LACK OF TREATMENT FOR PHANTON LIMB PAIN, AND THE POTENTIAL BENEFITS

AND CHALLENGES OF USING A VIRTUAL ENVIRONMENT TO FILL THIS GAP

Aurora Nelson

Addressing the phantom pain that a majority of amputees experience is a challenge that

continues to this day. For these patients, there is a wide array of complications associated not

only with amputation, but with finding ways to return to normal life and reduce pain. New

developments in augmented or virtual reality attempt to provide two major solutions: a method

of reducing phantom limb pain, and increasing the ease with which amputees can transition to

using prosthetic limbs.

The twofold benefits of this treatment would be invaluable in improving the lives of

patients. This form of treatment shows promise as a more successful alternative to mirror box

therapy. However, despite the success so far in researching this concept, most studies have been

small, with researchers consisting stating that further work needs to be done. I argue that in order

to make virtual reality treatments possible for more patients, larger case studies need to be

performed, and newer technologies explored. I also explore connections between studies that

could be useful for future developments, and point out several challenge that need to be

addressed in order to make virtual reality a realistic and accessible therapy.

The estimation of what percentage of individuals experience phantom limb pain varies

from study to study, but a common estimate, as mentioned by Alphonso et al. (2005) is that

phantom limb pain occurs in as many as 80% of amputees. Other studies have put this number

even higher. In a study by Brodie et al. (2003), 95% of the subjects reported phantom limb pain.
However, despite the conflict between these numbers, they all suggest that a high majority of

amputees will deal with this pain.

Whatever the true percentage may be, it is clearly important that we find ways to help

individuals who are suffering. Overcoming the limitations imposed by loss of a limb, whether

through learning to use a prosthetic or by other methods, becomes more of a challenge when the

patient is suffering. An ideal pain treatment would allow a patient to make a quicker recovery

and more rapidly figure out what will work best for them in navigating their life.

Unfortunately, addressing phantom limb pain has been a major challenge for the medical

field. Over the years, attempted treatments have ranged from analgesic drugs and temporary

anesthetics to antidepressants and psychological treatments (Cole et al., 2009). Even surgeries

have been attempted. None of these have yielded any promising results. According to Brodie et

al., as of 2012, more than 68 different treatment strategies had been reported. While these

strategies claim effectiveness, studies show their success rates are poor in reality and rarely

exceed the results achieved by placebo treatments.

Brodie et al. (2012) also stated, “Additionally, the majority of treatment studies in this

area suffer from significant methodological weaknesses as the published literature has mainly

consisted of single‐group designs, clinical commentaries and case studies, with very few

randomized controlled clinical trials.” Research is scattered and inconsistent, and each patient

has a different experience attempting treatments. Plus, the added uncertainty around the exact

cause of phantom limb pain or how it works makes it harder to determine the best approach to

treating it.
 With lack of viable treatment options, many took into consideration what risk factors

might be playing a role in phantom limb pain, in hopes of reducing a patient’s likelihood of

suffering. It is generally believed that early use of prosthetics reduced phantom limb pain.

Interestingly, some studies have made claims in conflict with this idea. A 2010 study analyzed

the relationship between phantom pain and prosthetic use for their subjects, and “no association

between phantom pain and prosthetic use was found” (Bosmans et al., 2010). Of course, even if

this is the case, virtual reality therapies could still be highly beneficial in not only helping a

patient transition to a prosthetic limb, but reduce pain even without one.

Bosmans et al. (2010) also reference another study in which “it was found that not

phantom pain but phantom limb awareness may be influenced by the frequent use of a functional

prosthesis.” However, the small sample size for this study should be noted, although its

contribution to the research into factors associated with limb pain is important. Clearly,

correlation between a variety of patient characteristics and phantom limb pain is a complex

matter that also warrants further investigation.

This question of whether or not early prosthetic use combats phantom pain does not

negate the potential value of wider use of virtual reality technology. The improvement in

developing prosthetics will help patients return to normal life quicker, and virtual reality

treatments have shown promise in treating pain even without taking prosthetic limbs into

account.

