Innovative treatments for phantom limb pain: Israel's approach to cutting-edge rehabilitation

Despite nearly incessant war and terror in recent decades, Israel has long had many fewer rehabilitation facilities than the average in OECD countries. The murderous October 7 incursion by Hamas and the resultant war against Hamas in Gaza and Hezbollah in the North has resulted in the wounding of about 4,300 soldiers, 640 of them seriously hurt – suffering amputations, blindness, and other such injuries, 1,100 moderately injured, and the remainder lightly hurt, according to data from the Israel Defense Forces.

Surprisingly, there are no exact statistics on the number of Israeli soldiers, security staffers, police officers, and civilians whose limbs have been amputated in the last 11 months, but the Defense Ministry’s rehabilitation department has reported the figure to be about 2,000. Besides that, the number of patients per capita whose legs have developed serious sores and necrosis from uncontrolled diabetes and have to undergo amputations is among the highest in the OECD.

And limb amputation almost always results in agonizing pain from nerve endings that used to be attached to the surgically removed limbs. The ends of the nerves that have been cut send messages of pain to the brain as if they have come from the organ that has been removed.

FORTUNATELY, most amputees report that the excruciating tingling, throbbing, and sharp pins-and-needles feelings in the limb that is no longer there – called phantom limb pain (PLP) – passes within six months, but for the rest, the phantom pain is chronic and may never go away.

PLP reportedly affects an estimated 64% of the 356 million amputees worldwide each year, often causing chronic pain that standard treatments can’t fully ease.

A centuries-old phenomenon 

Surprisingly, PLP has been known and documented for centuries. The sensation was described by the 16th century French military surgeon Ambroise Pare, but even now, specialists lack a clear explanation of this complex condition. The specific term is most often attributed to Silas Weir Mitchell, who published a study in 1872 based on his experience with traumatic amputation patients in the US Civil War.

Rehabilitation specialists, orthopedic surgery, and physical medicine around the world have been searching desperately for unconventional techniques to relieve PLP among soldiers and civilians.

In the US alone, an estimated 1.7 million people have undergone at least one amputation and another 215,000 amputations are performed each year, 86% of which are of the leg. The leading cause of such tragic surgery there is trauma from diabetes and due to cancer or vascular disease. Of these amputations, about 65% will develop PLP within one month of amputation, 82% within one year, and 87% throughout their lifetime – so successful PLP treatment is a major theme for all professionals dealing with amputees.

VIRTUAL REALITY was developed for gaming. A simulated experience puts users into 3D near-eye displays worn on the head that provide pose tracking to give them an immersive feel of a virtual world. However, since then VR has been utilized for less-trivial pursuits including medical, military, and safety simulation and virtual business meetings – so it wasn’t outlandish for scientists and doctors to consider VR to reduce PLP.

US teams have been testing VR on small groups of chronic PLP patients as early as 2018 and reported good results. A California team published in the journal Pain Medicine in 2019 their study of 14 military veterans. They underwent mirror therapy for PLP, navigating in a VR environment with a bicycle pedaler and motion sensor to pair their cadence to a VR avatar that made it possible to visualize an intact limb.

Mirror therapy “tricks” the brain by having amputees conduct exercises while looking in a mirror reflection of their intact limb, making it appear visually as if the missing limb is still there.

VR triumphs PLP

Ratings of helpfulness, realism, immersion, and satisfaction were uniformly high to very high, and no one complained of any negative experiences; in fact, most said it was very enjoyable. Some asked for equipment that they could use at home and not only in the lab. The researchers urged continued research on using VR for PLP that would compare results with conventional treatment.

RESEARCHERS AT the University of Texas in Dallas, working with the Veteran Affairs Health Care System, did a study in 2022 on retired soldiers whose limbs were amputated and who suffered from PLP. Their technology, called Mr. MAPP (Mixed Reality to Manage Phantom Pain) was used at home with a camera, laptop, and VR headset worn while the patients played a series of games to complete tasks such as stomping or bursting a bubble on the screen. This fools the brain into actually seeing a leg and foot and minimizes and even eliminates PLP.

