Review

Mirror therapy for the

alleviation of phantom limb
pain following amputation:
A literature review
Jason Timms, Catherine Carus
Background/Aim: Phantom limb pain (PLP) is a debilitating condition that affects 50–85% of patients
following an amputation and significantly diminishes their quality of life. Mirror therapy has been
reported to have potential success for the alleviation of PLP. However, due to a lack of understanding
of the mechanisms underlying PLP and the fact that no current consensus as to the effectiveness of
mirror therapy exists, guidelines for treatment protocols are lacking. This review aimed to assess the
current best evidence for using mirror therapy to treat PLP in patients with amputation.
Methods: The authors conducted a systematic review of original research papers specifically
investigating the use of mirror therapy in populations of patients experiencing PLP after unilateral limb
amputation. Literature was sourced from PubMed, AMED, CINAHL and Google Scholar. The following
search terms were used in combination: ‘phantom pain’; ‘PLP’; ‘phantom limb’; ‘phantom limb pain’;
‘mirror’; ‘mirror treatment’; ‘mirror therapy’; and ‘virtual limb’. All available studies were marked
against predetermined inclusion and exclusion criteria.
Results: Seven primary articles met the inclusion criteria, all of which reported significant PLP alleviation
after using mirror therapy, with a trend for achieving phantom limb movement prior to pain relief.
Conclusions: Mirror therapy is a promising intervention for PLP. Regular sessions of mirror therapy are
required to maintain treatment effects. Causes of PLP and treatment pathways may be multifactorial;
therefore, further well-conducted randomised controlled trials are required to identify best practice.
Key words: n Amputation n Phantom limb pain n Neuropathic pain n Mirror therapy n Rehabilitation
Submitted 21 July 2014; sent back for revisions 12 November 2014; accepted for publication following double-blind
peer review 9 January 2015

I
n the UK, over 5600 amputations occur
each year due to numerous causes, such
as vascular changes, diabetes, trauma,
cancer or infection (NHS Choices, 2014).
The sensation of a phantom limb—or feeling
that an amputated body part is still present—
is a common complication post-amputation.
While the mere presence of a phantom limb
may be tolerable, 50–85% of patients may also
experience ongoing phantom limb pain (PLP)
(Weeks et al, 2010) with or without the ability
to move the phantom limb. In addition, PLP
is a debilitating condition that may have a
significant negative impact on a person’s quality
of life (Foell et al, 2011).
The causes of PLP are still unclear and
potentially multifactorial, involving peripheral,
© 2015 MA Healthcare Ltd
PLP consist of pharmacological interventions, such
as analgesics, and non-pharmacological treatments,
such as transcutaneous nerve stimulation (TENS)
(Subedi and Grossberg, 2011). The efficacy of
pharmacotherapy in PLP has been determined
by extrapolating from positive findings of other
neuropathic conditions (Knotkova et al, 2012), with
the majority of treatments showing to be ineffective
for PLP (Flor, 2002). Spinal cord and regional
anaesthesia (based on spinal or peripheral causes) Jason Timms,
have only yielded modest efficacy (Hsu and Cohen, Physiotherapist, Hull
2013). Additionally, a Cochrane review recently and East Yorkshire
identified a lack of evidence for the effectiveness of Hospitals NHS Trust, UK;
Catherine Carus,
TENS for PLP (Mulvey et al, 2013).
Physiotherapy lecturer
One emerging treatment producing perceived and admissions tutor,
positive effects for PLP is mirror therapy. School of Allied Health
By placing a mirror parasagittally between Professions and Sport

spinal and supra-spinal structures (Hsu and Cohen,
2013). As a result, effective interventions are
difficult to prescribe (Knotkova et al, 2012) and
no specific guidelines are available to clinicians
(Viswanathan et al, 2010). Treatment options for
the arms or legs and viewing the reflected University of Bradford, UK.
movements of the intact limb while attempting
Correspondence to:
simultaneous movements with the phantom Jason Timms
limb, the intention is that the patient perceives E-mail:
the reflection to be their amputated limb. jasontimms@ymail.com

