Category Archives: Phantom Limb Pain

Smearing Pain Away with Ambroxol 20% Cream

Feature Image of Ambroxol molecule sourced from:

Dear Pain Matters readers,

Treatment via topical* Ambroxol* 20% cream may offer significant pain relief from severe and localised nerve pain conditions including:

  • Complex regional pain syndrome (CRPS);
  • Trigeminal nerve pain;
  • Postherpetic nerve pain;
  • Phantom limb pain;
  • Deafferentation pain;
  • Post-surgical nerve pain;
  • Nerve pain in both feet; and
  • Multifocal neuropathy.

Prepared by a local pharmacist, topical Ambroxol 20% cream comprises:

  • Ambroxol;
  • Dimethyl sulfoxide; and
  • Linola cream (that includes linoleic acid).

Specifically, 50.0 g of topical Ambroxol 20% cream contains Ambroxol (10.0 g), dimethyl sulfoxide (5.0 g) and Linola cream (up to 50.0 g for the total mixture) (Kern & Weiser, 2015).


Ball-and-stick model of Ambroxol molecule sourced from:

As a strong local anaesthetic, Ambroxol works by blocking sodium channels, and in particular, the TTX-resistant (TTX-r) Nav1.8 sodium channel.  In fact, Ambroxol is 40 times more potent than lidocaine.  Preferentially expressed in nociceptive C-fibres, Nav1.8 may be upregulated during inflammation and pain (Weiser, 2006).

Topical Ambroxol for Complex Regional Pain Syndrome 

Eight (8) patients who suffered from CRPS for less than a year received topical Ambroxol 20% cream, together with standard treatments.

Topical Ambroxol resulted in many therapeutic benefits including:

  • Less spontaneous pain and pain during movement (N=6);
  • Less allodynia and hyperalgesia (N=6 and N=7, respectively);
  • Decreased swelling and skin reddening (N=7 and N=4, respectively) as well as enhanced skin temperature (N=4); and
  • Improved motor dysfunction (N=6).

In summary, topical Ambroxol 20% cream may be a useful treatment option for CRPS (Maihöfner et al, 2018).

Topical Ambroxol for Trigeminal Nerve Pain 

Five (5) patients with trigeminal neuralgia suffered pain attacks while 3 of them also endured spontaneous pain.  Their facial pain levels ranged from 4 to 10 (out of 10, using the Numerical Rating Scale; NRS).

The good news:

All 5 patients enjoyed significant pain reductions including decreased pain attacks following application of topical Ambroxol 20% cream (in addition to standard treatment).  Specifically, their pain levels dropped between 2 to 8 points (out of 10, using NRS) within only 15 to 30 minutes following topical Ambroxol treatment.   Pain relief lasted 4 to 6 hours.

Pain was completely eliminated in one patient after a week of topical Ambroxol treatment, while 2 patients were able to reduce their medication intake.

There were no adverse effects nor skin reactions.

In summary, topical Ambroxol 20% cream can lead to significant pain relief from trigeminal neuralgia within 15 to 30 minutes following application thereof onto painful areas (Kern et al (2019).

Topical Ambroxol for Severe Chronic Pain – 7 Successful Cases


A German study reviewed the effects of topical Ambroxol on 7 patients (2 females; 5 males) with severe nerve pain.

Specifically, 2 patients had postherpetic nerve pain while the remaining 5 suffered from phantom limb pain, deafferentation pain, post-surgical nerve pain, nerve pain in both feet and multifocal neuropathy.  Their average pain levels ranged from 4 to 6, while their maximum pain reached 6 to 10 (NRS).

Four (4) patients had tried lidocaine 5% without success, while a 5th patient did not benefit from capsaicin 8%.

The good news:

All 7 pain patients enjoyed pain relief within 5 to 30 minutes after topical application of Ambroxol 20% cream onto painful areas (details follow).  The topical Ambroxol-evoked pain relief included reduced pain attacks and lasted 3 to 8 hours.  Four (4) patients had improved mobility, better sleep and other benefits.

There were no adverse effects nor skin changes during application of topical Ambroxol, even 4 years later.

Case 1 – Local Nerve Pain in Both Feet

A male patient named John** (born in 1942) suffered from nerve pain in both forefeet despite topical lidocaine 5 % plasters and other pain treatments.

The goods news:

John first started using topical Ambroxol in June 2011.  Within 5 minutes, the stabbing pain and allodynia (8/10) in both of his feet disappeared completely for more than 8 hours.  Furthermore, John was able to significantly reduce his Gabapentin intake and discontinue opiates altogether.

At follow-up after 4 years, John continued to be successfully treated with topical Ambroxol.  As a result, John was able to enjoy walking and gardening again.

Case 2 – A Double Amputee with Cold Phantom Limb Pain

Both of Joe’s** lower legs were amputated due to peripheral arterial occlusive disease and diabetes mellitus.

Joe regularly suffered severe cold phantom limb pain (7–9, out of 10) that shifted from his missing toes to the balls of his phantom feet.  These spontaneous bursts of pain usually lasted anywhere from a few minutes to many hours and even affected his sleep.

Joe’s pain treatment including opiates and anticonvulsants failed to offer pain relief.

One day, 15 minutes after applying topical Ambroxol 20% cream onto his stumps, Joe finally found significant relief from his cold phantom limb pain.  This pain relief that also included warmer phantom limbs lasted several hours.

At the 11-month follow-up, Joe continued to enjoy pain relief without skin changes nor other side effects thanks to regular application of topical Ambroxol 20% cream onto his stumps.

Case 3 – Chronic Knee Pain Following Total Knee Replacement 

After a total knee replacement in November 2010, Jan** (58) suffered ongoing nerve pain including allodynia and hyperalgesia in her knee.

Despite pain treatments including Tapentadol (that replaced Buprenorphine), lidocaine patches and capsaicin 8 % plasters, Jan was unable to find pain relief.

One day, within only 15 minutes following application of topical ambroxol 20% cream to her painful knee, Jan finally found (quoting) ‘clear pain relief’!  The burning and stabbing in her knee was significantly reduced while the ‘raging feeling’ in her knee was almost gone.

At follow-up almost one year later, Jan continued to enjoy substantial pain relief for 4 – 6 hours following repeated application of the topical ambroxol 20% cream.  Specifically, her average knee pain levels dropped from 8 down to 4 (and sometimes even lower, down to 1).  There were no skin changes nor other side effects.

Case 4 – Deafferentation Pain after a Motorbike Accident

A patient (38) named Allan** suffered deafferentation pain in his  left arm including allodynia in his hand and forearm due to a plexus lesion caused by a motorcycle accident in 1997.

Despite a nerve graft, ketamine, gabapentin, a lidocaine infusion and lidocaine plasters as well as mirror therapy, Allan’s pain was severe and relentless.

The sedative effects of amitriptyline treatment were intolerable, as were the psychoactive effects of cannabis.

Trigger point treatment and Tapentadol were also not tolerated.

Despite being on pregabalin and duloxetine, Allan suffered ‘burning pain’, ‘crushing underlying pain’ and ‘shooting tingling pains’, with pain levels ranging from 4 to 8 (of 10).

One day, topical Ambroxol 20% cream was applied over Allan’s pectoral muscle.

Guess what happened next?

The shooting and tingling pains dropped from 8/10 to 4/10!

Substantial pain relief would kick in within 15 minutes and last for 4 to 6 hours following regular application of topical Ambroxol 20% cream.  Allan’s sleep improved and his spasms and cramps disappeared.

Unfortunately, the ‘deep underlying pain’ persisted despite topical Ambroxol 20% cream treatment (and pregabalin and duloxetine).

Case 5 – Postherpetic Nerve Pain on Chest

A male patient named Pete** (55) suffered postherpetic nerve pain (5/10) and allodynia on the right side of his chest.

Whilst lidocaine plasters helped relieve his pain, the plasters could not cover all the painful skin regions.

One day, Pete added topical Ambroxol 20% cream to his pain management protocol.  Analgesia occurred in only 30 minutes after topical application of Ambroxol cream to areas not covered by lidocaine patches.  Pain attacks reduced from 6/10 to 4/10 and this pain relief was sustained for 4 to 6 hours. There were no skin reactions nor other side effects, even after 3 years of Ambroxol cream treatment.

Case 6 – Multifocal Neuropathy

A male patient named Sam** suffered nerve pain in the arch of his left foot as well as multifocal neuropathy*** caused by vasculitis.  Sam’s persistent pain including severe pain attacks (8/10, especially in the evenings and at night) prevented him from engaging in activities.

Although amitriptyline drops helped with sleep, lidocaine patches, peripheral analgesics and Tilidine did not offer pain relief.

In December 2013, Sam tried topical Ambroxol cream for the first time.

The good news:

Within only 15 minutes of topical Ambroxol application in the evening, Sam’s nerve pain levels were significantly reduced from 6/10 to 2/10.  This pain relief lasted more than 6 hours, hence improving his sleep.  Sam was also able to stop using Zolpidem.

After 4 months of topical Ambroxol cream treatment, Sam’s underlying pain during the daytime had almost vanished.

At the 17-month follow-up, Sam continued to obtain pain relief from topical Ambroxol treatment without any skin reactions nor other side effects.

Case 7 – Trigeminal Postherpetic Nerve Pain

A 91-year old female patient named Edith** suffered facial nerve pain up to 8/10 and poor sleep after a zoster infection of the maxillary branch of the left trigeminal nerve in June 2014.

