http://www.cnn.com/2008/HEALTH/03/19/mirror.therapy/index.html
updated 10:17 a.m. EDT, Wed March 19, 2008
For amputees, an unlikely painkiller: Mirrors
* Story Highlights
* Expert says "phantom pain" afflicts as many as 95 percent of amputees
* Cause isn't certain; one theory says brain interprets signals
from pain pathways
* Mirror therapy tricks the brain into "seeing" the amputated leg
* Next Article in Health »
By Saundra Young
CNN
WASHINGTON (CNN) -- Army Sgt. Nick Paupore was in the lead Humvee in a
convoy rolling through Kirkuk City, Iraq, when the vehicle was hit by a
roadside bomb.
Paupore says it wasn't a very big explosion, more like a loud
firecracker. He could feel the rush going through the vehicle, the
change of pressure, smoke filling the cab. He felt a burning sensation
in the back of his legs, but he wasn't in pain, and he could actually
move his legs. He felt lucky. He was alive. He got out of the vehicle,
intending to help the others, and passed out.
When he regained consciousness, medics were working on him. The blast
had ripped out a chunk of his leg, including 6 to 8 inches of an artery,
and he was bleeding out. By the time they had stanched the flow, he had
less than two pints of blood left. The average person has 10 pints of blood.
Paupore was flown to Germany, where doctors fought to save his life. He
survived, but they couldn't save his leg.
And he was in excruciating pain -- in the leg he no longer had.
Dr. Jack Tsao, a Navy neurologist with the Uniform Services University,
was looking for ways to help soldiers like Paupore. He remembered
reading in graduate school a paper by Dr. V.S. Ramachandran that talked
about an unusual treatment for amputees suffering "phantom limb pain,"
using a simple $20 mirror.
The mirror tricks the brain into "seeing" the amputated leg, overriding
mismatched nerve signals.
Here's how it works: The patient sits on a flat surface with his or her
remaining leg straight out and then puts a 6-foot mirror lengthwise
facing the limb. The patient moves the leg, flexing it, and watches the
movement in the mirror. The reflection creates the illusion of two legs
moving together.
Paupore was one of the first to give it a try. At first, he was
skeptical. When approached about joining a clinical trial at Walter Reed
Army Medical Center to test Tsao's theory, he declined. But sometimes
his phantom pains were coming five to six times an hour and lasting up
to a minute.
"I was laying in bed and it just, all of a sudden, it felt like I was
getting shocked," he said. "I called the nurse, 'cause I was like,
'What's going on?' " The nurse told him, "This is probably your phantom
pain."
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Tsao explains it this way: "It's the sensation that the limb is still
present, and phantom pain in particular is the sensation that the limb
is experiencing pain of some form."
That pain is intense, and often medication brings very little relief.
For Paupore, it was relentless.
"All of a sudden, it was like someone kept turning on and off the Taser,
and my whole leg started twitching. ... I sat up, and I was holding on
to my stump, and it just wouldn't stop. At that time, I was hooked up to
the Dilaudid [a powerful narcotic], and I was pushing it. But you can
push all the medicine in the world, and it won't stop it."
Paupore and 17 other amputees who joined Tsao's mirror therapy trial
were randomly assigned to one of three groups. The first group used the
mirror to look at their reflected image as they tried to move both legs.
The second group used a covered mirror and did the same. And members of
the third group were asked to visualize moving their amputated limbs.
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After a month of treatment, all of the patients in the mirror group had
significantly less phantom pain. In the covered mirror group, only one
patient experienced a decrease in pain, and for half of those patients,
the pain worsened. Sixty-seven percent of the patients visualizing their
limbs got worse instead of better. The pain decreased in almost 90
percent of the patients who then switched to mirror therapy.
It worked wonders for Paupore, 32. Within five months, he was off
painkillers completely. Tsao says the difference is like night and day.
"To see him walking, he's able to drive his car; he works downtown; I
mean, that is incredibly gratifying!"
Phantom limb pain plagues as many as 95 percent of amputees, Tsao said.
He says even though phantom pain dates to Civil War days, no one knows
what causes it. The current thinking is that it has to do with how the
brain interprets signals from the pain pathways that are left after
amputation.
The neurons that control leg movement are still there, but in the
absence of a limb, they are not sure what they're supposed to do and
begin firing randomly. Proprioception, the body's ability to sense the
position of a limb, tells the body that the limb is still there, sending
mismatched signals to the brain.
"The visual neurons are still intact, and they're firing off, telling
the brain one thing," Tsao said. "The propriaceptive neurons are firing
off, telling the brain something else. ...My thinking is that there is
some sort of center in the brain that coordinates these signals. ...
Somehow, this mismatched feedback is what's generating the sensation
that the limb is frozen or in pain."
Since the conflicts in Afghanistan and Iraq began, more than 750
amputees have returned home from that area. Walter Reed has treated more
than 550 of them. On any given day, between 100 and 125 amputees are
there, working to rebuild their lives.
At Reed, mirror therapy is now offered routinely. Tsao says this
treatment has the potential to benefit amputees worldwide, and the best
part is, no special training is required to do it. He gives interested
parties instructions over the phone or by e-mail.
And he's already taken this therapy halfway around the world to
Cambodia, a country Tsao says has a large and growing amputee population
because of mines left over from its civil war. E-mail to a friend E-mail
to a friend
Saundra Young is a senior producer with CNN Medical News.
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