Mirror visual feedback for phantom pain : international experience on modalities and side effects discussed by expert panel. A Delphi study

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