While lidocaine patches offered pain relief, there were bad skin reactions.

Edith finally enjoyed pain relief and better sleep after starting topical Ambroxol 20% cream.

Repeated application led to consistent pain relief including a ‘calmer’ cheek within only 15 minutes, as confirmed at the 11-month follow-up.

There were no adverse effects.


The Nav1.8 sodium channel plays a key role in certain pain mechanisms while TTX-sensitive sodium channels contribute to others.  Sodium channels including TTX-r Nav1.8 are upregulated during inflammation in many pain conditions (e.g. trigeminal neuralgia).

As a strong sodium channel blocker, Ambroxol preferentially blocks TTX-r Nav1.8.  Specifically, a study confirmed that Ambroxol blocked resting TTX-r sodium channels more potently than lidocaine, mexiletine or benzocaine.  Thus, Nav1.8-mediated nerve pain may be blocked by topical Ambroxol (Weiser, 2006).  Similar results were reported by other studies (Gaida et al, 2005; Hama et al, 2010; Moon et al, 2012).

Another local anesthetic called Mepivacaine also blocks Nav1.8, contrary to Bupivacaine that inhibits TTX-sensitive sodium channels instead (Leffler et al, 2010).

Warning: Possible Adverse Effects of Ambroxol

Like most drugs, Ambroxol can cause serious side effects (Kreicas, 2016; Combalia et al, 2017).

Studies reported that adverse effects usually arose after systemic intake (e.g. oral ingestion), as opposed to topical application, of Ambroxol (Monzón et al, 2009).

Where can Topical Ambroxol 20% Cream be Found?  

An Update

Sometimes I receive very inspiring comments from blog readers.  Here is a comment dated 29/11/19 that is worth repeating here (quoting):

‘Hi Tom [and other readers with pain],

I don’t know if you’ll see this but the cream is produced by the ABF Apotheke in Nuremberg, Germany. This is the same pharmacy that produces the cream for Dr. Christian Mainhöfner’s hospital. (Apotheke is the german word for pharmacy). You DO require a prescription. I’m not sure if they ship to Australia but they ship to my country. You can contact them through the email:

Tiago Henriques’

Thank you, Tiago, for adding value to this blog post!


Ambroxol is a strong local anaesthetic and peripheral analgesic that selectively targets and potently blocks the TTX-r Nav1.8 that may play a role in many nerve pain conditions.

As such patients with localised nerve pain may obtain significant pain relief from topical Ambroxol cream that preferentially targets TTX-r Nav1.8.

Topical Ambroxol is non-addictive and relatively safe for long-term use (subject to medical supervision) (Kern & Weiser, 2015; Kern & Weiser, 2015 (Poster 239)****; Casale et al, 2017).

Now that’s a good way to cover up localised nerve pain!

Sabina Walker

Blogger, Pain Matters (in WordPress)


* Topical means locally through the skin.

* Ambroxol is sometimes called na872.

** Not his/her real name.

*** Multifocal neuropathy is sometimes called mononeuritis multiplex or mononeuropathy multiplex.

**** Poster 239 by Kern & Weiser (2015) outlines several more successful cases not mentioned above.  See Poster 239 for further details.


Clinical Papers

Topical Ambroxol for Complex Regional Pain Syndrome 

(1A) Maihöfner et alSuccessful treatment of complex regional pain syndrome with topical ambroxol: a case series. Pain Management (

Topical Ambroxol for Trigeminal Nerve Pain  

(1B) Kern et al. Topical Ambroxol 20% for the Treatment of Classical Trigeminal Neuralgia – A New Option? Initial Clinical Case Observations. Headache The Journal of Head and Face Pain (17 January 2019);

Topical Ambroxol for Severe Chronic Pain – 7 Successful Cases

(1C) Kern & Weiser. Topical ambroxol for the treatment of neuropathic pain. An initial clinical observation. [in German: Topisches Ambroxol zur Behandlung neuropathischer Schmerzen.] Schmerz (20 November 2015); 29 Suppl 3: S89-96.

doi: 10.1007/s00482-015-0060-y

(1D) Kern and Weiser. Topical Ambroxol for the treatment of neuropathic or severe nociceptive pain – First case reports. 9th Congress of the European Pain Federation (EFIC) (Sept 2015: Vienna); Poster 239.

doi: 10.13140/RG.2.2.35671.27041

Related Papers and Articles

(1E) Casale et al. Topical Treatments for Localized Neuropathic Pain. Curr Pain Headache Rep (2017); 21(3): 15.


(2A) Weiser, T. Comparison of the effects of four Na+ channel analgesics on TTX-resistant Na+ currents in rat sensory neurons and recombinant Nav1.2 channels.  (13 March 2006); 395(3):179-84.

(2B) Gaida et al. Ambroxol, a Nav 1.8-preferring Na(+) channel blocker, effectively suppresses pain symptoms in animal models of chronic, neuropathic and inflammatory pain. Neuropharmacology (2005); 49: 1220–1227.

doi: 10.1016/j.neuropharm.2005.08.004.

(2C) Hama et al. Antinociceptive effect of ambroxol in rats with neuropathic spinal cord injury pain. Pharmacol Biochem Behav (2010); 97: 249–255.

doi: 10.1016/j.pbb.2010.08.006

(2D) Leffler et al. Block of sensory neuronal Na+ channels by the secreolytic ambroxol is associated with an interaction with local anesthetic binding sites. Eur J Pharmacol (2010)630:19–28.

doi: 10.1016/j.ejphar.2009.12.027

(2E) Moon et al. The differential effect of intrathecal Nav1.8 blockers on the induction and maintenance of capsaicin- and peripheral ischemia-induced mechanical allodynia and thermal hyperalgesia.  (Jan 2012); 114(1): 215-23.

doi: 10.1213/ANE.0b013e318238002e.

(2F) Weiser, Thomas. Ambroxol: a CNS drug?. CNS Neurosci Ther (2008); 14(1): 17-24.

doi 10.1111/j.1527-3458.2007.00032.x.

(2G) Weiser, Thomas. Nav1.8 channel blockade as an approach to the treatment of neuropathic pain. Drugs of the Future (July 2006); 31(7); 597.


Warning: Possible Adverse Effects of Ambroxol

(3A) Kreicas, Leonard. Topical ambroxol possible treatment of neuropathic pain. Nerve Neuropathy (1/6/2016).

(3B) Combalia et al. Stevens–Johnson syndrome probably induced by ambroxol. CED (24 April 2017); 42(4): 465-467.

(3C) Monzón et al (2009). Ambroxol-induced systemic contact dermatitis confirmed by positive patch test. Allergologia et immunopathologia (2009); 37: 167-8.

doi: 10.1016/S0301-0546(09)71730-6

(3D) Benstetter, Monika. Ambroxol and bromhexine expectorants: safety information to be updated. European Medicines Agency (27/02/2015).






Mirror Therapy for Relief from Phantom Limb Pain Inspired By Professor Ramachandran

Feature Image of Professor Ramachandran sourced from: 

Thanks to Professor Ramachandran’s inspiring research into mirror therapy, the world is now a better place for many amputees with phantom limb pain and other patients!

For related blog posts, see:

Dear Pain Matters blog readers,

This blog post discusses:

  • A clinical trial involving mirror therapy;
  • Two (2) amputees who had successful mirror therapy for phantom limb pain; and
  • Professor V.S. Ramachandran’s ground-breaking research into mirror visual feedback via mirror therapy.

Phantom pain affects at least 90% of all amputees.  It includes a myriad of painful sensations including the following:

  • The limb feels frozen in an awkward position;
  • Burning;
  • Stabbing;
  • Shooting; or
  • Electrical shocks.

The good news is that mirror therapy (aka mirror visual feedback) may offer a cheap and effective treatment option for some amputees with phantom limb pain and other pain sufferers.


Sgt. Wallace Fanene’s Story  

Sgt. Wallace (‘Wally’) Fanene, a 25-year old Samoan in California, was severely injured on September 8, 2007, while serving in Iraq.  He lost both his right arm and his right leg in an improvised explosive device (IED) blast.  At first, Wally did not feel any pain, although he had a burning sensation in his injured legs.  In his words,

‘I knelt down on a landmine;  I sat on it.  I knew my leg was gone right when I was hit, but I didn’t feel any pain, and I didn’t know about my arm.’

Things got even weirder at the hospital when Wally asked his wife to scratch his bandaged right hand to relieve itching.  What Wally did not realise was that his lower right arm was also missing!

[My wife] told me my arm was gone. We argued about that for five minutes. I mean, I could feel it.’

It was at the hospital when the pain kicked in big time, even affecting his sleep.  There were nails in his phantom toes as well as needles and a knife-like pain in his missing leg.

Wally added,

‘It was the most excruciating pain in my life.’



Enter Mirror Therapy  

Not knowing what to expect, Wally enjoyed immediate pain relief as soon as he started mirror therapy.  

In Wally’s words,

‘I was sceptical at first, but then I said, what the heck. So we tried it and [mirror therapy] worked right away. The pain just stopped. Four hours later the pain came back again, and again the mirror helped right away … 

… The pain still comes back, but it’s nowhere as bad as it was.  It comes back several times a day.  But if [the phantom limb pain] starts to bother me, I use the mirror.’