International Journal of Therapy and Rehabilitation, March 2015, Vol 22, No 3 135
 Review
Figure 1. The homunculus shows the motor and sensory location of specific body parts represented within the
somatosensory cortex. From: Penfield and Rasmussen (1990)
This phenomenon possibly addresses
incongruence between proprioceptive and
visual inputs caused by cortical reorganisation
(Weeks et al, 2010). Ramachandran et al
(1992) hypothesised that sensorimotor cortical
reorganisation explains the reason why phantom
limb sensations can be induced by stimulation
of peripheral receptors in unrelated body parts
whose cortical representations are—as per the
homunculus (Penfield and Rasmussen, 1990)
(Figure 1)—adjacent to one another. They
suggested that the areas representing the phantom
limb within the primary motor and sensory
cortices that no longer receive adequate afferent
input are invaded by adjacent regions, thereby
creating a painful response in the phantom limb.
The use of mirror therapy to alleviate
PLP was first undertaken by Ramachandran
(1993), involving a patient with an upper
limb amputation with continuous PLP for
the previous 11  years who reported almost
instant pain relief. Ramachandran and Rogers-
Ramachandran (1996) demonstrated that visual
feedback from a perceived intact limb would
allow patients greater phantom limb control,
enabling them to voluntarily release paralysis
and/or clenching spasms caused by what
they termed ‘learned paralysis’ and ‘learned
pain’ as a result of functional neglect prior to
amputation. A similar effect was reported by
another eight out of ten heterogeneous patients
using a variety of protocols and methods, with
increased use enhancing effect.
136 International Journal of Therapy and Rehabilitation, March 2015, Vol 22, No 3
In a study by MacLachlan et al (2004), the
participant also experienced a significant reduc-
tion of PLP and an increased sense of control
of the phantom limb. However, mirror therapy
was replaced by mental visualisation (MV)
part way into the study; therefore, it is difficult
to know whether mirror therapy was the pri-
mary cause of the PLP alleviation. Yet, mirror
therapy has been shown to alleviate PLP. More
recent yet exiguous randomised controlled tri-
als (RCTs) indicated that 15 minutes of daily
mirror therapy was highly effective in treat-
ing PLP, with a 100% reduction for the mirror
therapy group and a 50% reduction in the MV
group (Tsao et al, 2007). Chan et al (2007) also
reported a significant 100% PLP alleviation in
their mirror therapy group.
The theory that cortical reorganisation occurs
after amputation and contributes to PLP has
been observed in studies utilising functional
magnetic resonance imaging (fMRI), where
reversion back to a normal/pre-amputation state
coincides with PLP alleviation (Birbaumer et
al, 1997; Flor et al, 2006). Diers et al (2010)
concluded that viewing mirrored movements
evoked significantly more bilateral sensorimotor
activation in non-PLP patients than those with
PLP, and the severity of PLP was negatively
© 2015 MA Healthcare Ltd
correlated with the degree of reorganisation.
This reversion of cortical activity alongside
PLP reduction concurs with Seidel et al (2011),
who found significant reduction in PLP after
12 sessions of mirror therapy.
 AIM PRISMA flow diagram of study selection

Identification
This review aims to explore and discuss current Records identified through Additional records identified
best evidence to assess the efficacy of mirror database searching through other sources
therapy to treat PLP in patients with amputation. (n=143) (n=2)

Records after duplicates removed

Methods (n=137)

Screening
Search strategy
A systematic review was completed of original Records screened Records excluded
(n=137) (n=123)
research studies investigating the use of mirror
therapy in populations of patients experiencing
PLP after unilateral limb amputation. Studies Full-text articles Full-text articles
were identified using PubMed, AMED, CINAHL assessed for eligibility excluded, with reasons

Eligibility
(n=15) (n=9)
and Google Scholar, in addition to a hand search
of relevant articles. The literature search included
the period from January 2003 to December Studies included in
2013. The following search terms were used in qualitative synthesis
(n=0)
combination: ‘phantom pain’; ‘PLP’; ‘phantom
limb’; ‘phantom limb pain’; ‘mirror’; ‘mirror
Included

treatment’; ‘mirror therapy’; and ‘virtual limb’. Studies included in

Screening
Each article was screened against the inclusion
criteria; studies not meeting these criteria were
excluded. The inclusion criteria were:
n Published in the English language
n Published between January 2003 and
December 2013
n Participants were aged 18 years and above,
with a unilateral amputation of any level and
suffering from PLP (not including controls)
n Participants were allocated an intervention,
including mirror therapy (not virtual reality)
n Pain was measured using the visual analogue
scale (VAS).
A total of 137 articles were retrieved; seven
of these met the inclusion criteria and were
eligible for appraisal. A preferred reporting
items for systematic reviews and meta-analyses
(PRISMA) (Moher et al, 2009) flow diagram
of study selection is shown in Figure 2 and an
overview of the appraised studies is presented
in Appendix 1. A level of evidence was ascribed
to the included studies. These levels included:
meta-analysis or systematic reviews (level 1);
one or more well-powered randomised controlled
trials (level  2); retrospective studies, open-label
trials, pilot studies (level 3); and anecdotes, case
reports, or clinical experience (level 4).
© 2015 MA Healthcare Ltd
quantitative synthesis
(n=6)
Figure 2. PRISMA flow diagram of study selection
RCTs conducted by Moseley (2006) and
Brodie et al (2007) (Appendix 2). The Centre
for Evidence-Based Management Critical
Appraisal Tool for Case Studies was used for
the remaining level 4 articles (Appendix 3).
A data extraction table is included (Table 1),
showing an appreciation for the samples and
protocols used, as well as identification of
results, adverse effects and dropouts.
Results
Pain
Each of the seven critically appraised articles
reported improved PLP after mirror therapy. After
a single treatment, Brodie et al (2007) reported a
significant decrease in total score of the McGill
Pain Questionnaire (Melzack and Torgerson, 1971)
post-mirror therapy (p<0.05); the MV control
group also indicated a significant reduction of PLP.
Even though the result of both intervention and
control groups showed significant improvement,
the pre-/post-VAS score difference was much
larger for the mirror therapy group (n=17)

Quality appraisal compared with the MV control group (n=4).

