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Clinical Rehabilitation 2002; 16: 368377

Arnold 2002 10.1191/0269215502cr507oa

Address for correspondence: David Oakley, Hypnosis Unit,Department of Psychology (Remax House), UniversityCollege London, Gower Street, London WC1E 6BT, UK.e-mail: [email protected]

Hypnotic imagery as a treatment for phantomlimb pain: two case reports and a reviewDavid A Oakley Department of Psychology, University College London, Lionel Gracey Whitman Leeds GeneralInrmary, Leeds and Peter W Halligan School of Psychology, University of Cardiff, UK

Received 18th August 2000; returned for revisions 20th November 2000; revised manuscript accepted 3rd April 2001.

Objective: To provide a theoretical background, to review existing literatureand to present new case material relevant to the treatment of phantom limbpain using hypnotic imagery. Method: This paper presents two new case reports involving the use ofhypnotic imagery procedures in the alleviation of phantom limb pain andreviews 10 previous clinical studies which have involved a similar approach.The earlier studies were identied by electronic and manual searches of therelevant literature.Results: Two main treatment strategies can be identied: (1) ipsative/imagery-based approaches and (2) movement/imagery-based approaches.A common nding is the need to treat the phantom limb as a real bodypart, to accept its existence as a valid mental representation and to avoidtreating the amputation stump as the sole source of the phantom painsensations. Conclusion: Hypnotic procedures appear to be a useful adjunct to establishedstrategies for the treatment of phantom limb pain and would repay further,more systematic, investigation. Suggestions are provided as to the factorswhich should be considered for a more systematic research programme.

surgically the majority of amputees (between 50and 85% according to Jensen et al.5) develop painthat they attribute to the phantom limb itself(phantom limb pain: PLP). The qualitative expe-rience of PLP is very variable between individu-als, and includes sensations of burning, cramping,stabbing and clenching spasms.6

Different accounts have been put forward toexplain this debilitating phenomenon.6 One viewis that PLP represents a continuation, or mem-ory, of normally transduced pain which was pre-sent prior to the amputation.7 Other accounts forthe origin of the pain include the release of spinalcord neurons from inhibition following loss of

Introduction

Traditionally, phantom limbs (i.e. residual, non-visual experiences of the affected body part) havebeen reported following limb amputation1 andbrachial plexus avulsions,2 though similar phe-nomena also occur after mastectomy3 andremoval of a variety of other body parts andinternal organs as well as following stroke.4 Post-

Hypnosis and phantom limb pain 369

afferent impulses8 and the reorganization of cor-tical maps following limb amputation.9,10 Theview that phantom limb pain is accompanied byremapping of cortical areas has received recentempirical support from clinical11 and neurophys-iological studies.12 There is also neuroimagingevidence that phantom limb sensations, includingPLP, are accompanied by activity in the samebrain areas as when the body is intact.13

Even when present, the phantom experience isnot static and several factors such as emotion,weather change, eating and fatigue can affectPLP.6 There is also evidence that the nature ofthe phantom limb experience may be inuencedby suggestion and expectation (e.g. refs 11 and14).

The results achieved with PLP from surgicaland pharmacological treatments are generallyreported to be poor1517 though there is evidencethat psychological interventions are more effec-tive.18 To the extent that PLP is variable and maycorrespond with past experience, current beliefs,expectations and fantasies one possible approachto its management may be via imagery and sug-gestion. This may be particularly effective if hyp-nosis is used as an adjunct to treatment,19 ashypnosis procedures encourage focused attentionand facilitate absorption in central imaginativeprocesses.

Furthermore, hypnotic procedures using sug-gestion and imagery have a long and establishedhistory of alleviating a range of painful condi-tions2022 and recent brain-imaging studies haveshown that changes in the subjective experienceof pain produced by suggestions given in hypno-sis are reected in alterations in the activation ofbrain areas known to be involved in normal painperception.13,23

No systematic research appears to have beencarried out either to evaluate the effectiveness ofhypnosis as an adjunct to the treatment of PLPor to determine the types of treatment withwhich hypnosis might be most effectivelyemployed. There are, however, a number of sin-gle-case studies where hypnosis has been usedwith PLP and these provide useful insights intopossible treatment strategies. We propose herethat two basic treatment approaches can be iden-tied: (1) ipsative/imagery-based and (2) move-ment/imagery-based.