Prosthetic limbs should be given more consideration when setting up these studies in the

future. As I will address later, there is a potential relationship between technology used to

generate phantom limbs in immersive virtual environments, and other studies exploring robotic
prosthetic limbs. However, if virtual reality does prove to be the best option for treating phantom

pain, it would also be valuable to patients who are not using prosthetics.

The concept of using virtual reality is based on mirror box therapy, and hopes to address

some of the major drawbacks to using a mirror box to treat pain. Mirror box therapy was first

proposed by Ramachandran et al. in the 1990s, and has since become one of the most influential

ideas in regards to treating phantom limb pain (Cole, 2008).

Mirror box therapy involves the use of a mirror to create the visual illusion of the limb

the patient had amputated. As the normal limb is moved, the phantom is reflected and induces

sensation of movement. This was demonstrated to relieve painful, involuntary spasms in subjects

(Cole, 2008). An interesting note is that patients who saw success were those seen within seven

months of amputation, while those attempted this treatment later did not experience the same

effect.

In contrast to claims of the mirror box’s effectiveness in treating phantom limb pain,

Brodie et al. suggest in 2012 that while the mirror condition helped subjects control their

phantom limb, it was not sufficient for relief of pain. Whether or not a patient feels this method

can successfully treat their pain, the mirror box has several obvious limitations. As Murray et al.

(2007) point out, the mirror box requires the patient to remain in roughly the same position

throughout the exercise. The patient also has to focus on keeping their phantom limb

synchronized with movements of their normal limb (Herrador et al., 2017). It’s a very delicate

solution that lacks flexibility, the illusion is easy to disrupt, and the relief is short-term. This is

one of the problems that virtual reality seeks to solve.

 Another interesting note is the lack of understanding behind why visual therapies work,

although suggestions have been made. Some suggest they help to correct the imbalance between

motor and sensory systems, while others believe the therapies the pain relief results from

changing the perception of the limb itself, possibly making it nothing more than a “distraction

therapy” (Herrador et al., 2017), which has been addressed in some research studies, but no

sufficient evidence has been produced to prove or disprove it.

Ambron et al. (2018) state their belief that these visual therapies, along with other

treatments, “attempt to normalize the cortical representation of the missing limb and improve the

correspondence between actual and predicted sensory feedback.” This does work with many of

the leading theories about the causes of phantom limb pain. If we can build a stronger

understanding of the physiological mechanisms behind phantom pain and visual therapies, it

could lead to better methods of setting up these therapies. It may even lead us to alternative

methods that could be more effective.

2009 saw some of the earlier studies presenting the idea of using virtual reality, along

with motion capture technology, to improve upon the concept of mirror box therapy. One

example, described by Cole et al. (2009) used this technology to capture motion data “directly

from a patient’s stump (rather than using the opposite remaining limb) and then transforms it into

goal directed, virtual action enacted by an avatar in a VR environment.” Other studies take

movements of the intact limb and transfer them into the virtual limb environment in a

representation of the phantom limb (Herrador et al., 2017).

There are pros and cons wide variety within virtual reality therapies. Each patient is

different, and some may find certain methods more effective than others. Different studies could
be done to determine which methods typically work best, which may also contribute to our

understanding of why and how these visual therapies work.

But, with so many options to explore, a patient’s treatment options quickly become

complicated. It is unrealistic to try all of them, and there could be other factors impacting varying

success between protocols. Untangling the web of different types of virtual reality, different

equipment setups, and advancements in technology will take time and far more research than has

been done.

Virtual reality comes with options and techniques that are impossible with a mirror box,

such as playing games and performing tasks with the generated phantom limb. These immersive

environments are an important improvement over the mirror box setup. It also offers a more

realistic experience in regard to asymmetry. Mirror box methods generate a phantom limb that is

identical (albeit reversed) the normal limb, which makes the illusion more difficult to believe.

Evidence points to these features being key for the patient’s improvement.