An assessment of methodological quality of Moseley (2006) reported a significant effect
the seven articles included in this review was for the treatment group (p=0.002), with the mean
conducted using the Scottish Intercollegiate reduction of the VAS scores for the treatment
Guidelines Network (2012) tool for the group and control groups being 23.4 mm and

International Journal of Therapy and Rehabilitation, March 2015, Vol 22, No 3 137
 Review

Table 1. Data extraction of the sample, protocol and results from the appraised articles
Number of MT participants Intervention PLP intensity (VAS or NRS)
With With Mean Control Follow-up
Study Total PLP PLP ATT age group Frequency Duration Pre-MT Post-MT (duration) Adverse events
Brodie et al 41 (6 f) 35 7 55 39 (11 f) Once 1 day 57.0 40.0 N/A None reported
(2007) (10 × 10 (±24.2) (±41.0)
movements)
Moseley 51 (32 f) 51 51 41 25 Approximately 6 weeks 57.0 33.6 24.9 None reported
(2006) 9 (5 f) amputees 4 amputees 9 × per day (2 weeks MT) (±18.5) 6 months
Foell et al 13 (4 f) 13 13 50.6 N/A 1 × 15 mins 4 weeks 28.3 20.6 23.44 None reported
(2014) per day 2 weeks
Sumitani et al 21 (6) 21 21 48.4 N/A 1 × 10 mins Participant 6.6 4.2 N/A None reported
(2008) 11 amputees per day discretion (±1.7) (±2.8)
Darnall and Li 31 (13 f) 31 31 61 N/A 1 × 25 mins 2 months 6* 5 N/A Increase in PLP=4
(2012) per day Low mood=1
Darnall 1 (0 f) 1 1 35 N/A 20–30 mins 3 months 4* 0 N/A None reported
(2009) 3 × per week
Clerici et al 1 (0 f) 1 1 41 N/A 1 × 30 mins 6 months 3.6* 1.8 N/A None reported
(2012) per day
ATT: at time of testing; f: female; MT: mirror therapy; PLP: phantom limb pain; NRS: numeric rating scale; VAS: visual analogue scale
*On a scale of 1–10

10.5 mm, respectively. This effect continued
to the six-month follow-up, with mean VAS
scores of 32.1 mm and 11.6 mm, respectively.
The results of Sumitani et al (2008) showed a
significant alleviation of pre-/post-treatment
PLP VAS scores (6.6 mm vs 4.2 mm; p<0.002).
They also reported that deep and superficial pain
descriptors differed significantly post-treatment
in favour of deep pain. Foell et al (2014) reported
a significant decrease (p=0.005) in pain rating
at the end of the intervention period—week  2
(28.26 mm) vs week 7 (20.6 mm)—with a total
mean decrease in PLP of 27%.
The case study by Clerici et al (2012) reported
benefit after undergoing mirror therapy for
30  minutes per day, which was still present at
six  months. They also reported a significant
decrease in PLP (p<0.005) by analysing the VAS
scores of weeks 1–6 vs weeks 20–26. Darnall and
Li (2012) showed a significant reduction in PLP
at month 1 (p=0.0002) when mirror therapy was
delivered for 25 minutes daily and at month  2
(0=0.002), with a mean percentage reduction of
15.5%. The earlier case study by Darnall (2009)
had a complete resolution (100%) of PLP after
12 weeks, particularly when switching from
20  to  30 minutes per day, yet the PLP would
return should he have missed one to two days
of mirror therapy. All studies that reported a
follow-up of effect after ceasing mirror therapy
showed insignificant increases in pain scales.
was negatively correlated with treatment
effect (increased telescope intensity = less
pain alleviation). The positive results of pain
alleviation in this study were due almost
exclusively to those without a telescopic
distortion. Darnall and Li (2012) observed that
treatment effect was significantly improved
in patients with over 16 years of education
(≥4 years of university education). They further
reported a trend for those with low mood to
drop out of the study. In the study conducted
by Sumitani et al (2008), those with willed
visuomotor imagery abilities (WVA) of the
phantom limb pre-treatment benefited more
from greater PLP alleviation post-mirror
therapy than those without WVA. Additionally,
deep pain descriptors reduced significantly
post-mirror therapy treatment for those with
WVA (p<0.0004), but not for superficial pain
descriptors (p=0.34) nor for those without
WVA. Brodie et al (2007) supports this,
positing that because mirror therapy elicits
more phantom limb movement than controls,
those with an increased ability to move the
phantom limb may be more likely to experience
a reduction in PLP via mirror therapy.
Mechanism of effect
Foell et al (2014) reported that treatment effects
were associated with cortical reorganisation.
For those who experienced a decrease of
© 2015 MA Healthcare Ltd

