Treating Phantom Limb Pain - Essay Example

? HSBH5004 Bodily senses in health and disease Dr Tatjana Seizova-Cajic The Use of Virtual Reality in Treating Phantom Limb Pain By wsam ghandourh 430014060 Introduction This paper explores phantom limb pain and the use of treatment protocols that use of immersive virtual reality to treat the condition. The idea to use virtual reality in the treatment of phantom limb pain builds on the use of the mirror for a similar purpose. In the treatment known as the mirror box treatment, an image of the intact limb is projected into the part of the visual field where the missing limb should be located . The goal is to revisit the existing literature with the aim of determining the way forward for addressing the condition (Murray et al., 2006, pp. 167-170; Lamont, Chin and Kogan, 2011, pp. 369-372; Murray et al., 2010, pp. 175-196). Discussion: Using Virtual Reality in Phantom Limb Pain Treatment As the name suggests, phantom limb pain is perceived pain arising from the non-existing, , amputated limb. Such debilitation around the area of the missing limb is seen as being  This is doubly crippling for the affected patient, because the amputation is coupled with a hesitation or the outright rejection of the use of prosthetic devices (Murray et al., 2006; pp. 167-170). The use of mirror box therapy has been cited to be an effective means to address phantom limb pain. In Ramachandran and Rogers-Ramachandran (1996) ten subjects had subjective improvements in the level of pain they experienced in the missing limbs following mirror box therapy. In Chan et al on the other hand, it was noted that visualization of the phantom limb together with the use of mirror box therapy resulted in the mitigation of pain for 33 percent of 18 patients, even as 67 percent of the patients reported an escalation of pain (Lamont, Chin and Kogan, 2011, pp. 369-372). Meanwhile, even with the presence of mirror box therapeutic and virtual reality methods, the literature notes that the treatment of phantom limb pain or PLP remains problematic because of difficulties in determining the ailment’s aetiological foundation. Ramachandran and Rogers-Ramachandran (1996) and Maclachlan, McDonald and Waloch (2004) however do point out that the presence of visual cues that are subject to the manipulation of the subject in the area where the amputated limb is can result in the evocation of movement sensations that seem to emanate from the amputated limb, resulting in the alleviation of PLP. The mirror box technique does work in this context, and a study further posits that virtual reality methods can build on and improve results from mirror box therapy (Murray et al., 2010, pp. 175-196; Ramachandran and Rogers-Ramachandran, 1996; Maclachlan, McDonald and Waloch, 2004; Gold et al., 2005, pp. 203-210; Sato et al., 2010, pp. 622-629). Ramachandran and Rogers-Ramachandran (1996) note that there is a connection between visual cues from the virtual transposition of the remaining limb and into the space of the missing limb on the one hand and the triggering of new neuronal or brain pathways from the visual cues on the other. These visual cues and the resulting plastic reaction of the brain is characterized by felt sensations in the phantom limb. Clenched fists sensations in the missing limbs, for instance, are unclenched with the projection of the visually cued intact limb back into the missing limb. The unclenching of the intact had unclenched and clears the spasm in the absent limb. The study notes that for a substantial majority of the sample population of patients that were subject to the virtual box or mirror box, there was a rewiring of the brain to address the symptoms of phantom limb pain and to in essence reprogram it to adjust to the new reality of a virtual limb operating in the space where the amputation is. The implications of this finding of course is that interventions to treat PLP have to take into consideration the essential role of the human brain and its capacity to be plastic. This means that the brain, with visual cues, can be retrained en route to alleviating PLP and rehabilitating the patient to move forward with prosthetics. This is apart from the patient developing the necessary coping behaviors in order to live more fully (Ramachandran and Rogers-Ramachandran, 1996). More recently, the theory on the effectiveness and mechanism of action of the mirror box therapy has progressed somewhat from the more general findings in the above study, but the basic science still revolves around the plastic nature of the brain evolving and growing to compensate and react to the phantom limb and the visual cues afforded by the mirror box therapy. The mechanisms around the primary motor cortex are involved, and specific brain areas in the superior temporal gyrus as well as the superior occipital gyrus. These two areas have been mapped for their specific responses to the mirror box therapy and the subsequent treatment of pain associated with the phantom limb. (Lamont, Chin and Kogan, 2011).  