Wallace Fanene, double amputee, and his wife



Inspired by Professor Ramachandran’s ground-breaking research into mirror visual feedback in the mid-1990’s, Jack Tsao, Neurologist, offered mirror therapy for his patients who suffered phantom limb pain.

Soon after, Tsao set up a clinical trial involving mirror therapy for phantom pain at the Uniformed Services University in Maryland.

Specifically, 22 lower limb amputee patients with phantom pain from Walter Reed Army Medical Center (WRAMC) were randomly allocated to 1 of 3 groups.  Four (4) patients were unable to complete this study.

The 1st group (N=6) received mirror therapy.  The remaining 2 groups underwent covered mirror treatment (N=6) and mental visualisation (N=6).

Each group was instructed to do their assigned therapy for 15 minutes daily for 4 weeks.

This study found that ALL 6 amputees in the first group who received mirror therapy enjoyed reduced phantom limb pain after one month!  Some even experienced complete relief from phantom pain after mirror therapy.

In comparison, half of the 2nd group who received covered mirror treatment and 2/3 of the 3rd group who performed mental visualization exercises had increased pain after 1 month.

Nine (9) amputees from the 2nd and 3rd groups were subsequently re-assigned to classical mirror therapy for 4 weeks.  Eight (8) of these 9 amputees (89%) enjoyed less pain thereafter.

The first group performed 4 additional weeks of mirror therapy, totalling 8 weeks.  This resulted in further improvements for all 6 participants.  

Jack Tsao, Neurologist, said that the results ‘astounded me … I didn’t expect [the results] to be that good.’

Mirror therapy is now available at 3 US military amputee centres including WRAMC as well as other locations for amputees and patients with other painful conditions (Chan et al, 2007; Dobyns, 2008).

Nick Paupore, Amputee and Participant in Above Trial

Nick Paupore (32), a participant in the aforementioned trial, enjoyed significant relief from excruciating phantom pain following mirror therapy.

Nick lost his lower right leg in Iraq when a roadside bomb hit his vehicle.  While he felt a burning sensation in the back of his legs, Nick did not feel any pain.  Unfortunately, the blast tore out a chunk of his leg including 15cm to 20cm of an artery that almost caused him to bleed to death.

At the hospital, Nick suffered excruciating phantom pain in his missing leg 5 – 6 times an hour, with each bout of pain lasting up to a minute.  As he screamed and dry-heaved, the searing shock raced from the missing sole in his foot up the back of his phantom calf and into his thigh.

Quoting Nick,

‘I was laying in bed and it just, all of a sudden, it felt like I was getting shocked.  I called the nurse, ’cause I was like, ‘What’s going on?’  

The nurse told Nick that it was likely his phantom pain.

Nick continued,

‘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.’

‘It was like sticking my finger in a light socket. … getting electrocuted.’

‘… the [phantom] pain was driving me insane.’

And now for the good news:

Nick was almost pain-free after mirror therapy for a month.  Furthermore, he no longer needed pain medication 5 months later.

Jack Tsao

Jack Tsao, Neurologist, with Nick Paupore during mirror therapy

Quoting Tsao, Neurologist,

‘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!’ (Burgess, 2008; Young, 2008).



Professor Ramachandran did research in the mid-1990’s based on amputees who had lost their limbs many years earlier.  His studies led to mirror therapy as a pain treatment option for phantom limb pain and other painful conditions.


Neuroscientist V.S. Ramachandran


Many ground-breaking research findings were reported by Ramachandran including:

(1) An amputee named ‘D.S.’ lost his left arm 9 years ago.  His phantom arm felt as if it was ‘frozen … in a cement block’.  Ramachandran offered mirror therapy involving bilateral mirror-symmetric movements.  During this therapy, D.S. felt movement in the muscles and joints of his phantom arm while looking at his intact arm in the mirror.

When Ramachandran removed the mirror, D.S. was no longer able to feel his phantom arm move.  In his words, ‘It feels frozen again.’   

This experiment demonstrates the importance of visual feedback via mirror therapy in restoring movement in ‘frozen’ phantom limbs.  This movement may even be a prerequisite before phantom limb pain can be reduced or eliminated altogether.

(2) A left arm amputee known as ‘R.T.’ (55) suffered a paralysed phantom arm.  His left hand often had clenching spasms with ‘fingernails digging into the palm’.

Mirror visual feedback was done to provide an illusion of a restored left arm.  The reflection of his intact right arm in the mirror provided the visual feedback that R.T. desperately needed before he could finally ‘unclench’ and ‘move’ his paralysed phantom arm in a mirror-symmetric manner.

(3) Five patients suffered painful ‘clenching spasms’ in their phantom hand.  Following mirror therapy, 4 of 5 patients were finally able to ‘open’ their phantom hand leading to relief from painful spasms.

Mirror therapy may lead to new connections in the brain.  This may include novel and/or reactivation of pre-existing neural pathways between both cerebral hemispheres (Ramachandran & Hirstein, 1998).

Graded Mirror Therapy vs Traditional Mirror Therapy

A male patient (43) suffered deafferentation pain in his right arm following brachial plexus avulsion due to a traffic accident 23 years ago.  Specifically, he endured severe tingling pain including numbness in his right fingers (pain rating of 10/10).

Traditional mirror therapy for 4 weeks failed to offer pain relief.

Graded mirror therapy, on the other hand, ultimately led to complete relief from pain.

Graded mirror therapy comprises 5 steps, being:

  1. Observing the mirrored reflection of the unaffected side without imagining any movements in the amputated limb;
  2. Observing the mirrored reflection of the 3rd and 4th fingers while slowly moving them from a flexed position to an extended position;
  3. Observing the mirrored reflection of the unaffected side during passive movements;
  4. Motor imagery of the affected fingers while observing the mirrored reflection of the unaffected side; and
  5. Motor imagery of the affected fingers without a mirror.

Graded mirror therapy involving the aforementioned 5 steps was done for 3 – 4 weeks.

The good news is that during graded mirror therapy, pain levels decreased and finally disappeared altogether.  The patient was also able to imagine finger movement both with and without a mirror (Mibu et al, 2016).

Possible Mechanisms

Although there is no shortage of possible explanations, no one really knows why mirror therapy may work better in some patients than in others.

Professor Herta Flor, Neuroscientist, believes that both peripheral input and central changes may be involved in phantom limb pain (Perur, 2014).

Competitive interaction may arise between the two brain hemispheres in stroke patients (and presumably also in amputees).  This can lead to abnormal interhemispheric inhibition (IHI) and weakened motor function.

In stroke patients, mirror therapy and motor training could increase the excitability of the stroke-affected primary motor cortex (M1).  Specifically, mirror visual feedback training could alter the excitability of the transcallosal pathway and restore IHI back to normal.  This could in turn strengthen motor function in the stroke-affected side.

Thus, mirror visual feedback training may help normalise IHI and restore the hemispheric balance between the stroke-affected (or amputation-affected) M1 and the healthy M1 (Avanzino et al, 2014).

Another study reported that mirror visual feedback via a mirror led to improved motor function in 2 patients who had callosal disconnection.  Based on this, they concluded that mirror therapy that leads to improved motor performance does not affect interhemispheric interaction via corpus callosum (Nojima et al, 2013).  Whether this also occurs in amputees is unknown.

See 5-minute TED-Ed Animations video called ‘The fascinating science of phantom limbs’ by Joshua Pate.

Some Questions to Ponder

Could an amputation lead to abnormal IHI and a hemispheric imbalance between the amputation-affected M1 and the healthy M1?

If yes, could this contribute (in part or in full) to ‘painfully frozen limbs’, ‘paralysed phantom limbs’ and phantom limb pain in amputees?

If so, could mirror visual feedback training using mirrors reduce phantom limb pain and other symptoms in some amputees?

Another Question

In my blog post called:

A Doctor and a Nurse who can Literally Feel Pain in Other People,

we learn that Dr Joel Salinas, a neurologist, has mirror touch synesthesia.  This means that he can literally feel his patients’ pain and tactile sensations.  Automatically triggered by sight, he said that, for example, when he sees someone’s right arm being touched, he also feels a touch on his own left hand – just like in a mirror.

Could Dr Salina’s experience with mirror touch synesthesia offer certain insight into why mirror therapy may offer relief from phantom limb pain in many amputees? 


Mirror therapy including graded mirror therapy may be a very effective treatment option for amputees with phantom limb pain and other chronic pain sufferers.

Benefits derived from mirror therapy vary from one patient to the next.  According to Professor Christoph Maier, while some amputees are pain-free after only 1 mirror therapy session, others may need to do mirror therapy for the rest of their lives to reduce phantom pain (Liebling, 2010; translated from German).

Who would have thought that a humble mirror could offer relief from excruciating phantom limb pain for some amputees??

Sabina Walker

Blogger, Pain Matters (in WordPress)



Patient Stories

(1) Dobyns, Stephen. Certain San Diegans feel their missing limbs. San Diego Reader (9 July 2008).

(2) Saundra Young. For amputees, an unlikely painkiller: Mirrors. CNN (19 March 2008).

(3) Burgess, Lisa. Mirrors helping amputees fight phantom pain. Stars and Stripes (2/2/2008).

(4) Colapinto, John. Brain Games – The Marco Polo of Neuroscience. The New Yorker (11 May 2009).

