or visualization had far less success, Commander Tsao said. Some said their phantom pain actually worsened until they began therapy with an actual mirror.

More than a year after completing his mirror therapy, Sergeant Paupore said he still experiences occasional phantom pain, but “only once in a great while.” He is off painkillers altogether.

“It tricks your brain into thinking your leg is still there, so it’s not misfiring,” he said. “I don’t know how it works, but it works.”