839 - Reprogramming Phantom Limb Pain: Use of Virtual Reality Following Amputation

Case Diagnosis: Phantom limb pain following quadruple amputation

Case Description: A 52-year-old female who presented with nausea, vomiting, and headache was found to have Group A strep bacteremia with resultant toxic shock syndrome and meningitis. Her course was complicated by disseminated intravascular coagulation, heart failure, hemorrhagic stroke and endocarditis. She required bilateral below knee, left transradial, and right digit amputations due to pressor-induced ischemia. She was admitted to acute rehabilitation 2 months later with the chief complaint of phantom limb pain (PLP). Her treatment regimen included pregabalin plus a multimodal nociceptive regimen. Prior to admission, she underwent training in the utilization of virtual reality (VR) for which she noted provided significant reduction in her PLP when massaging and manipulating her residual limb within the VR environment.

Discussions: 30,000-40,000 amputations are performed annually in the United States. PLP, defined as perception of discomfort in a limb that is no longer present, is a common condition affecting 60-85% of amputee patients. PLP can be debilitating, with its complex origin posing treatment challenges due to limited understanding of its exact pathophysiology. One theory suggests that after amputation, nearby cortical regions encroach upon the brain areas responsible for the missing limb, causing "cortical remapping." This disrupts sensory perception, manifesting as pain in the phantom limb. VR presents as a potential treatment option for PLP, whereby movements of a virtual limb, under volitional myoelectric control, are transposed into a digital environment. Visual input from this "virtual world" deceives the brain into interpreting virtual limb activity as real limb movements, reactivating cerebral areas tied to the amputated limb. It is theorized this process reverses cortical reorganization, thus alleviating PLP.

Conclusions: Patients with amputations commonly suffer from PLP. Treatment is difficult due to poor understanding of its pathophysiology. This case report shows that VR is a promising potential treatment modality for PLP.