Peer-Reviewed Science Papers

(5) Chan BL et al. Mirror therapy for phantom limb pain. N Engl J Med (22 Nov 2007); 357: 2206-2207.

doi: 10.1056/NEJMc071927 

(6) Uniformed Services University of the Health Sciences. Phantom Limb Pain May Be Reduced By Simple Mirror Treatment. Science Daily (24 November 2007).

(7) Ramachandran VS & Hirstein W. The perception of phantom limbs. Brain (1998); 121: 1603-30.

(8) Avanzino et al. Training based on mirror visual feedback influences transcallosal communication. Eur J Neurosci (Aug 2014); 40(3): 2581-8.

doi: 10.1111/ejn.12615.

(9) Nojima et al. Mirror visual feedback can induce motor learning in patients with callosal disconnection. Exp Brain Res (May 2013); 227(1): 79-83.

doi: 10.1007/s00221-013-3486-4

(10) Perur, Srinath. The mirror man. mosaic (7 July 2014).

(11) Mibu et al. Successful Graded Mirror Therapy in a Patient with Chronic Deafferentation Pain in Whom Traditional Mirror Therapy was Ineffective: A Case Report. Pain Practice (April 2016); 16(4): E62-E69.

Non-Fiction Book

(12) Ramachandran VS & S Blakeslee. Phantoms in the Brain – Human Nature and the Architecture of the Mind. HarperCollins Publishers (20 May 1999); pages 1 to 352.

ISBN 9781857028959

(13A) Ramachandran VS. The Tell-Tale Brain – A Neuroscientist’s Quest for What Makes Us Human. W.W. Norton & Co (5 April 2012); pages 1 to 357.

ISBN: 9780099537595

(13B) V.S. Ramachandran’s Tales Of The ‘Tell-Tale Brain’. NPR (14/2/2011).

Medical Articles (in German) 

(14) Mit der Spiegeltherapie sind Schmerzen “verlernbar”. Ärzte Zeitung online (22.02.2010).

(15) Liebling, Patricia. Spiegeltherapie hilft gegen Phantomschmerzen. Aachener Zeitung (27 Feb 2010).

(16) Hawlik, Michaela. Leben mit Phantomschmerz. My Handicap (1/2011).

Other Medical Articles (not discussed in this blog post)

(17) Peterzell, David H. Psychophysical investigations into Ramachandran’s mirror visual feedback for phantom limb pain: video-based variants for unilateral and bilateral amputees, and temporal dynamics of paresthesias. 2016 Society for Imaging Science and Technology (Feb 2016).

doi: 10.2352/ISSN.2470-1173.2016.16HVEI-093

(18) Timms, Jason & Carus, Catherine. Mirror therapy for the alleviation of phantom limb pain following amputation: A literature review. International Journal of Therapy and Rehabilitation (March 2015); 22(3): 135-145.

(19) Datta & Dhar. Mirror therapy: An adjunct to conventional pharmacotherapy in phantom limb pain. J Anaesthesia Clin Pharmacol (Oct-Dec 2015); 31(4): 575–578.

(20A) Ol, Ha Sam et al. Mirror therapy for phantom limb and stump pain: a randomized controlled clinical trial in landmine amputees in Cambodia. Scandinavian Journal of Pain (3 July 2018); 18(4): 603-610.

doi: 10.1515/sjpain-2018-0042

(20B) Ol, Ha Sam et al. Mirror therapy: Curing phantom pain in landmine victims. Science Discoveries (26.10.2018).



A Phantom Leg And Frozen Fingers Treated By Mirror Therapy

‘Disability is only a state of mind.’

Bryan Wagner, Amputee 

Feature Image showing mirror therapy sourced from:

For related blog posts, see:


Dear Pain Matters blog readers,

Phantom limb pain (PLP; phantom pain) is a terrible affliction that affects up to 90% of all people who have lost a limb, or part thereof, due to trauma, injury, disease or surgery.

Mirror therapy may be an effective and inexpensive pain treatment option for patients with phantom pain, complex regional pain syndrome (CRPS), pain and lost motor function after stroke, hand immobility and pain caused by spinal stenosis and other conditions.

Mirror therapy is sometimes called mirror visual feedback or graded motor imagery.


Bryan Wagner, Amputee and War Veteran  

Bryan Wagner (23) lost his lower right leg in an improvised explosive device (IED) explosion on 17 December 2007 while serving in Baghdad.  Thereafter, Bryan suffered phantom pain in his missing toes and in the arch of his heel.  The pain included knife-like stabbing pain between his toes and poker-like pain.

Mirror therapy is offered to patients just like Bryan at the Walter Reed Army Medical Centre (WRAMC).  This therapy is done 15 minutes a day, 5 days a week, for 8 consecutive weeks.  If necessary, this cycle is repeated.

During mirror therapy, Bryan stated:

‘It … really feels like you are moving your [missing] foot … It feels like your foot is there …’

If you look very closely at the video below, you will see Bryan’s stump actively participate in all the foot exercises at the same time as the good leg.

It is as if the residual stump is doing all the exercises that the missing foot would be doing, if it were to still exist.  Thus, the stump is acting in lieu of the missing foot!  I don’t know about you but I find this very fascinating!

In other words, the leg stump (that is 100% hidden from Bryan’s view) is moving in complete harmony and unison with the foot’s reflection.  Could it be that optimal results from mirror therapy are possible when this occurs?  (Go to 1:28 minutes.)

Mirror therapy enables the brain to finally ‘feel movement’ again in the (phantom) limb.  Using mirror therapy to restore movement in a missing limb (and in a stump) may be key to reducing phantom limb pain.

Treating Phantom Limb Pain with Mirror Therapy 

Above, a 2-minute YouTube video and narrative by UPIVideo dated 27 July 2009.  NB The narrative may only be available if you open the video in a separate window.



Bob McKeefery, a long-time fisherman, has spinal stenosis (i.e. tightening or narrowing) of the spinal canal.  Spinal stenosis can lead to compression and ‘pinching’ of the spinal cord and nerve roots.  This can cause pain, cramping, weakness and numbness as well as abnormal signalling between the brain and the body.

Bob suffered ongoing pain and limited mobility in his right hand following several surgeries over a year ago.

In his words,

‘I could move my right arm, but I couldn’t move my right hand.  So 3 of my digits, the last 3, were like ‘frozen shut’ and 2 were frozen open.’

The good news is that mirror therapy led to immediate benefits including complete pain relief for Bob!  

Quoting Bob,

‘All my pain, a year’s worth of pain, went away in one day!’

After only 1 week of mirror therapy, Bob was finally able to use muscles and do movements that he had long given up on.

Bob said,

‘It was impossible last week for me to do this.  I could not ‘palm up’. …’ 

As Bob continued with mirror therapy, 10 minutes each session, several times a day, he has one goal that keeps him going.

Quoting Bob,

‘[My goal] would be to pick up my grandchildren … because I’m not allowed during this crisis … and they are 1 and 3.’

Thanks to mirror therapy, Bob is now one step closer to his goal!

For more details, watch Mirror Therapy Helps Patients Reduce Pain, Gain Mobility in Limbs, by NJTV News (30 April 2015).


I hope that these stories will inspire others to try mirror therapy for their phantom pain and other painful conditions.  After all, there is no downside in trying mirror therapy.

Sabina Walker

Blogger, Pain Matters (in WordPress)




* Tibia bone – One of 2 bones in the lower leg.


Mirror Therapy For Phantom Limb Pain – ‘What Your Eyes See IS Reality’

‘What Your Eyes See Is Reality’

Erez Avramov, Life Rebuilder

Feature Image of Erez Avramov and the mirror box was sourced as a still frame from the YouTube video dated 8 July 2013 (below).

For related blog posts, see:


Dear Pain Matters blog readers,

Phantom limb pain (PLP; phantom pain) is a terrible affliction that affects up to 90% of all people who have lost a limb, or part thereof, due to trauma, injury, disease or surgery.

Mirror therapy may be an effective and inexpensive pain treatment option for some patients with phantom pain, complex regional pain syndrome (CRPS), pain after stroke and other pain conditions.


Erez’s Traumatic Life Events 

Erez Avramov, Life Rebuilder, survived 3 serious motor vehicle accidents (MVA) and a serious heart attack.  Sounding more like an action thriller story than an enriched life story, Erez is a perfect example of ‘what doesn’t kill you, makes you stronger’.


During his first accident, Erez was involved in a serious head-on crash with a semi-truck after his vehicle hit black ice and spun out of control near Merritt, BC, Canada, in November 2010.  He suffered many injuries including fractures to the sternum, hand and ankle, a crushed rib cage as well as a leg that was broken in 17 different places.

Several years and multiple surgeries later, Erez opted for elective amputation to improve mobility of his MVA-injured right leg below the knee (ADV Pulse, 2014)

Erez holds the honour of being the first amputee ever to enter the Dakar Rally race in South America.  Sadly, he had his second near-fatal accident when he crashed his motorbike during one of these desert races.

More recently, Erez had another vehicle accident in December 2017 that was followed by a serious heart attack just one (1) month later.

Being optimistic by nature, Erez always tries to gain valuable insight even from the worst moments in his life.  For his inspirational views, please visit his website:

Erez’s Mirror Therapy for Phantom Limb Pain  

Following his elective lower right leg amputation, Erez suffered phantom pain.

In his words,

‘… the results and the process [of mirror therapy are] just amazing.’

