title: Mirror visual feedback for phantom pain: international experience on modalities and adverse effects discussed by an expert panel: a delphi study.
abstract: 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.
  
  
  OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Centre for Medical Humanities, University of Leicester, Salisbury Road 7, Room 201, Leicester, LE1 7RQ, Great Britain(∗). Electronic address: ah413@le.ac.uk.
authors.forename: Annegret
authors.initials: A
authors.lastname: Hagenberg
authors.affiliation: Department of Health Professions, Faculty of Health and Life Sciences, Coventry University, Coventry, Great Britain(†).
authors.forename: Christine
authors.initials: C
authors.lastname: Carpenter
mesh_terms: D000328:Adult; D000671:Amputation, Surgical / Q000523:psychology*; D003697:Delphi Technique; D056228:Feedback, Sensory / Q000502:physiology*; D005260:Female; D006801:Humans; D008297:Male; D010146:Pain / Q000175:diagnosis / Q000523:psychology*; D010147:Pain Measurement / Q000379:methods*; D010591:Phantom Limb