The ipsative/imagery approach takes accountof the way the individual represents their pain tothemselves and then attempts to modify thoserepresentations in order to alleviate the painexperience. The movement/imagery-based ap-proach encourages the PLP patient in hypnosisto move the phantom limb and to take controlover it.

We rst of all describe two previously unpub-lished cases of our own and then present in theform of a table a review of ten other single-casestudies in which hypnosis was used in the treat-ment of PLP classied according to the two treat-ment approaches we have identied.

Previously unpublished case reports

Mrs D Application of an ipsative/imageryapproach

Mrs D is a 76-year-old woman with a historyof peripheral vascular disease that eventually ledto an above-knee amputation of her right leg. Itis worth noting that Mrs D was pain-free at thetime of her operation and that her PLP did notbegin until some two years after the amputation;two years after that she was referred to a localpain clinic. There were four different componentsto the pains in her missing lower limb:

1) pins and needles in her foot,2) her toes felt as thought they were being held

in a tight vice,3) a slicing, cutting pain in the sole of her foot

and4) a chiselling pain in her ankle.

Over the next four years various treatmentswere tried, including injection of the stump withlocal anaesthetic, acupuncture, the use of a TENS(transcutaneous electrical nerve stimulation)machine, antidepressants and analgesics, includ-ing morphine, with little or no effect. Mrs D wasthen seen eight times on a weekly basis for one-hour counselling sessions, with approximately 25minutes of each session being taken up with hyp-nosis.

Mrs D responded well to the hypnotic proce-dures that were introduced in the rst treatmentsession. A modied Spiegel eye-roll24 was usedfor induction, followed by progressive muscular

370 DA Oakley et al.

his left brachial plexus some ve years previously.He describes two types of PLP. The rst is anintense cramp-like experience in his denervatedleft arm which occurs intermittently, approxi-mately once per day, and lasts for 20 minutes.During this pain he feels his left hand becomeclenched and he experiences a burning sensation.The second type of pain occurs more frequently,every two to three minutes, is like small electricshocks which shoot down from his upper armand terminate in the little nger of his phantomleft hand, and is accompanied by a throbbing sen-sation in the knuckles.

NB had previously used a Ramachandran mir-ror apparatus10 which prevented him from seeinghis right hand directly but allowed him to see itas a reection where his left hand would be. Hereported experiencing the reected image as thatof his phantom left hand, which he described asmoving normally when he moved his right hand.Whilst viewing the mirror image both types ofPLP disappeared. When NB closed his eyes thesensation of moving his left hand was lost, eventhough he continued to move his right hand asbefore. NB had used the mirror apparatus athome on a daily basis and he reported that hispains could be reduced for up to three hoursafterwards. When he was tested by us in the cliniche rated his PLP as 7 out of 10 before the mir-ror test, during the mirror viewing test it was 0,and immediately afterwards it was 2.

One hour after testing with the mirror appara-tus NBs pain had reached 4 and he was thentaken through an eyes-closed hypnotic inductionand deepening. He was asked to place his righthand in the (now removed) mirror apparatus andto see his reected right hand in the left of themirror as usual. In reality his eyes were closedthroughout but he made real movements with hisright hand. He said he could see his left handclearly and was asked to try to move both handsin synchrony. He reported that he felt his lefthand moving though the feeling was not asstrong as usual in the mirror apparatus. With fur-ther encouragement to watch closely the hand inthe mirror while he continued to make (actual)movements of his right hand, he reported that thesensation of movement in his left hand becameclearer, though he said it was still not as strongas usual. Nevertheless he did report freedom

relaxation for deepening. This was followed bysuggestions of visualization of a special place.Her choice of Italy as her special place suggestedimagery which might be used for the chisellingsensation in her phantom ankle, which sheranked as the most disturbing of her pains.