PLP, peak activity within the contralateral

Prediction of treatment effect somatosensory cortex began to recreate its
Telescopic distortions of the phantom limb presumed normal location prior to amputation,
were reported by 8 of 13 participants in Foell but no connection with the motor cortex was
et al (2014). The intensity of the telescope found. Furthermore, pain alleviation was

138 International Journal of Therapy and Rehabilitation, March 2015, Vol 22, No 3
 associated with decreased cortical activity in
the inferior parietal cortex, an area known to
influence the feeling of agency (the experience
of ownership) and pain generation. Although
magnetic resonance imaging was not conducted
in the other studies, this mechanism of cortical
reorganisation is considered in the discussions
of Brodie et al (2007) and Moseley (2006).
Recommendations
Due to the heterogeneity of the sample,
further large and more homogenous RCTs are
required to help explain the mechanisms of
pain alleviation of graded motor imagery and
mirror therapy (Moseley, 2006). Additional
larger studies are needed to identify follow-up
effectiveness and whether multiple sessions are
more beneficial; and if so in what way (Brodie
et al, 2007). Darnal and Li (2012) called for
larger, better-powered RCTs to evaluate the
efficacy of self-delivered mirror therapy. They
also recommended that treatments for those with
lower mood should be bolstered with additional
psychological support. Foell et al (2014)
suggested that a large study that utilises a control
group and the division of groups according to
telescoping severity may yield more compelling
results. They also recommended that the virtual
limb must be congruent with the phantom limb if
benefit is to be gained.
Discussion
The articles appraised in this review appear to be
in agreement with the previous primary research,
which suggests mirror therapy is effective in the
alleviation of PLP (Ramachandran and Rogers-
Ramachandran, 1996: MacLachlan et al, 2004;
Chan et al, 2007; Tsao et al, 2007). However, due
to the heterogeneity of these studies, it is difficult
to ascertain: i) who with PLP would benefit most
from mirror therapy; ii) how mirror therapy
should be delivered. These studies suggest
that mirror therapy is not protocol-, intensity-,
frequency- or subject-dependent as the pain
alleviation identified was found using various
protocols among heterogeneous groups. Rather,
what is perhaps more important is the ability
to produce phantom limb movement or gain a
sense of control/ownership while using mirror
therapy as this coincided with previous studies
© 2015 MA Healthcare Ltd
that reported PLP alleviation (Moseley, 2006;
Brodie et al, 2007; Sumitani et al, 2008; Clerici
et al, 2012). The mirror therapy group of Brodie
et al (2007) were twice as effective as the control
MV group at creating phantom limb movement
International Journal of Therapy and Rehabilitation, March 2015, Vol 22, No 3
and gained more phantom limb awareness than
the controls. Additionally, ten out of 14 patients
who were only ‘aware’ of a phantom limb pre-
mirror therapy in Sumitani et al (2008) reported
vivid voluntary movement post-treatment.
Whether this voluntary phantom limb movement
was present prior to gaining PLP alleviation was
not reported. The results showed that: i) phantom
limb movement supports previous research
with regards to ‘learned paralysis’, with mirror
therapy and MV allowing the patient to move the
phantom limb out of painful distorted positions
(Ramachandran and Roger-Ramachandran,
1996); ii) phantom limb exercise can modify the
PLP experience (Sherman et al, 1980).
It is suggested that visual feedback through
mirror therapy may not be an important factor
in phantom limb movement and subsequent
PLP alleviation as this has been achieved in its
absence. Phantom limb movement and subsequent
PLP alleviation was experienced by patients with
vivid as well as sparse MV abilities (Brodie et al,
2003). Notably, after a single treatment of MV,
the control group in Brodie et al (2003) reported
significant PLP alleviation. Although it is thought
that MV only partially activates the same cortical
pathways as mirror therapy, which suggests we
should not expect MV to be as effective as actual
visual feedback (Ramachandran and Altschuler,
2010), Moseley (2006) states that using MV prior
to mirror therapy within the graded motor imagery
protocol allows for rehabilitation of the pre-motor
cortex prior to the primary cortex, and showed
significant results post-intervention and at six-
month follow-up. The patients in Sumitani et al
(2008) did not undertake an MV element prior to
mirror therapy, but those who benefited most from
mirror therapy were already able to use WVA and
therefore concurs with previous studies.
There may be value in a combined approach,
yet without a long-term follow-up in mirror
therapy studies, postulation of the necessity
for MV prior to mirror therapy is not possible.
Studies that used the two methods indicate that
the addition of visual feedback may create a
much more concentrated effect, which may be
a critical component in PLP alleviation as it
dominates proprioceptive/sensory feedback, thus
dampening down conflicting afferent signals
(MacLachlan et al, 2004; Moseley, 2006; Chan
et al, 2007; Darnall, 2009; Weeks et al, 2010).
Interestingly, in Chan et al (2007), three out of
six participants in the covered mirror group and
four out of six participants in the MV group
reported an increase in PLP. However, after
crossover to mirror therapy, PLP decreased in
eight out of nine participants (Figure 2).
139
 Review
70 Randomised trial Crossover to mirror therapy
60
Mental visualisation
Visual analogue scale score
50
40
Covered mirror
30
20
10 Active mirror
0 mirror neuron system (Rizzolatti and Craighero,
0 1 2 3 4 5 6 7
Week
Figure 3. The effects of mirror therapy—active mirror and covered
mirror—and mental visualisation before and after crossover to
mirror therapy. Adapted from: Chan et al (2007)
Agency of the phantom limb may be crucial in
the creation of volitional movements (Tsakiris,
2010). The finding of Foell et al (2014) that
those with a ‘telescoped’ phantom limb were
less able to relieve their PLP suggests that the