Erez used a custom-made 3-sided mirror box that included a white-framed mirror.  Hinged on both sides, the mirror box can be unfolded and assembled like a ‘triangular tunnel’.  A plain mirror may also be used.

Erez’s good leg was placed right next to the mirror while his amputated right leg remained well hidden inside this triangular tunnel.

As Erez moved his toes very slowly, he tried to imagine moving the same muscles in his phantom toes at the same time.

Given that he spoke about mirror therapy with such amazing clarity, I will quote Erez from here on (see his YouTube, below),

‘… This is the important part … you move your toes and you try with your mind to move … your missing toes – but when you look at them in the mirror, it’s as if they are there … and you feel your muscles in your residual limb …  Move those toes as if they are there.  

Then I will start to do some rotational work , and I will move both legs in the same direction as if everything is there.  

Because what happens is:  Your brain sees this leg and your foot.  It thinks it is there.

This is the most bizarre thing there is.  It is as if you still have it … You  really have to be open-minded and to accept the fact that what your eyes see is reality … It’s almost like you bypass this reasoning side of your brain …

I will move my muscles.  I will move my residual limb as if I have an intact full foot …

The results were amazing … [inserted: my painful ‘tiger-clawed’ phantom toes were] released, so the pain is gone …

… the protocol is 4 weeks of 10 minutes every day.  You do this for 4 weeks …

… You cover your residual limb.  You use … a … magazine cover, or whatever, … to hide your good foot so you don’t see it, and all you want to see is your reflection of your foot, as if you still have [a] missing limb …’ 

Watch Erez Avramov’s helpful video, here:

‘Mirror Therapy – Personal Success Story’

An 8-minute YouTube dated 8 July 2013


Thank you very, very much, Erez, for sharing your powerful story about your personal experience with mirror therapy!

I am sure that your story will inspire others to try mirror therapy for their phantom pain.

Sabina Walker

Blogger, Pain Matters (in WordPress)




(2) Amputee Pursues Lifelong Dream to Race the Dakar Rally. ADV Pulse (27/10/14).





Mirror, Mirror, Short Or Tall, Which One Has No Pain At All?

Title adapted from:

Mirror, mirror on the wall, who is the fairest of them all?

Feature Image sourced from:

For related blog posts, see:


Dear Pain Matters blog readers,

Up to 90% of all amputees suffer from phantom limb pain (PLP), or more simply, phantom pain.

Mirror therapy is an inexpensive pain treatment option for some patients with phantom pain, complex regional pain syndrome (CRPS), pain after stroke and other painful conditions.

Stephen Sumner (aka Mirror Man), an amputee and humanitarian from Vancouver, Canada, was so impressed with the pain-relieving effects of mirror therapy on his phantom pain that he set up his mission called ‘Me and My Mirror’.


Reality is merely an illusion, albeit a very persistent one.

Albert Einstein

Stephen’s Story, Before Mirror Therapy

Stephen endured a left above-knee amputation after a truck crashed into his scooter in a hit-and-run accident that left him for dead on a quiet country road near Siena, Italy, one balmy evening in 2004.

Using his words, Stephen ‘suffered terribly … suicidally’ from severe PLP for 4 – 5 years thereafter.  He used to endure ongoing electrifying shocks that shot up his missing left leg and throughout his body.

Quoting Stephen, it was like having ‘lightning bolts through my foot’ in a leg that no longer existed.  His entire body would jolt and spasm uncontrollably, as if he was ‘being spiked with a cattle prod day and night’.  Stephen would be reduced to screaming and tears with no sleep at all during these severely painful bouts.

Stephen added, ‘I could have killed myself.’

Stephen’s phantom toes would be ‘stuck’ in an excruciatingly painful and clenched position.  The pain ‘was like a vice over the back of my heel.  It was like it was being crushed.’  Stephen’s phantom pain felt like ‘crippling electric pulses’ … ‘burning and crushing, but the worst is the itching’.

Stephen stated that his phantom pain was ‘… not in the head, it’s in the limb.’

Stephen’s Story, After Mirror Therapy

Then one day, Stephen read about mirror therapy on-line.  The first time he placed a mirror against his left thigh and looked at the reflection of his right leg (where the left leg used to be), he felt immediate relief.  Five (5) minutes later, his pain was gone.  Stephen did mirror therapy twice daily for 10 minutes at a time.  Finally, after 5 weeks, his phantom pain disappeared for good. 

Quoting Stephen, mirror therapist:

‘… within … 3 and 5 weeks, the pain … disappeared … my phantom pain had gone away, almost magically …’ 

Stephen continued,

‘… 10 minutes per session, 2 sessions per day, 5 weeks, and you’re done for life … If I get some kind of a flare-up, I just whip out the mirror, and I’m good again …’

(Go to the following 10-minute video called The Me & My Mirror Back Story; 2:30 minutes).

Stephen offers mirror therapy to amputees with phantom pain in 3rd world countries including Cambodia, Laos, Vietnam, Sri Lanka, Burma, Myanmar, Vietnam, southern part of India, Lebanon, Ethiopia, Syria, Egypt, Tunisia, Algeria and the western Sahara region.

Stephen often treats amputees with PLP due to traumatically torn or mutilated limbs resulting from war, landmine blasts, unexploded ordnances (cluster bombs, cluster munitions) and road accidents.  Stephen also treats patients who lost their limbs due to severe diabetes and other diseases.

Stephen collaborates with medical experts in the local hospitals, trauma centres, physical rehabilitation centres and prosthetic clinics.  Recently, he was at the ‘Jaffna Teaching Hospital’ with Physical Rehabilitation Therapists and Orthopedic Surgeon.  He also teaches locals how to make therapeutic mirrors for pain relief.

Stephen uses this simple mantra for mirror therapy:







In Stephen’s words,

‘… You feel immediate relief, but you have to carry on for 4 or 5 weeks.  So, my mantra is:

  • 2 sessions a day 
  • 10 minutes per session
  • 5 weeks.’

(Global News, 2016)



Stephen uses acrylic mirrors due to their cost-effectiveness, safety, lightweight nature and transportability (i.e. on the back of his beloved bicycle).




According to Stephen, it is often difficult for amputees in Cambodia and other 3rd world countries to open up about their phantom pain.  Many amputees with phantom pain are ashamed.  They would rather suffer in silence than risk being labelled as ‘outright crazy’ or ‘insane’ for ‘complaining’ about pain in a limb that does not even exist.

Also, the fact that many amputees here are Buddhists raises the topic of karma including what the amputees ‘must have done in a previous life to deserve this fate’.

When Stephen is seen riding around on a bicycle with his prosthesis clearly visible to all, the locals are more likely to empathise and connect with him.  When Stephen tells them that he used to suffer from phantom pain, they finally open up about their own phantom pain.





A Cambodian Amputee Named Pov Sopheak 

Pov Sopheak (50), a former soldier and security guard in Cambodia, is also an amputee with phantom pain.  He traumatically lost his left leg in a landmine explosion in 1990.  Pov’s severe phantom pain including sharp pains in his phantom big toe and little toe affected the quality of his life including sleep for 2 decades.

In Pov’s words,

‘[It] feels like my leg is shaking.’   

Pov’s life finally turned a corner after meeting Stephen.

With Stephen’s guidance, Pov used the mirror to ‘trick’ his brain into thinking that his left leg was not missing after all, but rather, still very intact.  While moving his right leg including wiggling his toe and flexing his foot in front of the mirror, Pov was able to ‘fool’ his brain into thinking that the reflection of his good leg was that of his missing left leg.

This simple yet elegant treatment helped to relax Pov immensely.  Furthermore, Pov’s brain was able to imagine and ‘perceive movement’ in his missing left leg again, after decades of ‘immobility’ and ‘non-use’.  Mirror therapy was able to jump-start brain circuitry pertaining to his left leg.  For Pov (and many others just like him), this was a prerequisite for phantom pain relief.

Quoting Pov,

 ‘It’s a new sensation. It’s strange but in a good way … I see my leg in the mirror and I feel happy, like my mind is at ease.’

Pov made a commitment to mirror therapy for 4 – 5 weeks in the hope that his phantom pain would lessen with time.

Additional Thoughts

In the absence of incoming signals from both legs (and/or in the presence of abnormal signals coming in from the stump itself), a brain may become chronically stressed.  This often leads to phantom pain.  

On the other hand, many amputees with phantom pain instantly feel better during mirror therapy.  The reflection of the intact limb in the mirror helps to ‘convince’ their brain that it is finally perceiving two (2) normal limbs.  

Importantly, many amputees are finally able to ‘move’ their phantom limb for the first time in years, and perhaps decades, during mirror therapy.  This can lead to a state of calm and relaxation, together with immediate pain relief.  

In Stephen’s words,

‘Looking in the mirror, the brain suddenly enables you to move your phantom foot and do everything the real foot is doing.’

‘The brain just wants to be tricked. It’s dying for release’ (Fitzpatrick, 2012).




Photo sourced from:

If you would like to support Stephen’s important mission to deliver mirror therapy and a therapeutic mirror to PLP amputees in 3rd world countries, please go here:

More details are available on Stephen’s website and in his book called Phantom Pain: A Memoire: It’s All in Your Head.

You can also follow Stephen on social media including Twitter and Facebook.