At the second session she was asked in hyp-nosis to return to her special place, to imagineMichaelangelo toiling and hammering away at ablock of marble with a chisel to create a thing oflasting beauty. At the third session, the image ofthe sculptor was related to the pains in her ankle:Just as Michaelangelo sculpted David, imagine alittle man with a chisel hammering away at yourankle. It was then suggested that this man hasbeen working so long and so hard and his workis done and it is time for him to go away on hol-iday. Though she had initially found the littleman and his specic activities difcult to visual-ize, Mrs D later announced that the chisellingpain in her ankle had, in fact, completely gone.The disappearance of the pain had coincided withsending [him] off on holiday.

Sessions 4 and 5 incorporated more generalimages of change and progress without any fur-ther specic pain-control imagery. Over this timeMrs D experienced a marked improvement in hermood but her other pains remained. She com-mented that the vice-like pain had become morenoticeable since the chiselling pain had gone.Pressures on the hypnosis clinic were such thatMrs D was only able to have two more sessionsand the nal two sessions concentrated on thevice-like pain. In these sessions she was asked toimagine wading in the sea, with the tides loosen-ing the vice around her toes. This image appearsto have been a much less effective one forMrs D.

Contacting Mrs D three months after the endof her treatment, she reported that the the chis-elling pain had not come back. The little fellow,she wrote, is having a long holiday. Thank good-ness! The toes are still in a vice but I am copingand I am not quite as jumpy as I was.

NB Application of a movement/imageryapproach

Our second case is a report of observations car-ried out with NB, a 46-year-old man who hadexperienced PLP since he suffered an avulsion of


from pain in his phantom left arm and hand (arating of 0 out of 10) as he watched the mirrorhand moving. Shortly after the end of the hyp-nosis session NB rated his pain at 2.5 on the 10-point scale.

These tests with NB were not carried out aspart of a therapeutic intervention and conse-quently he was not instructed in how to use thetechniques for his own pain control and no infor-mation is available on any long-term effect theymay have had. They do however, support theview that movement/imagery-based strategies inhypnosis might be used in the treatment of PLP.Initially they might be employed for alleviatingPLP during self-hypnosis routines but ultimatelythe therapeutic aim would be to extend the effectinto everyday situations.

Review

We have limited our review of PLP to casesinvolving limb amputation and brachial plexusavulsion as these are the most common causes.In preparing the review, seven reports were iden-tied electronically via Ovid/MEDLINE usinghypnosis and phantom as the target and search-ing keywords, abstract and heading word from1966 to the present. Of these, three wereexcluded: Two because they concerned otherphantom organs25,26 and one because it was insuf-ciently detailed to classify in terms of the hyp-notic procedures used.14 One report not identi-ed by this search27 is included in the review andwas identied again via Ovid/MEDLINE byusing phantom limb from 1966 to the present asthe target (661 citations). A manual search of pri-vate and institutional libraries in London underthe headings hypnosis and hypnotherapyyielded six additional reports; three as parts ofchapters in edited volumes, two in very recentissues of journals, and one in a single-author textbook. One of these28 was not used in the reviewas it contained insufcient detail. Salient pointsfrom all of the reports excluded from the revieware included in the Discussion section.

A structured summary of the remaining 10 pre-viously published cases using hypnosis in thetreatment of PLP plus the two new casesreported here is shown in Table 1.

Table 1 summarizes ve cases (plus our caseMrs D) in which a ipsative/imagery-basedapproach was used and a further ve cases (plusour case NB) where a movement/imagery-baseapproach was involved.

