Cognitive Behavior Therapy (CBT) and Mirror Training for Phantom Limb Pain

The proposed study is a randomized controlled trial designed to test whether CBT plus mirror
therapy (CBT+MT) is superior to supportive care (SC) for treatment of PLP in amputees. The
primary hypothesis is that CBT+ MT will lead to significantly greater reductions in PLP
compared to SC. Secondary hypotheses will test whether CBT+MT also leads to significantly
greater improvements in psychiatric symptoms, functioning, and quality of life than SC.

Eighty veterans from the San Diego VA Healthcare System will be recruited. All veterans will
have a unilateral upper or lower limb amputation. All participants will complete an intake
assessment prior to treatment randomization. The assessment will include measures of pain
(Phantom Limb Pain Questionnaire, Descriptive Differential Scale, McGill Pain Questionnaire)
psychiatric symptoms (Patient Health Questionnaire, Posttraumatic Stress disorder
Checklist), psychiatric diagnosis (Mini-International Neuropsychiatric Interview) and
functioning (Trinity Amputation and Prosthesis Experiences Scale, Short Form-36).
Participants will then randomized to either CBT+MT or SC. Participants will complete pain
and mood assessments weekly during treatment, and be retested on the full assessment battery
at the end of treatment and 12 and 24 weeks posttreatment.

The CBT+MT intervention will consist of 8 individual sessions of CBT, including
psychoeducation, cognitive restructuring, relaxation training, and acceptance techniques.
Participants in the CBT+MT condition will also learn to use a mirror apparatus to reduce
PLP, and will receive a set of mirrors to use at home. The SC treatment will consist of the
therapist meeting with the patient and using listening and reflection skills to discuss the
patient's pain. The SC condition will have no pain education or skills training component.

Data analyses will use a repeated-measures ANOVA approach to test whether the two conditions
differ on change in the primary measure (Phantom Limb Pain Questionnaire) as well as in
other pain, psychiatric symptom, functioning and quality of life measures. Exploratory
analyses will test whether patient variables and amputation characteristics predict
treatment outcomes.