incongruent mirror image of the phantom limb
did not allow adequate agency. As mentioned,
those with increased ability to produce voluntary
phantom limb movement may experience more
PLP alleviation. Therefore, if agency of the
telescopic phantom limb cannot be experienced
using a mirror, virtual reality protocols may
be more useful with these patients, allowing
greater flexibility (Foell et al, 2011) and a more
realistic visual phantom limb interpretation,
which increases their potential to gain agency
and phantom limb movement. Additionally, only
patients who reported predominantly deep pain
descriptors with WVA benefited significantly
from mirror therapy (Sumitani et al, 2008).
Muscle spindles within the deep tissue have been
shown to contribute more to joint position sense
than that of superficial skin receptors (Macefield
et al, 1990). Therefore, the combination of
afferent inputs from vision and joint position
sense (either by MV or phantom limb movement)
should benefit sensorimotor congruency and
agency more than that of visual feedback alone.
Results from the fMRI imaging of Foell et
al (2014) agrees with past research that visual
feedback via mirror therapy has the potential
to reverse sensorimotor cortical reorganisation
after amputation and subsequently reduce PLP
(Flor et al, 2006; MacIver et al, 2008; Diers et
al, 2010; Seidel et al, 2011). However, there
140 International Journal of Therapy and Rehabilitation, March 2015, Vol 22, No 3
are differences in all of these studies regarding
the precise cortical regions involved. The
finding of Foell et al (2014) that activation of
the inferior parietal cortex reduced alongside
PLP reduction is interesting as this area is said
to be related to body image, proprioception
and pain generation (Harris, 1999), which links
to the previous suggestion that an inability to
gain agency limits the effectiveness of mirror
therapy. However, Seidel et al (2011) showed
that significant activity was identified not in
the primary sensorimotor cortices, but instead
the reduction of PLP was due to increased
prefrontal activity, which is associated with the
8
2004). The apparent differences with cortical
involvements suggests that PLP experiences
are diverse and individual to the patient, or that
the speed and ability of cortical re-learning is
individual. Studies that have tried to observe
changes have not been of sufficient length to
identify consistent patterns.
The mechanisms for PLP alleviation may be
more multifactorial than previously thought
and not attributed to a single cause or corti-
cal area. Additionally, full reorganisation of
the neural cortices is said to take from a few
weeks (Merzenich et al, 1984) to a few months
(Smirnakis et al, 2005). So this may not solely
explain the immediate pain relief found by
Ramachandran and Rogers-Ramachandran
(1996) or the fact that the first-week VAS scores
in Clerici et al (2012) and Foell et al (2014)
showed improvement, and the participants of
Brodie et al (2007) and Sumitani et al (2008)
found benefit after a single intervention. This
may suggest the interaction of mirror neurons,
which are activated when we observe the actions
of others and allow patients to experience touch
and physical response due to the lack of inhibi-
tion to mirror neurons by absent touch recep-
tors (Ramachandran and Brang, 2009), thereby
blocking protopathic pain (Chan et al, 2007;
Subedi and Grossberg, 2011).
Mirror neurons have been identified in the
supplementary motor, pre-motor, somatosensory
and inferior parietal cortex (Rizzolatti and
Craighero, 2004), which can be activated by
mirror therapy (MacIver et al, 2008; Diers et al,
2010; Seidel et al, 2011; Foell et al, 2014). The
authors propose that mirror neurons are activated
once agency is achieved and visual feedback is
© 2015 MA Healthcare Ltd
returned, immediately relieving ongoing PLP as
well as modulating longer-term reorganisation.
The existence of mirror neurons is a recent theory
and direct evidence of their recruitment using
mirror therapy is lacking (Rothgangel et al, 2011).
 The trend for PLP to slowly return during
follow-ups suggests that mirror therapy may
need to become a long-term intervention
(Moseley, 2006; Foell et al, 2014). It is possible
that the extent of cortical reorganisation is
related to the duration of symptoms (Subedi
and Grossberg, 2011). Therefore, the frequency
and intensity of mirror therapy before pain
attenuation that is experienced may be patient
specific. Cortical reorganisation certainly seems
to be an important factor of mirror therapy;
however, based on the present review, firm
conclusions cannot be drawn regarding its sole
contribution in PLP production or alleviation.
Limitations
It was thought that the search term ‘mirror
therapy’ would identify all studies investigating
this intervention; however, many studies refer
to ‘visual feedback’ or ‘mirror visual feedback
therapy’. Thus, it is possible that some articles
were missed. Only two articles are classified
as being of high levels of evidence, yet they
include significant limitations with regards to
the topic of this review; Brodie et al (2007)
tested a single intervention without follow-up,
while Moseley (2006) and Sumitani et al
(2008) carried out multifaceted interventions
and included participants with alternative
pathologies. Although all conditions create
PLP, their mechanisms are obviously
fundamentally different and therefore their
significant positive results on pathological pain
reduction may lack validity and reliability.
Finally, studies on virtual reality were
excluded due to its potential cost and availability;
however, as the mechanisms of action would
be similar to mirror therapy, they may have
provided useful information.
Conclusions
This review suggests that mirror therapy is a
promising and low-cost treatment for PLP, which
may attenuate pain if agency and subsequent
phantom limb movement is achieved. Health pro-
fessionals prescribing treatment need to take the
amount of telescoping into account and advise
patients on its regular use to maintain treatment
effects. However, after nearly 20 years, the evi-
dence regarding mirror therapy for PLP can still