Discussion and conclusions

Two main treatment strategies for PLP havebeen identied: an ipsative/imagery-basedapproach and a movement/imagery-basedapproach. Both appear to have promise thoughthere is insufcient evidence to say which is likelyto be the more effective for any given patient orwhether they should be administered singly, incombination or perhaps at different stages oftreatment. It is possible, however, that a move-ment/imagery-based approach would be particu-larly relevant where a cramped or unusualposture of the phantom is an important compo-nent of the patients description of their PLP. Ofthe six cases using an ipsative/imagery approachreported in Table 1 only two included posture ofthe limb as part of the PLP description, whereasit was present in ve of the six cases whichadopted a movement/imagery based.

Shrinking of the phantom occurred sponta-neously in one case (case 1036) and in responseto suggestion in two cases (case 331 and case 734).In common with some mirror box studies36 thisappeared to be associated with recovery fromPLP. In another of the case reports (case 533)indirect suggestions for phantom shrinkage wereused, though the effectiveness of these sugges-

Clinical messages

Phantom limbs should be regarded as realbody parts and treatment of phantom limbpain (PLP) should be directed to the phan-tom itself.

Hypnotic imagery-based approaches areworthy of further consideration for thetreatment of PLP.

The imagery used should be based on theclients own perception of their pain or mayinvolve movement of the missing limb.


Table 1 Summary of 12 cases using ipsative/imagery-based approaches (cases 16) or movement/imagery-basedapproaches (cases 712)

Case Problem Treatment Outcome

Ipsative/imagery-based1) Siegel (1979)29 Left above-knee 10 sessions 2 months after

amputation (pain (7 of hypnosis). treatment, patientbefore) Relaxation, self- using pain control

hypnosis, transfer of for herselfPLP for several hypnotic (coldweeks nature of imagery) glove Pain medicationpain not described anaesthesia reduced to 50%

2) Chaves (1986)30 Amputation of arm 3 hypnosis sessions. Free of PLP over 5-(pain before) Relaxation, tension year follow-up

reductionPLP for 5 months felt suggestions. Using tape once peras tension and Warmth imagery. monthfrustrated Home use ofmovement in hand hypnosis audiotape& ngers(hand/arm inuncomfortableposture)

3) Chaves (1993)31 Mid-thigh Number of sessions At end of therapyamputation of right not specied. discomfort down toleg (pain before) In hypnosis 30% of previous

relaxation & levelPLP for 4 years felt suggestions ofas phantom shrinking. Occasionallya) biting ants, Hypnotic images: pain-freeb) tight bands decapitate ants,c) muscle tension cut bands. Phantom reported to(leg in Daily use of be shrinkinguncomfortable hypnosis audiotapeposture)

4) Sthalekar Avulsion of right 21 sessions over 8 At 2-week follow-(1993)32 brachial plexus (no weeks. Self- up, pain under

pain before) hypnosis relaxation control. No longer training plus interfering with daily

PLP for 3.5 months imagery of activity. Returnedfelt as constant beach/garden/ to worktingling in right woods.arm and Healing warmth Right arm no longerintermittent owing through arm. in a slinglocalized stabbing, Positive, future-burning pains in oriented Optimistic aboutarm and hand suggestions future

5) Brown et al. Amputation of right Three sessions (5 At 12 month follow-(1996)33 leg at the knee hours in total) up wearing

(pain status before prosthesis andnot reported) Hypnotic metaphor engaging in

or tree damaged by mountain bikingDetails of PLP not ood water, losingreported, but branches, then No report of painsevere regrowing stronger status


6) Mrs D Above-knee 8 weekly sessions of At end of treatmentamputation of right 1 hour (25 mins of chiselling pain hadleg (no pain before) each was hypnosis) gone and had not

returned at 3-monthPLP for 6 years Hypnotic imagery: follow-up. Otherbegan 2 years after chiseller on pains still thereamputation, felt as: holiday,a) pins and needles sea water loosening Coping better andin foot, vice less jumpyb) toes in a vicec) cutting pain in Positive images offoot change and progressd) chiselling pain in ankle

Movement/imagery-based7) Muraoka et al. Above-knee 64 hypnosis At end of treatment

