Mirror Visual Feedback for Phantom Pain: International Experience on Modalities and Adverse Effects Discussed by an Expert Panel: A Delphi Study

Background: Mirror visual feedback (mirror therapy) is practiced worldwide in very different ways to alleviate phantom pain; no study has compared these variations yet or researched the associated risk and harm. Objectives: To establish use and justification of a generally accepted mirror visual feedback treatment plan after amputation; to explore the occurrence and handling of adverse effects; and to increase knowledge about contributing factors. Methods: Experiential knowledge of 13 experienced practitioners from 6 countries and 5 professions was explored with a 3-round Delphi technique. Results: Experience with the use of 5 different treatment plans was described, of which 1 has never been mentioned in the literature: an intense 1-off plan in which the illusion was carefully set up before the patient was left to the experience with no interference, resolving pain as well as adverse effects. In the 4 known treatment plans, the expectations of response time varied, which influenced the definition of responders/nonresponders; the set-ups, control, and use of material reflected the professional background of the practitioners. Contraindications also were defined according to the professional confidence to deal with the adverse effects. Adverse effects were reported, including emotional reactions, pain increase, sensory changes, freezing of the phantom limb, dizziness, and sweating. The attitude toward, and the handling of, adverse effects varied in patients as in practitioners according to their professional background. A tool to fine tune the experience was reported with covering of the limb during therapy. Full consensus was reached on several treatment modalities. Conclusion: Analysis of the results suggests that the different treatment plans suit different patients and practitioners. Matching these could enhance effectiveness and compliance. Knowledge about adverse effects needs to inform treatment decisions. These findings triggered the development of a mirror visual feedback gateway to guide patients to the treatment plan for their needs, and to collect data from the practitioners to enhance neuroscientific understanding and inform practice.