Meanwhile, challenges remain with regard to the successful use of mirror box therapy and immersive virtual reality in PLP. Chief among them are difficulties with regard to predicting how different patients will react to treatment interventions involving the two protocols. The reason is not clear, but the observation in many studies is that there are problems with gauging just how well different patients will respond to treatment, and the unpredictability limits the universal application and the benefits to be derived from the use of the therapy modes. On the other hand, there are observations too relating to the absence of correlations between the length and intensity of the mirror box and virtual reality interventions on the one hand, and the degree of pain relief experienced by the patients. Also, novel ideas regarding extending the potential effectiveness of virtual reality and mirror box therapies for PLP include investigating their effectiveness to relieve PLP when introduced prior to the amputation of the limbs. Here there are promising results with a small sample of patients indicating that the administration of virtual reality and mirror box protocols prior to the amputation results in lower levels of PLP post-amputation (Lamont, Chin and Kogan, 2011). Moving on, the literature is clear that virtual reality as a treatment protocol for PLP offers several benefits and improvements over traditional mirror box therapy, even though the mechanisms of action are similar to the latter, and is therefore potentially as effective as mirror box therapy. Among the key advancements are that virtual reality limbs move independent of how the patient moves and how the patient is oriented. In the mirror box protocol the patient is in control of the projected limb. There is therefore an isolation of cause and effect local to the movement of the body area directly attached to the phantom limb and the movement of the virtual limb as a result of that. The literature from 2006 does note that there is a dearth of literature on the efficacy and mechanisms of action of such a setup, distinct from the vast literature on the mirror box therapy, and so care has to be taken in the setting up of the experiments and the gathering and analysis of the data. In all the potential advancements are in the area of designing experiments around virtual reality treatments that are geared towards getting as much quantitative and qualitative data as possible, to inform the results and future studies on the protocols. The prognosis though is that virtual reality interventions are at the minimum as effective as conventional mirror box therapies for alleviating PLP (Murray et al., 2006; Murray et al., 2010). Conclusion The literature on phantom limb pain and the effective interventions to relieve that pain centering on mirroring to project either the working limb or a virtual limb for a patient is vast and well-established, proving the effectiveness of such treatment protocols (Murray et al., 2006). A review of the literature on PLP and immersive virtual reality from 2000-2010 TreA reA likewise show that the protocol has promise in treating PLP. However, the same studies admit that the study methods and analyses need to be made more rigorous. (Lamont, Chin and Kogan, 2011). Murray et al. (2010) point to many limitations in current literature on virtual reality and PLP, including that the current crop of studies have limited sample sizes. The studies they reviewed also did not incorporate such factors as the placebo effect in accounting for decreases in pain for patients with PLP subjected to immersive virtual reality treatments (Murray et al., 2010). References Gold, J. et al. (2005). Virtual anesthesia: The use of virtual reality for pain distraction during acute medical interventions. Seminars in Anesthesia, Perioperative Medicine and Pain (2005) 24. Retrieved from http://www.usc.edu/schools/medicine/departments/cell_neurobiology/research/isnsr/rizzo_docs/06_Seminars_in_Anesthesia_Pain_Distraction_Review.pdf Lamont, K., Chin, M. and Kogan, M. (2011). Mirror Box Therapy- Seeing is Believing. EXPLORE November- December 7(6). Maclachlan, M., McDonald, D. and Waloch, J. (2004). Mirror treatment of lower limb phantom pain: A case study. Disability and Rehabilitation 26(14). Retrieved from http://www.ireflex.co.uk/10.maclachlan.pdf Murray, C. et al. (2010). Virtual Solutions to Phantom Problems: Using Immersive Virtual Reality to Treat Phantom Limb Pain. Amputation, Prosthesis Use, and Phantom Limb Pain: An Interdisciplinary Perspective/Springer Science Business Media. Murray, C. et al. (2006). Immersive Virtual Reality as a Rehabilitative Technology for Phantom Limb Experience: A Protocol. Cyberpsychology & Behavior 9(2). Retrieved from ftp://flash.ict.usc.edu/arizzo/Phantom/Murray%20cpb[1].2006.9.167.pdf Ramachandran, VS and Rogers-Ramachandran, D. (1996). Synaesthesia in Phantom Limbs Induced with Mirrors. Proceedings of the Royal Society Biological Sciences 263 (1369). Retrieved from http://rspb.royalsocietypublishing.org/content/263/1369/377.abstract Sato, K. et al. (2010). Nonimmersive Virtual Reality Mirror Visual Feedback Therapy and Its Application for the Treatment of Complex Regional Pain Syndrome: An Open-Label Pilot Study. Pain Medicine 11a. Retrieved from http://www.thblack.com/links/RSD/PainMed2010_11_622.pdf Read More