© 2015 MA Healthcare Ltd
only be described as weak as the majority is
anecdotal and RCTs have either been too short,
included multifaceted protocols, heterogeneous
patient groups, or have not been reported thor-
oughly enough to fully identify their methods.
International Journal of Therapy and Rehabilitation, March 2015, Vol 22, No 3
Key points
n Mirror therapy is a promising treatment for the alleviation of phantom limb
pain (PLP); all of the reviewed articles reported PLP relief after mirror therapy
n Treatment effect is associated with cortical reorganisation and enhanced by
regular and frequent use of mirror therapy
n Increased agency and an ability to produce phantom limb movement
enhanced treatment effect, but telescoping needs to be taken into account
to achieve an acceptable level of agency
n Further well-powered randomised controlled trials are needed to identify
follow-up effectiveness and the benefits of multiple mirror therapy sessions.
At present, the 2006 and 2012 guidelines
from the British Association of Chartered
Physiotherapists in Amputee Rehabilitation do
not include recommendations for PLP alleviation
(Broomhead et al, 2006; 2012). Thus, further
large and more homogenous RCTs with extended
follow-ups to measure quality and intensity of
pain over time as well as in-depth qualitative
accounts of participant experiences are needed
in order to: i) compare the effectiveness of mirror
therapy, MV, pharmacotherapy, or a combined
approach; ii) identify which unilateral limb loss
patients may respond more favourably than
others; iii) develop a standardised protocol to
allow the production of a well-informed and
evidence-based guideline. IJTR
Conflict of interest: none declared.
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141
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Staff Nurse
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142 International Journal of Therapy and Rehabilitation, March 2015, Vol 22, No 3
 Appendix 1. Summary of appraised articles
Study Methods
Brodie et al 80 patients with lower
(2007) limb amputation were
RCT assessed for PLP, PLS, PLM
and PLA
Randomly allocated to
MT or control (obscured
mirror) group
Both groups carried
out 1 session of 10 x 10
movements of intact limb
and phantom limb
PLP and PLS recorded
pre- and post-intervention
using MPQ and VAS
Moseley 51 participants with
(2006) complex regional pain
RCT syndrome, brachial
plexus avulsion pain and
amputation
Randomly allocated to
GMI or control groups and
assessed for VAS pre- and
post-intervention
GMI protocol:
Weeks 1–2: limb laterality
recognition
Weeks 3–4: imagined
movements
Weeks 5–6: MT
Each stage was performed
once every waking hour
(approximately 9 × per day)
Foell et al 13 (4 f) patients with
(2014) upper limb amputation
Pilot study with chronic PLP;
11 measured with fMRI
MT at home for 4 weeks,
15 minutes per day
Hand and lip movements
performed during fMRI
to measure brain changes
pre- and post-MT
VAS reported daily
Sumitani et al 21 participants with
(2008) amputation, brachial
Pilot study plexus avulsion pain,
partial spinal cord injury
and peripheral nerve injury
1 × 10 minutes of MT
every day; duration of
treatment was individually
determined by each
participant
Pre- and post-evaluation
© 2015 MA Healthcare Ltd
of pain descriptors and
qualities, PLA and pain
intensity using numeric
rating scale
International Journal of Therapy and Rehabilitation, March 2015, Vol 22, No 3
Sample Results
MT: 41 (6 f) Significant MPQ effects
Control: 39 (11 f) for time in both groups
Mean age = 55 (p<0.05), but failed to
reach 80% power
Mean years since
amputation = 9 Analysis of VAS not
reported yet
Pre- and post: MT 57/40
vs control 33/29
Significant main effect
for PLM in MT (p<0.001)
Complex Main effect for treatment
regional pain group post-intervention
syndrome: 37 showed significant
Brachial plexus reduction in VAS scores
avulsion pain: 5 (p=0.002)
Amputees: 9 Main effect for treatment
Mean age = 41 group six months post-
intervention showed
significant reduction in
VAS scores (p<0.001)
Mean age = 50.6 Showed significant
Mean years since reduction (27%) in PLP
amputation = 21 Effects predicted by
presence of telescope
(telescope = reduced effect)
Pain reduction = decreased
activation in inferior
parietal cortex over the
course of MT
Amputees: 11 Numeric rating scale
Brachial plexus score significantly
avulsion pain: 7 decreased across all
Partial spinal participants:
cord injury: 2 pre-evaluation 6.6 vs
Peripheral nerve post=evaluation 4.2
injury: 2 (p<0.002)
Mean age = 48.4 MT induced greater
MV ability for those
describing deep pain
Those with willed MV
reported significantly
greater reductions in
PLP (p<0.001), whereas
those without willed MV
ability did not (p=0.5)
Strengths
An RCT
Large sample
Only included patients
with lower limb
amputations, therefore
more homogenous than
a sample of patients
with upper and lower
limb amputations
An RCT
Sample was subject
to a large amount of
treatment; however,
performing interventions
9 times per day is
probably an unrealistic
frequency for a home
programme
Used a standard protocol
of MT exercises and
frequency for each
participant
The use of fMRI to
observe and measure
peak activity locations
Baseline VAS assessed
from average of 2 weeks
pre-intervention
Mirror supplied by
researchers, i.e. provision
of standardised materials
Self-delivered MT,
therefore reduces risk of
a Hawthorne effect
Uses pain descriptors
alongside numeric
rating scale
Identifies participants
with superficial vs
deep pain
Weaknesses
Only used a single
intervention
Potential for placebo
effect
Few participants who
reported experiencing
PLP prior to testing had
PLP at time of testing
GMI is a multifaceted
intervention, which
includes limb laterality
and mental visualisation
prior to MT
Only a small proportion
of amputees in sample
and their results were not
analysed separately
Level 4 study
Small sample
Use of self-report
exercise diaries
No control or comparison
groups
Unimpaired hemispheres
used as a control
Level 4 study
No control group
Duration of treatment
determined by individual
participants
Heterogeneous sample
disabilities
Continuation of
pharmacological
and physical therapy
143
 Review