Biking Laos – Mirror Man Cycling Laos 

2 Times, 10 Minutes, 4 Weeks (21/1/2013)


Several questions to ponder over include:

  • What % of amputees are finally pain-free after 4 – 5 weeks of mirror therapy?
  • What % of amputees remain pain-free 6 – 12 months after mirror therapy?
  • If the benefits are not lasting in some amputees, can mirror therapy be done repeatedly to relieve phantom pain?
  • Are left-sided amputees more likely to benefit from mirror therapy than right-sided amputees (or vice versa)? If so, why?  If not, why not?
  • Is the corpus callosum in the brain involved?


Stephen’s easy-going, can-do attitude as well as his passion and commitment to treat amputees with PLP via mirror therapy have made him a welcome hero in many 3rd world countries.

In his friend’s words,

‘He’s not your regular officious [non-government organisation] guy.  He rides up on his bicycle with a smile on his face and a bunch of mirrors.’

In my view, Stephen is one amazing guy with one big heart!

… And I am not the only one who thinks this!

A fiction movie called ‘ Phantom Pain’ (in German, ‘Phantomschmerz’), released in 2009, was completely inspired by Stephen’s early experiences as an amputee.

Sabina Walker

Blogger, Pain Matters (in WordPress)



Your perception IS your reality.




(1A) Sumner, Stephen. Me and My Mirror.

(1B) Fitzpatrick, Michelle. Mirrors ease Cambodian amputees’ phantom pain. The China Post and AFP (28/2/2012).

(1C) Perur, Srinath. The mirror man. mosaic (7 July 2014).

(1D) Otis, Daniel. Meet the ‘Mirror Man’ who’s on a mission to help fellow amputees. CTV News (25 December 2018).

(1E) Ross, Amy. Mirror Medicine: A Cure for Phantom Limb Pain? Pacific Rim Magazine.

(1F) Mullen, Dene. The man with the mirror. Southeast Asia Globe (12 July 2013).

(1G) Man in the Mirror. Asia Life (2/2/2012).

(1I) Lazaruk, Susan. Local amputee bikes through Asia helping others who have lost limbs. Vancouver Sun (22 April 2019).

(1M) Boynton, Sean. Vancouver humanitarian promotes therapy for amputees, thanks to gift from Yaletown shooting survivor. Global News (22 April 2019).

(1N) Other articles:


(2A) Me and My Mirror 2018 (6-minute YouTube)

(2B) Mirror-therapy and how it helps amputees. Global News (12 January 2016) (3-minute video)

(2C) Mirror therapy hoping to help amputees with pain. Global News (30 Oct 2014 (a 6-minute video).

(2D) Other videos:

Film (Fiction, in German; Inspired by Stephen Sumner’s Experience)

(3) Emcke, Matthias. Phantom Pain (Original Title: Phantomschmerz) (2009).



Restoration of Sensation May Lead to Reduced Phantom Limb Pain in Amputees

Dear Pain Matters blog readers,

Biomedical engineers at the Case Western Reserve University, Cleveland, Ohio, have (unwittingly) reduced/eliminated phantom limb pain in 2 amputees with severe phantom limb pain while also restoring sensation across both hands via novel ‘prosthetic system’ treatment.


Source:   Case Western Reserve University, Cleveland, Ohio

Prior to prosthetic system treatment to help restore sensation, both men were unable to feel their hands.  Both men had also suffered from phantom limb pain. 

Post-prosthetic system treatment, both patients gradually began to feel familiar sensations again.

Both patients were also able to ‘feel’ their hands for the first time since their accidents, and this helped them control their prosthetic hands better.

Restoration of Sensation and Possible Reduction of Phantom Limb Pain via Novel Prosthetic System Treatment:

Electrode cuffs (2-3) that encircle major nerve bundles were surgically implanted into both patients’ arms.  These electrode cuffs enabled the patients to feel 16-19 distinct ‘contact points’.

The sensory nerves were stimulated via unique and changing patterns and intensities of electrical signals that were sent to the 16-19 distinct ‘contact points’ on the electrode cuffs.  Different signal patterns (transmitted to the electrode cuffs via the prosthetic system) are interpreted as different feelings by the brain.  This can lead to the restoration of certain sensations.

For example, certain patterns and intensities of electric signals may evoke the feeling of cotton, while other electrical signal patterns may feel like ‘water running across the back of a hand’, sandpaper, a smooth surface or even a ridged surface.

An unexpected positive outcome from this prosthetic system treatment was that, after 2 years of testing, the phantom limb pain was gone.

The 2 Patients:

(1) The first patient, Mr Spetic, lost his right hand in an industrial accident 4 years earlier.  He suffered phantom limb pain since the accident.  Quoting Mr Spetic (in the video):

‘The way I described it was:   My hand was in a vice and crushed, and it kept on going and going.’

Following experimental prosthetic system treatment whereby a computer algorithm sent certain patterns of electric signals into the nerves, Mr Spetic said that his phantom limb pain subsided.  Quoting Mr Septic (in the video):

‘Just about, I’d say, 90-95% gone.’

(2) The second patient, Mr Vonderhuevel, who had phantom limb pain following the loss of his right hand and part of his forearm in an accident, said that his phantom limb pain was ‘nearly gone following experimental prosthetic system treatment.

Credit:   Case Western Reserve University, Cleveland, Ohio 


Targeted restoration of sensation via prosthetic system treatment may lead to significant reduction, and even elimination, of phantom limb pain for some phantom limb pain sufferers.  This offers hope to amputees with pain.

Sabina Walker


(1) Amputees discern familiar sensations across prosthetic hand

(2) Prosthetic hands endowed with a sense of touch; Elizabeth Pennisi; 8 October, 2014

(3) Thomson, H.

Once more with feeling

New Scientist, Volume 224, Issue 2991, 18 October 2014, Pages 8–9




‘Pokémon Go-style’ Pain Management?

Dear Pain Matters blog readers,

‘Augmented reality’ not only forms the basis for Pokémon Go for entertainment, but it may also offer novel treatment for some patients with phantom limb pain.

Phantom limb pain is very common in amputees affecting up to 70% of all people who have lost a limb.

A successful case study involving augmented reality:

A 72-year old man suffered moderate to unbearable phantom limb pain since the loss of his arm below his elbow joint in 1965 caused by traumatic injury.  Since the amputation, this patient lived with constant burning pain that changed hourly, ranging from ‘3’ (on a scale from 0 – 10) to ‘excruciating pain levels’.  He also awoke nightly as a result of intense episodes of pain.

Conventional pain treatment failed him, and for almost half a century, he was never completely free of pain.

After 48 long years of severe phantom limb pain, and following experimental treatment involving augmented reality and gaming, this man finally found significant pain relief.  Using the myoelectric signals (‘myoelectric  pattern recognition’) at the arm stump, it was now possible to volitionally and directly control the ‘virtual arm’ (through the prediction of motion intent).  This in turn resulted in reduced phantom limb pain (Ortiz-Catalán et al, 2014).

Specifically, augmented reality pain treatment involved:

  • ‘Projection of a virtual reality arm’ from the patient’s painful limb stump –
    • This virtual arm was superimposed onto the patients’ painful limb stump (to resemble a real arm) on the computer screen;
  • Real-time recording of muscle signals from the painful arm stump –
    • This recording of residual electrical signals in the muscles via electromyography (EMG) is done via electrodes on the skin of the arm stump; and
  • Conversion (via software using complex algorithms) of the electrical signals from muscles in the arm stump –
    • The converted data was used to control specific movements of a virtual arm in augmented reality.
    • Specifically, the patient was able to imagine driving a car by ‘moving’ his virtual arm (that represented his missing arm) on the computer screen.  This enabled him to control his superimposed virtual arm in real-time during a computer car racing game.


A YouTube video and 2 photos are provided below for further details:

Please note:  Audio is not available for this YouTube. 



Above, photo #1:

The patient can see his virtual arm that is now superimposed onto his missing arm on the computer screen.  The patient can control his virtual arm via converted residual muscle signals arising from his arm stump.


Above, photo #2:

(A) Surface electrodes on the arm stump

(B) See first photo (above)

(C) Patient playing a computer car racing game by imagining ‘moving his missing arm’ to drive a car.  Specifically, the patient imagines specific and/or random arm movements, as requested by the computer during the car racing game.

(D) Patient using the ‘Target Achievement Control’ test for rehabilitation.

Credit (YouTube video and photos):   Ortiz-Catalán et al, Frontiers in Neuroscience


The patient stated that his pain was drastically reduced, albeit slowly, over 18 weeks.  He even enjoyed nil pain during some of his augmented reality treatments, and he no longer wakes up at night due to intense pain.

Quoting the patient:

“These pain-free periods are something almost new to me and it is an extremely pleasant sensation.” 

Quoting the patient’s wife:

“My husband can live 10 years more than I expected, as pain now plays a less important role in his life and those close to him can see it.”

(Ortiz-Catalán et al, 2014)

The patient also said that his phantom (missing) hand, that was painfully clenched in a permanent posture for 48 long years, was now ‘open and relaxed’ following augmented reality treatment.

Given that the electrical signals are obtained from the arm stump, this may indicate that the arm stump itself is driving the chronic and severe phantom limb pain suffered by the patient for 48 years.  Hence, in this particular patient, the phantom limb pain appears to be peripherally-induced (not centrally-induced).

