Military Medicine Comes Up with Novel Treatments for Phantom Limb: Pain Persists After Amputation

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By Sandra Basu

WASHINGTON — In October 2010, Marine Lance Cpl. Sebastian Gallegos stepped into a canal in Afghanistan just as a comrade stumbled onto an improvised explosive device (IED). The impact blew Gallegos forward and almost severed his arm.

The arm was just “hanging on by a little piece of skin,” said Gallegos, whose injury led to the amputation of his right arm. Yet, even after the arm was gone, he still had feeling where it once was.

“When it is not painful, it feels like someone is holding the artery under your armpit and is cutting off your circulation,” he told U.S. Medicine.

Navy Cmdr. Jack Tsao, MD, helps Army Sgt. Nicholas Paupore at Walter Reed Army Medical Center through the application of Mirror Therapy. Paupore was a 101st Airborne Division artilleryman who was serving on a military transition team training Iraqi troops when he was wounded in July 2006. Photo by Navy Mass Communication Specialist 2nd Class Jeff Hopkins

Medical innovations have allowed for a greater number of limbs to be preserved than in prior conflicts, but amputation still is needed for many injuries. What sometimes baffles clinicians and often disturbs patients is that, even with the body part removed, discomfort can remain through a phenomenon known as phantom limb pain.

Jack Tsao, MD, director of the Traumatic Brain Injury Programs for Navy Medicine’s Bureau of Medicine and Surgery and associate professor of neurology at the Uniformed Services University of the Health Sciences, Bethesda, MD, estimates that 85% to 90% patients have phantom limb pain at some stage after an amputation.

“It is usually quite bothersome,” Tsao told U.S. Medicine. “The typical person doesn’t have constant phantom pain. That, I would say, is a little bit atypical. The typical story people have is several episodes a day where they will suddenly have phantom pain coming on. It can vary from just the sensation of the limb and no pain at all, and that is phantom sensation, to severe burning pain, itching … and just horrible pain.”

Tsao and his colleagues explained in a 2010 paper that, in describing the pain, some patients said “they have volitional control over their phantom and can move their phantom at will, while others report their phantoms being fixed in a specific position.” One amputee explained that it felt like “he was pulling the trigger on his rifle with his index finger and was unable to move his hand to a different position.”

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One type of therapy showing great promise for relieving phantom pain is known as mirror therapy. In this seemingly simple therapy, patients use mirrors to look at the reflection of their intact limb and mentally visualize that their missing limb is making the movements.

In November 2007, Tsao and colleagues published a correspondence in the New England Journal of Medicine, “Mirror Therapy for Phantom Limb Pain,” discussing a randomized control study in a military population.

In that study, 22 patients at Walter Reed Army Medical Center were assigned to one of three groups. “Patients in the mirror group attempted to perform movements with the amputated limb while viewing the reflected image of the movement of their intact limb,” the study stated. “Patients in the covered-mirror group attempted to perform movements with both their intact and amputated limbs when the mirror was covered by an opaque sheet. Patients in the mental-visualization group closed their eyes and imagined performing movements with their amputated limb.”

Eighteen patients completed the study with six in each group, and, after one month of treatment, all of the members in the mirror group reported less phantom pain. In the covered mirror group, only 17% reported a pain decrease and 50% reported worsening pain, while, in the mental visualization group, 33% reported a pain decrease, while 67% reported worsening pain.

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