Darnall and Li 31 (13 f) patients with
(2012) unilateral upper and lower
Pilot study limb amputations
Participants self-treated
with MT for 25 minutes
daily for 8 weeks
Completed and posted
outcome questionnaires
back to researchers at
weeks 4 and 8
Darnall (2009) Self-delivered,
Case study unstructured MT 3 × per
week for 20–30 minutes
for 12 weeks
VAS measured pre- and
post-intervention
Clerici et al Self-delivered,
(2012) unstructured MT
Case study 30 minutes per day for
6 months
Exercises included patient
looking at, touching,
caressing, scratching and
moving his intact leg
Recorded daily self-report
diary, VAS and SDS
f: female; fMRI: functional magnetic resonance imaging; GMI: graded motor imagery; MPQ: McGill Pain Questionnaire; MT: mirror therapy;
MV: mental visualisation; PLA: phantom limb awareness; PLP: phantom limb pain; PLM: phantom limb movement; PLS: phantom limb sensation; RCT: randomised
controlled trial; SDS: Zung Self-Rating Depression Scale; VAS: visual analogue scale
Median age = 61 Median pain reduction of Large sample for Level 4 study
15.5% from baseline to a case series Limited inclusion and
month 2 Comprehensive reporting exclusion criteria
Significant pain reduction of demographic Participants were paid
for most educated information US$10 to complete
participants Self-delivered MT, questionnaires and
4 participants reported therefore reduces risk of US$10 to purchase
worse PLP; 6 reported a Hawthorne effect a mirror
no change; 16 reported Self-report home
reduced PLP exercise diaries and
questionnaires
35-year-old male VAS reduced to 0–10 Suggests that the Single person case study
Surgical from 4–10 at baseline frequency and intensity Self-purchased mirror,
above knee Patient was able to taper of MT is more important thus its appropriateness
amputation off his usual analgesics than a structured for the intervention
after trauma exercise protocol cannot be accounted for
Improvements were
PLP for 3 years sustained 4 months Self-delivered MT, Unstructured exercise
post-treatment with therefore reduces risk of protocol
regular MT a Hawthorne effect Used relaxation
treatment daily
Psychologically
compromised (depression)
Self-report diary
41-year-old male Significant reductions in Long-term (6 months) Single person case study
Surgical PLP, first 6 weeks vs last implementation of MT Part of a multifaceted
above knee 6 weeks (p≤0.05) Weekly recording of approach, including
amputation No evidence of VAS and SDS analgesics, exercise,
at age 17 due significant depression psychological and
to childhood via the SDS physiotherapy support
osteosarcoma Subjective enjoyment No report of statistical
PLP for 8 years and stress relief procedures