Quoting Max Ortiz Catalán:

“…the control signals are retrieved from the arm stump, and thus the affected arm is in charge…The promotion of motor execution and the vivid sensation of completion provided by augmented reality may be the reason for the patient improvement…”

(Chalmers University of Technology, 2014)


Max Ortiz Catalán, Assistant Professor

Chalmers University of Technology, Gothenburg, Sweden.


Ortiz Catalán and his team are optimistic that pain therapy involving augmented reality and gaming may offer hope for some phantom limb pain patients including bilateral amputees with phantom limb pain.  This new augmented reality/gaming treatment may also be a lot more fun and engaging than conventional pain treatments, hence encouraging increased patient compliance.

A follow-up multi-center clinical trial, led by Chalmers University of Technology, and performed at 4 hospitals, being:

  • Sahlgrenska University Hospital, Gothenburg, Sweden;
  • Örebro University, Örebro, Sweden;
  • BräckeDiakoni Rehabcenter Sfären, Stockholm, Sweden; and
  • University Rehabilitation Institute, Ljubljana, Slovenia,

was recently completed to assess the potential efficacy of augmented reality pain therapy for patients with chronic, intractable phantom limb pain.

We can expect some exciting results!  (Watch for an upcoming paper by Ortiz Catalán et al.)

Ortiz Catalán and his colleagues also helped implement augmented reality pain treatment in clinics in Belgium, the Netherlands, Slovenia and Japan (with Austria and Latvia to follow) for selected phantom limb pain patients who are refractive to other pain treatments.

Lower limb amputees with phantom limb pain are now included in the clinical trials.

(Source:   Email dated 3 August 2016 from Assistant Professor Max Ortiz Catalán.)

This is great news for all phantom limb pain sufferers!

Sabina Walker

PS Quoting from Assistant Professor Max Ortiz Catalán’s email dated 3 August 2016:

“You are welcome to encourage patients and clinicians to contact me if they would like to try this technology.  It’s non-invasive and safe so it poses little to no risks.  They can contact me at this e-mail:

Thank you again for your interest in our work.”


Media Releases:

(1A) Lewis, Tanya; Staff Writer, Live Science

Virtual Reality Treatment Relieves Amputee’s Phantom Pain

25 February 2014

(1B) Chalmers University of Technology

Phantom Limb Pain Relieved When Amputated Arm Is Put Back To Work

25 February 2014

Peer-Reviewed Papers: 

(2) Ortiz-Catalán M, Sander N, Kristoffersen MB, Håkansson B and Brånemark R (25 February, 2014)

Treatment of phantom limb pain (PLP) based on augmented reality and gaming controlled by myoelectric pattern recognition: a case study of a chronic PLP patient.

Front. Neurosci. 8:24.

Includes Supplementary Material – Video (audio unavailable)

doi: 10.3389/fnins.2014.00024



Ziconotide (Prialt) for Nerve Pain Including CRPS?

Dear Pain Matters blog readers,

For some pain sufferers, pain relief may be offered (in part or in full) by a component of the venom of an ocean-dwelling cone snail called Conus magus.

Before continuing, I would like to take a moment to celebrate the beauty, power, and energy (while also respecting the dangers) of our oceans with all its amazing creatures (including, of course, deadly cone snails).  I took this photo from BELOW the ocean waves (while snorkelling yesterday).


Today’s blog post is on Ziconotide (Prialt).  Ziconotide is the synthetic equivalent of a naturally-occurring conopeptide called SNX-111 (or omega-conotoxin MVIIA), a component of the venom of the marine cone snail, Conus magus.

Ziconotide, a novel non-opioid drug, can be used to treat patients with severe chronic pain.  It works by selectively and potently blocking the neuronal N-type calcium channel.

Some patients with severe chronic pain may receive significant pain relief from Ziconotide, either as sole treatment (monotherapy) or with other treatments.  Ziconotide is able to maintain its analgesic effects for month(s), even after a single infusion treatment.

Ziconotide treatment does not result in tolerance, dependence, nor respiratory depression (unlike opioids).  However, there can be adverse effects, especially if dosages are too high, or titrated too quickly (see below).


(1) Severe Intractable Deafferentation Pain Plus Phantom Limb Pain –

A 43-year old male patient suffered (quoting) ‘refractory, severe deafferentation pain’ and phantom limb pain for 23 years, following brachial plexus avulsion and consequent amputation.

Following  administration of SNX-111 (Ziconotide) via continuous intrathecal infusion via a cervical catheter, this patient had complete pain relief as well as (quoting) ‘elimination of hyperesthesia and allodynia‘.

Complete pain relief was still provided to this patient even after dosages were reduced to eliminate side effects.  Thus, SNX-111 (Ziconotide) may offer potent pain relief for both malignant and nonmalignant pain conditions (Brose et al, 1997).

(2) Three (3) Nerve Pain Patients and Ziconotide Infusion –

The 1st patient, with chronic complex regional pain syndrome (CRPS) in the leg, received a single Ziconotide infusion treatment.  This resulted in temporary and complete pain relief.  (There were adverse effects, however.)

The 2nd patient (with painful lumbar radiculitis) received complete (albeit temporary) pain relief following a test dose of Ziconotide infusion.  (There were also side effects.)

The 3rd patient, with persistent bilateral leg and foot nerve pain due to AIDS and related drug therapy, obtained significant pain relief following long-term continuous intrathecal infusion (Wermeling et al, 2006).

(3) Ziconotide in a 16-year-old Male With CRPS in Both Legs –

A 16-year-old boy with CRPS in both legs was given Ziconotide for 3 years.  Pain was reduced at 6 weeks, and a normal gait was achieved at 7 months.  The patient reported NIL pain after 3 years of Ziconotide therapy.  Side effects included urinary retention and depression (Webster, 2005).

(4) Ziconotide in a 17-year-old Female With Chronic CRPS in Right Lower Leg (Initiated by an Ankle Sprain at 13) –

A 17-year-old girl, who was wheelchair-bound due to chronic CRPS in her right lower leg, was given Ziconotide (and other medications) via intrathecal catheter.  As dosages were increased, the swelling in her leg and foot decreased.  At greater dosages, pain levels further decreased and the ‘desquamating skin’ receded toward her right foot.  At times, the edema disappeared completely.

As dosages were further increased, most of her skin scales had disappeared and her foot appeared pink.  Foot movement was regained, as was her quality of sleep that now included a bed cover.  By now, she had also progressed from a wheelchair to crutches.

Further months of Ziconotide therapy brought her VAS Pain Score down to 4 (from 8, pre-Ziconotide).  By now, ambulation and function was greatly improved, with little or no allodynia nor hyperalgesia.

Significant side effects were not observed, and this was attributed to a slow titration of Ziconotide (Stanton-Hicks et al; 2006). 

(5) Ziconotide for 7 CRPS Patients –

Five (5) of 7 CRPS patients had (quoting) ‘substantial improvement in pain, edema, skin abnormalities, and/or mobility with ziconotide therapy’.

In fact, 2 patients had complete pain relief and as such, discontinued Ziconotide treatment altogether.  

A 3rd patient had significantly reduced edema as well as decreased skin trophic changes, following Ziconotide infusion.

Adverse events (including depression, anxiety, hallucinations, and urinary retention) were managed via dose reductions/discontinuation, or otherwise (Kapural et al, 2009).


Several drawbacks and possible adverse effects must be noted including:

Ziconotide requires intrathecal administration.

NB  A properly performed trial of ziconotide infusion should always be done first before consideration is made whether to surgically implant an intrathecal device on a permanent basis, or not.  This trial phase is absolutely necessary to ascertain whether a patient will obtain pain relief from ziconotide in the first place (Knight et al, 2007);


– There is a risk of one or more adverse effects including dizziness, nausea, ataxia, abnormal gait, headache, abnormal sensations, nystagmus (involuntary eye movement), and/or confusion.

To minimise adverse effects while also maximising pain relief, initial dosages should be low, titrated slowly, and gradually increased as necessary.  It may a month (or more) to achieve a fine balance between minimal adverse effects and maximal pain relief (Webster, 2005).

Wishing all pain patients hope, inspiration, and less pain.

Sabina Walker



(1) Brose et al; Use of intrathecal SNX-111, a novel, N-type, voltage-sensitive, calcium channel blocker, in the management of intractable brachial plexus avulsion pain; Clin J Pain (Sep 1997);13(3):256-9.

(2) Wermeling et alZiconotide Infusion for Severe Chronic Pain: Case Series of Patients With Neuropathic Pain; Pharmacotherapy (Mar 2006); 26(3):395-402.

(3) Webster; Ziconotide in Complex Regional Pain Syndrome (2005)

(4) Stanton-Hicks et al;  An Effective Treatment of Severe Complex Regional Pain Syndrome Type 1 in a Child Using High Doses of Intrathecal ZiconotideJ Pain Symp Man (Dec 2006); 32(6):509-11.


Click to access J_Pain_Symp_Man_2006_32_6_pg509.pdf

(5) Kapural et al; Intrathecal ziconotide for complex regional pain syndrome: seven case reports; Pain Pract (Jul-Aug 2009); 9(4):296-303.

doi: 10.1111/j.1533-2500.2009.00289.x.

(6) Smith, Deer; Safety and efficacy of intrathecal ziconotide in the management of severe chronic pain; Therapeutics and Clinical Risk Management (Jun 2009); 5(3):521–534.