But, while most subjects did see improvement, studies so far have had small sample

sizes. Most research papers in this field end with the authors suggesting larger studies be done,

partially because patient experiences can vary greatly. One patient who found no success with a

mirror box later found that attempting a virtual reality system instead reduced their pain

(Ambron et al., 2018). This further indicates that we should be careful not to focus in on one

specific method too quickly. Another downside of these small sample sizes is they could

misrepresent the population as a whole when it comes to different virtual reality therapies. A

therapy that appears ineffective in a study may have major benefits to many patients who weren’t

included.
 In regards to asymmetry, it should be noted that there are some virtual reality studies that

did not offer much improvement over the mirror box. Some generated a phantom limb based off

of the opposite limb which was still present. Because many physical activities do not result in

symmetrical movement between limbs, this is a considerable issue. Advancements in technology

allowed later studies to instead generate a limb based on activity from sensors on the patient’s

stump.

The possibilities for advancements in the field of prosthetics is also important. Prosthetic

limbs bring another range of complications to the equation. In the early 1990s, it was believed

that only 70% of upper limb amputees who had the capability to use a prothesis would actually

do so, despite the prominent suggestion that fitting for a prosthetic limb within a month of

amputation would greatly improve a patient’s prospects for a successful outcome, and potentially

reduce chances of pain.

However, there are financial costs to attaining a prosthetic limb. Not only does the patient

have to pay for the limb itself, but they also generally need help from a physical therapist to train

how to use it (Pinzur et al., 1994). Should virtual reality therapies be implemented in assisting

patients transition to a prothesis, this would also need to be taken into account. But financial

burdens and improving access to medical care is another wide and complex issue that would

have to be addressed outside of virtual reality research and case studies.

The complications involved in learning to use a prosthetic limb effectively prompted

Pinzur et al. (1994) to perform their study on the use of myoelectric prosthetic limb fitting, and

suggest that this could lead to more patients successfully making use of prosthetic limbs. This

provides a basis for further research into advanced methods for fitting patients with prosthetics.

In 2005, Dhillon et al. performed a study on the belief that many issues with prosthetics could be
addressed through use of a direct neural interface with nerve fibers, allowing transfer of feedback

information through sensory pathways originally associated with the missing limb. This could

potentially make use of signals that are generated by the patient attempting to move the missing

limb.

Dhillon et al., (2005) concluded that their results were promising, and any needed

improvements were possible with existing technology. However, challenges could come from

areas such as weight and power supply. Further research on myoelectric protheses was done by

Atzori et al. in 2016. These prostheses have developed to be able to enable patients who have

had transradial amputations to perform some movements through the use of pattern-recognition

techniques. An analysis of a public database of sEMG recordings of hand movements also

revealed several studies where subjects were able to achieve over 90% accuracy. These results

could easily allow a patient to achieve control of a robotic hand with precision and flexibility

(Atzori et al., 2016).

More evaluation should be done between these kinds of results and clinical variables of

the patient. Atzori et al. (2016) suggest that factors such as remaining forearm percentage,

phantom limb sensation intensity, and time since amputation should be addressed. They believe

that these parameters could be used to improve surgical guidelines, and determine the best

procedures to improve a patient’s future prospects for successful integration of prosthetic limbs,

and generally improve their rehabilitation experience.

I also feel there is somewhat of a disconnect between these types of studies relating to

prosthetic limbs, and research regarding virtual reality. If connections could be made between

the technology used to impose a phantom limb in a virtual environment, and the procedure to
collect these movement signals from the patient, advancements could lead to better prosthetics

and possibly have the added effect of improving phantom pain.

Additionally, there is already evidence that virtual reality is helping some patients with

their current prosthetics. A 2018 study by Ambron et al. that had subjects participate in virtual

reality treatment sessions recorded success with reducing pain treatment over time. They also

experienced the added effect of improved overall activity. After only two sessions, one of the

subjects used their lower-limb prosthesis to walk to a local store for the first time. This

promising example, compounded with the study’s small sample size and the inability (for

varying reasons) of the subjects to continue with treatment long term, is more strong reasoning

for continued research and improved studies.