(1996)34 amputation of left sessions over 3 phantom hadleg (no pain before) years. disappeared for most

of time withPLP for 25 years felt 3 phases: intermittent burstsas intermittent a & b) suggested of pain. Overallburning pain and movements of leg pain had beenconstant dull pain and becoming reduced from 8 to 1(leg & foot in normal size on a scale 010uncomfortable posture c) suggestedand leg too short) shrinking of phantom

8) Le Baron and Amputation of left 3 hypnosis sessions. At 2-week follow-Zeltzer (1996)35 leg (pain status Relaxation, up 50100% pain

before not reported) suggestion in relief from self-hypnosis to relax suggestion, or by

PLP felt as jerking and contract listening to hypnosisin leg, cracking in muscles in both audiotape.toes, stabbing pain legs. Less bothered byin sole of foot Patient experienced residual PLP &

free movement in sleeping normallyHighly hypnotizable toes and leg.

Transfer of suggestednumbness in handto left leg

9) Ersland et al. Above-elbow Hypnosis for part of Reduction in PLP(1996)27 amputation of right rehabilitation (not quantied)

arm (pain status programme before not reported). number of sessions Feeling of control

not specied. made residual painPLP for 18 months in Relaxation & more tolerablengers and wrist hypnotic(ngers and wrist suggestions forin uncomfortable nger movementposture) and uncramping

10) & 11) Rosen et al. 10) Traumatic 10) Pain-free during(2000)36 amputation of right 1st hypnosis session

arm (no pain before) lasted 1 day thenpain returned

PLP for 5 years. Both 10 & 11: intermittently. AtRadiating heat pain Approx. 12 sessions end of treatmentin arm & ngers. over 6 months pain intensity downAbnormal from 80 to 50posture/contraction Cognitive/behaviouralin ngers and arm. treatment with Pain frequencyarm. Highly hypnotizable hypnosis reduced by 55%


towards their phantom limb and not to the ampu-tation stump. Similarly, in one study,28 hypnoticglove anaesthesia applied to the stump producedonly a temporary alleviation of the burningPLP; a later suggestion to visualize a stream ofcooling anaesthetic agent coursing through thephantom leg produced long-term pain reduction.

Closely related to the movement/imagery-based approaches, the Ramachandran mirrorprocedure appears to produce a dramatic, butshort-lived, effect of experiencing movement inthe missing limb and of eliminating PLP.10 Ourown observations with NB indicate that it is pos-sible to create a similar effect using a hypnoti-cally suggested hallucination of a mirror in apatient with previous experience of the mirror

tions is not reported. These observations suggesta third possible therapeutic approach in whichhypnotic imagery may be a useful adjunct.

In more general terms it seems that the phan-tom limb should be treated as real and the samepain management strategies applied as with aphysically present limb. The reality of the miss-ing limb as a continuing central representation isunderlined by recent neuroimaging studies show-ing activations in precentral cortex during phan-tom nger tapping27 and the involvement ofnormally activated brain areas during the experi-ence of both phantom limb movement and PLP.13In our own case of Mrs D and also in case 130 thepatients specically said that they expected psy-chological treatment of PLP to be directed

Table 1 Continued

Case Problem Treatment Outcome

In hypnosis11) Traumatic imagined phantom Phantom reported toamputation of in a comfortable be shrinkingngers on left hand position or moving(no pain before) in a comfortable 11) At end of

way treatment painPLP for 3 years intensity was down

from 40 to 20 andSevere pain in left 10) Also imagined pain frequencyhand, cutting pain skiing, both arms reduced by 50%in ngers, moving in rhythmespecially during These gainsuncomfortable 11) Also imagined maintained at 2.5movements. pain area shrinking years follow-upModeratelyhypnotizable