(7) Caraway et al; Intrathecal Therapy Trials with Ziconotide – A Trialing Protocol Before Initiation of Long-Term Ziconotide Intrathecal Therapy is Presented.


(8) Knight et al; Implantable Intrathecal Pumps for Chronic Pain: Highlights and Updates; Croat Med J (Feb 2007); 48(1):22-34.

(9) Miljanich; Ziconotide: Neuronal calcium channel blocker for treating severe chronic pain. Curr Med Chem (2004); 11:3029–3040.

doi: 10.2174/0929867043363884.

(10) Bowersox, Luther; Pharmacotherapeutic potential of omega-conotoxin MVIIA (SNX-111), an N-type neuronal calcium channel blocker found in the venom of Conus magus. Toxicon (Nov 1998); 36(11), 1651–1658.

(11) Rauck et al; Intrathecal Ziconotide for Neuropathic Pain: A Review; Pain Practice (2009); 9:327–337.



(12) Holmes, David; Conotoxins: how a deadly snail could help ease pain; The Lancet Neurology (Sept 2014); 13(9):867-868.


(13) Blog post by another blogger, ‘Baldscientist’

Magnificent Conotoxins – Expanded (27 July 2014)

The blog post by ‘Baldscientist’ includes these References: 

(13A) Brady, Baell, Norton; Strategies for the development of conotoxins as new therapeutic leads; Mar Drugs (Jul 2013); 11(7): 2293–2313.

doi: 10.3390/md11072293

(13B) Essack, Bajic, Archer; Conotoxins that confer therapeutic possibilities. Mar Drugs (2012); 10(6):1244-65.


Adverse Changes in the Brain Caused by Chronic Pain – Is this Reversible If Pain is Eliminated?

Dear Pain Matters blog readers,

It is now known that chronic pain (eg nerve pain) changes the brain.  This is true regardless whether the pain mechanisms are peripherally and/or centrally mediated.

Thus, regardless whether the pain mechanisms reside in the periphery (e.g. in a limb) and/or centrally (in the spinal cord/brain), the brain undergoes significant, adverse changes as a result of severe and persistent pain.  This is called pain-induced cortical reorganization.

The good news is that IF this nerve pain can be blocked, via Nerve Block, pain medicine, surgery, and/or another effective treatment, the brain can change back to normal.

Several studies show this including an important study by Birbaumer et al (1997) involving 6 Phantom Limb Pain patients.

Not only was Birbaumer’s team able to show that:

(1) severe, unrelieved nerve pain (Phantom Limb Pain) causes pain-induced changes in the brain,

(2) but they also showed that these brain changes were reversible,

but only in those patients who ‘experienced a virtual elimination of current phantom pain attributable to anesthesia (quoting from Abstract).   

In other words, the successful, pain-relieving effects of the Nerve Block (Regional Anaesthesia via Brachial Plexus Blockade) was simultaneously reflected by (quoting from Abstract)a very rapid elimination of cortical reorganization‘ in the brain in 3/6 patients.

The most impressive results were observed in a 56 year old patient with severe Phantom Limb Pain who lost his upper limb 28 years earlier.  This man (‘Subject Pr3‘) underwent both:

(1) reversal of pain-induced cortical reorganization; and

(2) complete elimination of Phantom Limb Pain

within only 20 minutes after complete anaesthesia in his stump and shoulder!

NB  It is likely that the pain mechanisms were peripherally mediated in the 3 patients who had pain relief from the Nerve Block.

In summary, the Nerve Block was effective for 3/6 patients with Phantom Limb Pain.  Thus, pain-induced brain changes were rapidly reversed as a direct consequence of the pain-relieving effects of the Nerve Block in these 3/6 patients.  However, this did not happen in the latter 3/6 who did not obtain relief from the Nerve Block.

Thus, the brain appears to change ‘for the worse’ to reflect persistent pain.  On the other hand, the brain is also able to change back to normal if/when persistent pain is finally successfully blocked.


Here is another patient with Phantom Limb Pain named ‘Trevor’:

While Trevor suffered from severe Phantom Limb Pain prior to his Nerve Block, his residual pain is now managed, post-Nerve Block.  Quoting (go to 27:43 in the video link):

“….At that moment, it was instant pain relief for me.”

While this video does not show images of Trevor’s brain, I would bet 2 cents that Trevor’s brain also changed, both ‘before’ and ‘after’ his Nerve Block.


Here’s to less chronic pain in the world,

Sabina Walker


(1) Birbaumer et al; Effects of regional anesthesia on phantom limb pain are mirrored in changes in cortical reorganization; J. Neurosci (1997); 17(14), 5503-5508.

Click to access 5503.full.pdf

CRPS and Phantom Limb Pain Treated with Memantine or Memantine/Morphine

Dear Pain Matters blog readers,


Three (3) German studies (by the same team) showed promising results following:

– Memantine; or

– Memantine/Morphine Combination Therapy

in CRPS patients.

(1) 1st Study –

In the 1st study, pain decreased in 3 CRPS patients (CRPS duration = 1 to 7 months) following oral Memantine treatment for 8 weeks.  Specifically, there was NIL ‘resting pain’ at the 6-month follow-up (Sinis et al, 2006).

(2) 2nd Study –

In 6 CRPS patients, the duration of CRPS ranged from 4 to 23 months before Memantine Treatment.

Pain decreased significantly, and ‘continuous pain’ disappeared in all 6 CRPS patients after 8-week Memantine Treatment (as at 6-month follow-up).   Motor function also improved, together with Autonomic Nervous System changes, in all 6 patients (Sinis et al, 2007).

(3) 3rd Study –

This study involved 20 CRPS patients, as follows:

– 10 were given ‘Memantine/Morphine Combination Therapy’; and

– 10 were given ‘Placebo + Morphine’.

Duration of CRPS ranged from 6 to 36 months.

In all 10 CRPS patients, ‘pain at rest’ and ‘pain during movement’ decreased significantly following Memantine/Morphine Combination Treatment for 8 weeks. 

Interestingly, the 10 patients who were not given Memantine (the ‘Placebo + Morphine’ group) did not benefit as much.

Only the 10 patients given Memantine/Morphine Combination Treatment for 8 weeks had significant pain reduction and reduced disability.  

… and guess what else happened (that is very interesting)??

Memantine/Morphine Combination Treatment also resulted in significantly reduced activity in certain brain regions (Primary Somatosensory Cortex – contralateral side (S1) and Anterior Cingulate Cortex) when the CRPS-hand was moved!

Thus, Memantine/Morphine Combination Treatment resulted in decreased pain.  Furthermore, this decreased pain was mirrored via reduced activity in certain brain regions (S1, S2) (Gustin et al, 2010).  


Two (2) patients had severe Phantom Limb Pain as a consequence of severe lower leg injuries.  When oral Memantine treatment was given, these 2 patients had significant reduction in Phantom Limb Pain (Hackworth et al, 2008).  More studies are needed.


In summary, treatment involving Memantine or Memantine/Morphine warrants more attention given its impressive results in:

– (a total of) 19 CRPS patients; and

– 2 patients with Phantom Limb Pain

who received either Memantine alone or Memantine/Morphine.  

Sabina Walker



Memantine/Morphine Combination Therapy may alleviate painful symptoms of CRPS by reducing tumor necrosis factor-α (TNF) and other inflammatory mediators.  An animal study reported that administration of Memantine Hydrochloride decreases TNF expression in rats.  Studies are warranted to determine whether Memantine decreases local TNF in pain patients including CRPS patients.  (Memantine is widely known for its antagonistic effects on the NMDA receptor.)

(Please refer to Review Paper by Sabina Walker and Prof. Peter Drummond for further details.  In particular, please refer to pages 1796 – 1797, plus 4 Memantine-related References on pages 1805-1806, plus papers below.)



(1) Gustin SM, Schwarz A, Birbaumer N, et al. NMDA-receptor antagonist and morphine decrease CRPS-pain and cerebral pain representation. Pain 2010;151:69–76.

Click to access Gustin_Pain_2010.pdf

(2) Sinis N, Birbaumer N, Gustin S, et al. Memantine treatment of complex regional pain syndrome: A preliminary report of six cases. Clin J Pain 2007;23: 237–43.

Click to access Sinis_Birbaumer_Gustin.pdf

(3) Sinis N, Birbaumer N, Schwarz A, et al. Memantine und komplexes regionales Schmerzsyndrom (CRPS): Behandlungseffekte und kortikale Reorganisation (Memantine and complex regional pain syndrome (CRPS): Effects of treatment and cortical reorganisation). Handchir Mikrochir Plast Chir 2006;38:164–71. (in German).

(4) Sabina Walker, Peter D. Drummond; Implications of a Local Overproduction of Tumor Necrosis Factor-α in Complex Regional Pain Syndrome [Review Paper, 24 pages]; Pain Medicine (Dec 2011), 12 (12), 1784–1807.

In particular, please refer to pages 1796 – 1797, plus 4 Memantine-related References on pages 1805-1806.

(5) Park et al; Antinociceptive Effect of Memantine and Morphine on Vincristine-induced Peripheral Neuropathy in Rats; Korean Journal of Pain (Sept 2010); 23(3):179-185.

doi: 10.3344/kjp.2010.23.3.179.


(6) Hackworth et alProfound pain reduction after induction of memantine treatment in two patients with severe phantom limb pain; Anesth Analg (2008); 107:1377–1379.