Some 70% of IDF veteran amputees receive comprehensive, in-house medical care and rehabilitation at Sheba Medical Center at Tel Hashomer, according to Dr. Avi Avitan, director of the hospital’s outpatient rehabilitation clinic. An expert in orthopedic surgery, rehab, and physical medicine and rehabilitation, he treats amputees and patients with complex injuries and sports injuries. Sometimes he prescribes medical cannabis, antidepressants and other medications but not potentially addictive opioids. Some therapists offer acupuncture or biofeedback.

While years ago, PLP sufferers may have been ashamed to complain about their pain because they might have been considered “crazy,” today this has disappeared, as the condition is recognized as a real problem.

In an interview with The Jerusalem Post, Avitan said he initially studied dental medicine at the Hebrew University in Jerusalem and then went to Hungary for a degree in general medicine. He then did his practical medical studies at Soroka University Medical Center in Beersheba and his specialization at Sheba.

COVID hurdles

During the COVID-19 pandemic, his unit initiated a study of VR treatment of PLP on a small group of sufferers, not only IDF wounded. “It wasn’t a good time for such a study, but we didn’t plan on the coronavirus,” he recalled, adding that his team plans to conduct a new and larger VR study on amputated IDF veterans.

AVITAN HEARD of an Israeli company called 6Degrees – established by an Israeli-born couple, Miri Berger and Aryeh Katz, whose wearable artificial intelligence device converts motion into digital commands allowing full control of any smart device. It adapts to individual abilities, a limited range of motion, tremors, and the like. 

The company founders said that “rehabilitation and physical therapy currently lack measurable tools to monitor the personal progress of therapy. Integrating 6Degrees wearable ‘MyMove’ plus into treatment increases patient motivation and allows real-time results and provides the therapist with daily updates on changes in parameters (speed, range, and angles) for each patient.”

They did the study with a grant from the Israel Innovation Authority, they said. “We had 10 weekly meetings with patients, assessing the level of pain each time. We noted a reduction in pain and an improvement in their condition. But it was a small group, so we have to do a larger one and focus on soldiers,” said Avitan, who also does research on sports for the wounded and other projects.

Avitan’s PLP study has been followed with interest by Sheba’s chief innovation officer Prof. Eyal Zimlichman, an internal medicine physician and researcher focused on assessing and improving healthcare quality and value, patient engagement and patient safety, who founded the hospital’s global innovation program (ARC – Accelerate, Redesign and Collaborate).

“PLP affects 78% of people who have undergone a major amputation, starting about three months after the surgery,” Avitan noted. “In 90% of them, the pain will go away in three to six months, but in the rest, it becomes chronic, sometimes [lasting] a year and sometimes for life. We studied patients – soldiers and diabetics – who had PLP for more than half a year.”

ASKED WHY there are so many amputations among patients with uncontrolled diabetes, Avitan said the victims are usually from lower socioeconomic groups who haven’t been educated about protecting their health. The diabetes begins in their 50s and 60s, and they usually smoke, don’t exercise, and don’t keep their sugar level under control.

6Degrees created a “leg bracelet” worn on the stump that recognizes the limb and vibrates. There is physical and vocal feedback when the patient is asked to kick a ball to the goal. The experience includes sensory feedback – sight, sound, and tremors –that simulates the presence and movement of their leg. These sensations tell the brain that the leg is there and doing what the patient wants it to do, thereby releasing the phantom pain.

According to the researchers, the experience “has shown positive results in reducing phantom pain, even for double amputees – a group typically excluded from mirror therapy. In addition to the pilot study at Sheba, ongoing VA clinical trials with US veterans show that the 6Degrees approach could offer superior pain relief compared to traditional methods.

Although there have been some complaints from wounded veterans about neglect and red tape at the Defense Ministry’s rehab department, Avitan declared vigorously that “the ministry gives us everything they need. There is no such help for any veteran in any military in the world,” he said.

“If a certain device or part is unavailable, the veteran is flown to the US, with an accompanying person, given hotel accommodations and all the support they need.”