12) NB Avulsion of left Previous experience During experiencebrachial plexus (no of pain control and of moving left handpain before) subjective in hypnotic virtual

movement of left mirror and duringPLP for 5 years felt hand in mirror age-regression PLPas intermittent apparatus was lost.cramping in hand Experience of leftand burning One session of hand movement notsensation. hypnosis with as strong as in realMore frequent suggestions of a mirror apparatusshooting pains return to thethrough arm & mirror experience Pain was rated 4 outthrobbing in and of age- of 10 beforeknuckles regression to a time hypnosis, 0 during(hand in before the injury hypnotic mirror anduncomfortable regressionclenched posture) experiences and 2.5

after hypnosis


systematic trials with appropriate controls for thehypnotic procedure. Particularly in the case ofipsative/imagery-based strategies it will be infor-mative to investigate the relationship betweenspecic suggestions or images and the alleviationof particular types of pain. In our own case (MrsD), for instance one of the images (for the chis-elling pain) appeared to be much more effectivefor her than the other (for the vice-like pain)and it may be important to encourage the patientto supply his/her own imagery rather than it orig-inating with the therapist. One way of investigat-ing the specicity of the effects of imagery wouldbe to use a multiple baseline, single-caseapproach with different pain types being targetedsequentially. A similar question for the move-ment/imagery-based approach concerns themodality of the suggested imagery in relation tooutcome. In our own case (NB), we encouragedvisual as well as kinaesthetic and somaestheticfeedback from the moving limb. In the othermovement/imagery cases the type of imageryemployed was not clearly specied but seems tohave been primarily proprioceptive, though inone case (case 8)35 the patient was also asked tovisualize his leg.

We conclude that, despite the relative paucityof published reports, hypnotic procedures holdthe promise of being an effective adjunct to otherstrategies for the treatment of PLP and otherphantom body part conditions and would repayfurther, more systematic, investigation. Hilgardand LeBaron38 selected PLP to illustrate theresearch opportunities which exist in the area ofhypnosis and persistent pain. It is unfortunatethat some 15 years later these opportunities stilldo not appear to have been explored.

AcknowledgementsLG-W was employed by Friarage Hospital,

Northallerton Yorkshire, UK during the timethat the clinical data reported here were col-lected. PWH is supported by the MedicalResearch Council.

We are grateful to Mrs D and NB for their co-operation as participants in our own case studieswhich we report here and to Derick T Wade andtwo anonymous referees for their helpful com-ments on an earlier version of this paper.

apparatus. It remains to be seen if a similar effectcould be produced in a mirror-naive patient. ForNB the hypnotic mirror effect was less powerfulthan that produced by the actual mirror so far asthe subjective experience of movement in themissing limb was concerned. This may mean thatactual peripheral visual feedback of limb move-ment is more effective in this regard than self-generated feedback through imagery.Nevertheless the elimination of PLP by the hyp-notic, virtual mirror seems to have been similarto that achieved using the actual mirror. A majorpotential advantage of the hypnotically producedmirror is that patients could recreate the imagerythemselves and use it on a continuous basis forpain relief. The fact that the experience of move-ment was not as striking for our patient using thehypnotic mirror compared to the actual mirrorwhilst the PLP reduction effect was maintainedmay mean that he was experiencing indirectlysuggested pain reduction based on his prior expe-rience and expectations rather than it beingattributable to subjective movement in his phan-tom limb.

Whilst they have been helpful in thinkingabout different approaches to the problem ofPLP, the cases reviewed here (including our own)have a number of shortcomings which need to beaddressed in future studies. A major problem isthat of the small numbers of patients involvedand consequently there is a need for randomizedcontrol trials with well-dened (and clearlyreported) hypnosis and treatment protocols toevaluate the efcacy of the various approacheswhich have been suggested. There is also a needfor standardized measures of the PLP to be takenpre and post intervention along with other mea-sures of psychological and social adjustment.Also, hypnotizability was measured in only threeof the cases reviewed here (case 8,35 case 1036 andcase 1136). It is perhaps signicant that in two ofthese three cases hypnotizability was found to behigh. This is potentially an important issue inselecting patients for hypnosis-based PLP treat-ment as a recent meta-analysis has shown greaterhypno-analgesic effects in those moderate to highin suggestibilty compared with those scoring lowon hypnotizability.21

Equally, it is important to determine the roleof hypnosis per se in the outcomes achieved in


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