Appendix 2. SIGN appraisal criteria and scores for the randomised controlled trials included in this review
SIGN Randomised Controlled Trial Checklist Brodie et al (2007) Moseley (2006)
Appropriate and clearly focused question? What effect does viewing a ‘virtual Is graded motor imagery equally
limb’ and attempting to move a effective for phantom limb pain as
phantom limb have on phantom limb it is for complex regional pain
pain, sensation and movement? syndrome?
Assignments of subjects to treatment groups randomised? Yes Yes
Adequate concealment used? No report of concealment No
Subjects and investigators kept blind to treatment allocation? No report of blinding No; single blinding only
Treatment and control groups similar at the start of the trial? Yes Yes
The only difference between groups is the treatment under Yes Yes
investigation?
All relevant outcomes are measured in a standard, valid Yes. McGill Pain Questionnaire and Yes. McGill Pain Questionnaire and
and reliable way? visual analogue scale visual analogue scale
What percentage of the individuals in each arm of the study No dropouts No dropouts
dropped out before the study was completed?
All the groups are analysed in the groups to which they were No No
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randomly allocated (intention to treat)?

Where the study is carried out at more than one site, results N/A Not able to determine
are comparable for all sites?
Score 6 / 9 6 / 10
Adapted from: Scottish Intercollegiate Guidelines Network (SIGN), 2012

144 International Journal of Therapy and Rehabilitation, March 2015, Vol 22, No 3
 Appendix 3. CEBMa criteria for the case studies/series included in this review
CEBMa Checklist
Clearly focused question
or issue?
Is the study design
appropriate for answering
the
research question?
Are both the setting and
the settings representative
with regard to the
population to which the
findings will be referred?
Is the researcher’s
perspective clearly
described and taken
into account?
Are the methods
for collecting data
clearly described?
Are the methods for
analysing the data likely to
be valid and reliable?
Was the analysis repeated
by more
than one researcher
to ensure reliability?
Are the results credible,
and if so, are they relevant
for practice?
Are the conclusions drawn
justified by
the results?
Are the findings
transferable to
other settings?
Score
SDS: Zung Self-Rating Depression Scale; VAS: visual analogue scale
Adapted from: Centre for Evidence-Based Management (CEBMa), date unavailable
Sumitani et al Darnall and Li
Foell et al (2014) (2008) (2012) Darnall (2009) Clerici et al (2012)
Yes. i) Does MT Yes. To determine Yes. To determine Yes. To determine No. A discussion of
attenuate PLP? whether the whether home-based whether home-based, the advantages of
ii) Do brain changes alleviation of PLP via PLP patients would patient-delivered using MT
occur during MT? MT is dependent self-treat with MT, MT would be as
iii) Are there any on pain description and whether this effective for pain
predictors of (superficial vs deep) would attenuate pain relief as structured,
treatment success? supervised MT
Yes. They were Yes, for a preliminary Yes. Since efficacy Yes, for a preliminary Yes, for a preliminary
unable to include a study has already been study, but does not study
control group due to observed in previous allow for strict data
small sample size pilot/case studies, a collection
controlled trial may
be more appropriate
Yes. Home-based Yes. Home-based Yes. Home-based Yes. Home-based Yes. Home-based
amputees amputees amputees amputees MT amputees
Yes Yes Yes Yes Yes
Yes. Daily pain rating No Yes. Self-report Yes. Brief pain No. Vaguely reports
(VAS). fMRI scans diaries, VAS inventory VAS for pain and
pre/post intervention control
Yes. Description of Yes. Description of Yes. Statistical Yes. Pre- and post- Yes. Weekly VAS and
statistical analysis statistical analysis Analysis System (SAS) intervention VAS SDS scores reported
included included software used scores displayed
Unable to determine Unable to determine Unable to determine No Unable to determine
Unable to determine. Unable to determine. No. Too much No. Too much No. Participant was
Potential for bias. Potential for bias potential for bias, potential for placebo undergoing other
Small sample. from other ongoing i.e. monetary and bias from other treatments alongside
therapies. Treatment incentives, use of ongoing therapies. MT treatment
delivery was not self-report diaries Single person sample
standardised
Yes Yes Yes No. Limitations of Yes. Takes into
ongoing therapies account multifaceted
not reported treatment
Yes Yes Yes No. Only home- No
based amputees
8 / 10 7 / 10 8 / 10 6 / 10 6 / 10

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