It could be suggested that part of this improvement comes from the visual therapy’s

improvement of a sense of agency and a patient’s body image, in addition to any pain reduction.

In fact, several subjects in a 2009 study (Cole et al.) found the virtual system “more enabling of

agency” than their prosthetic limbs. It is suggested that the heaviness of a prosthesis is a

contributing factor to the difficult a patient has in assimilating it into their body image. Hence, an

additional need for newly developed prosthetics to focus on reduction in weight.

Cole et al. (2009) also suggest that there is more to virtual reality than a “distraction

effect.” Pain relief was described as being greater than patient’s experienced with simple

distraction. Each individual experience varied. It was noted that different attitudes toward the

virtual reality system likely played a role in pain control. Because this would suggest that virtual

reality is not as viable an option for patients who are not open to new technology, ways of

helping patients become more open may need to be explored as well.

 Once again, Cole et al., (2009) also suggest the importance of treatment sooner rather

than later. They state, “Subjects seen sooner after amputation and the development of PLP may

gain agency and analgesia more easily.” If there are other factors at play, further research would

need to be done. Careful consideration of as many clinical variables as possible would be ideal

for analysis in these studies.

More recently, in 2016, Osumi et al. offered more evidence of virtual reality’s success in

restoring voluntary movement representations and reducing phantom limb pain, as well as

pointing out another important benefit: helping patients maintain motivation to continue with

their rehabilitation. The virtual reality sessions in this study were only ten minutes long. Osumi

et al. believe that this treatment is not very physically or psychologically demanding, another

benefit. If steps could be taken to reduce what demand there is, patients may see even greater

improvement.

Dunn et al. evaluated several virtual and augmented reality studies in 2017, and point out

several of the drawbacks to the consistently positive findings: inconsistencies between protocols,

difficulty in quantifying how much pain reduction may simply be due to distraction, low levels

of evidence, and generally small sample sizes. Many research papers cover case studies

involving only a few subjects.

Other potential challenges include simulator sickness from use of virtual reality

technology, but there is only one noted case of this (Dunn et al., 2017). Still, it is something to be

considered, especially in attempts to make virtual reality systems accessible to every patient.

Another possible accessibility issue is the cost. Studies have suggested that associated costs are

decreasing, but these claims are yet to be fully proven (Dunn et al., 2017). Any steps that could

be taken to reduce the financial burden on patients should be explored as well.

 And of course, to make this therapy a realistic means for patients to reduce their pain

when they need to, on their schedules, an at-home virtual reality system needs to be developed.

Not only would this be far more convenient, but it would reduce some of the physical and

psychological demand mentioned earlier. Rather than worrying about scheduling appointments

and traveling to the virtual reality setup, patients would be able to access it whenever they

needed.

Virtual reality technology is already fairly accessible to the general public. All that is

really needed, besides further research studies, is a way to incorporate the needed technology for

generation of a phantom limb in the virtual environment. Costs are likely the biggest obstacle,

although I would argue that making it easy for the patient to set up and enter the immersive

environment by themselves could also present a challenge.

While virtual reality technology is a promising alternative to mirror box therapy, research

has consistently failed to fully address its potential, and more work is needed. Larger sample

sizes, along with careful analysis of factors that may affect a patient’s success, should be used

going forward. Certain risk factors may reduce a patient’s chances of experiencing phantom limb

pain in the first place, which may lower the number who would want to use virtual reality

technology. This would be beneficial in reducing costs, but steps may need to be taken in other

areas of the healthcare system to address financial burdens. Because there is some conflict in

research regarding what factors make phantom pain more likely, further research should be done

in this area as well.

Efforts should also be made in improving both virtual reality technology and prosthetics,

ideally reducing costs and increasing accessibility for patients. If these steps are taken, virtual

reality technology has the potential to both reduce a patient’s phantom limb pain, and help them
transition to better prosthetics. Overall, this technology could greatly improve the lives of many,

and help them transition to a more normal life than they might otherwise have.
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