Pain Medicine 2010; 11: 133–141
© American Academy of Pain Medicine
Contralateral Stimulation, Using TENS, of
Phantom Limb Pain: Two Confirmatory Cases
Orazio Giuffrida, PhD, CPsychol, CSci,*†‡
Lyn Simpson, Dip COT,*† and
Peter W. Halligan, PhD, DSc*†
*School of Psychology, Cardiff University
†
ALAC, Rookwood Hospital Cardiff and Vale NHS
Trust, Cardiff
‡
Woodlands Centre—CNWL NHS Foundation Trust,
London, UK
Reprint requests to: Peter W. Halligan, PhD, DSc,
School of Psychology, Cardiff University, PO Box 901,
Cardiff CF10 3YG, UK. Tel: 029-2087-6911; Fax:
029-2087-0196; E-mail: HalliganPW@cardiff.ac.uk.
Abstract
Objectives. This study aims to evaluate the effec-
tiveness of trans-electric nerve stimulation (TENS)
for phantom limb pain applied to contralateral limb
(nonamputated limb).
Design. Two detailed single case studies using
TENS on the contralateral limb are reported in a
longitudinal study with one-year follow-up. Five
variables were measured across this period.
The study comprised of five sequential stages
(Pre-assessment, Preliminary baseline, Start
of intervention, Extended assessment, One-year
follow-up).
Setting and Patients. Patients were identified at the
Rookwood Hospital in Cardiff. They subsequently
received regular home visits. The first patient was a
24-year-old male who had suffered a left below-
elbow amputation following a car crash. The second
patient was a 38-year-old male who had a transfemo-
ral right amputation further to a viral infection.
Measures. The following semistructured interview
and questionnaires were used: McGill Comprehen-
sive pain questionnaire part A and B; The Cam-
bridge Phantom Limb Profile; The Groningen
Questionnaire: Problems after Arm Amputation; and
13 Visual Analog Scales.
Conclusions. Both patients showed a significant
improvement in their perception of phantom limb
pain and sensations that was maintained at one-year
follow-up.
A randomized blinded controlled trial to confirm
these positive outcomes is required.
pme_705 133..141
Key Words. Phantom Limb Pain; Contralateral
Stimulation; TENS Stimulation
Introduction
Following amputation, most subjects (60–80%) experi-
ence phantom limb phenomenon [1], a constellation of
painful and nonpainful sensations localized in or around
the phantom limb [2]. Although phantom pain decreases
with time [3], the occurrence of phantom pain is deeply
debilitating and independent of age in adults, gender and
level, or side of amputation [1]. The etiology of phantom
limb pain (PLP) remains unclear, however, painful sensa-
tions have been reported in 70% of amputees within the
first 2 years [4] and typically persist for years or even
decades [5]. Over the past century, many different inter-
ventions have been used for PLP, many with little success
[6–8]. Recently, following the studies by Ramachandran
[9] using of mirror visual feedback (MVF), several clinical
studies have confirmed [10,11] striking beneficial effects of
MVF on phantom pain.
Another intervention, however, that has shown promise
but is less well known is trans-electric nerve stimulation
(TENS). This intervention has the benefits of being easy to
self-administer, relatively inexpensive, noninvasive, few
side effects, and no drug interactions. Several studies
highlight the benefits of TENS for post-amputation pain
[12,13], though not all [14]. One interesting but neglected
permutation of applying TENS for PLP involves stimulating
the contralateral limb (i.e., the healthy limb) rather than the
more conventional application to the stump or healthy
areas of the affected limb. A systematic review of the
literature revealed a small number of published studies, all
of which reported the relatively successful outcome of
PLP using contralateral TENS stimulation.
The first study [15] to employ contralateral stimulation for
PLP involved 46 patients suffering with 13 different
chronic pain chronic conditions including five patients with
PLP. All clinical conditions were treated with TENS. The
intervention consisted of both ipsilateral and contralateral
application, but only the latter was used for the five PLP
patients reviewed. In this study [15], 19 patients (41%)
showed a significant reduction of the pain (including some
with complete extinction), 17 (37%) showed a mild reduc-
tion of pain, and in 10 (22%), the stimulation was ineffec-
tive. Critically, the patients who benefited most were the
five PLP patients. A 9-month follow-up showed that
the intervention with the PLP patients demonstrated the
greatest improvement for all conditions.
Four years later [16], a similar study reported 100 patients
suffering with chronic pain of various sources including
two PLP patients where TENS was applied to the con-
tralateral part of the body. One of these patients reported
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an excellent response to the treatment and showed a
clear reduction in the frequency and intensity of their pain.
The second described a moderate reduction in the fre-
quency and intensity of pain.
Another study [17] again produced an encouraging
response using TENS applied only to the contralateral limb
and resulted in the complete elimination of PLP in three
adult patients (aged 48–64 years) with chronic pain origi-
nating from various sites of the amputated extremity. The
results at 6-month follow-up showed no pain recurrence
of PLP such that that all patients were able to avail of
prosthetic training.
In 1985 [18], a similar treatment for PLP in a group of
amputees using cutaneous electrical stimulation applied
to the contralateral limb was reported. The 10 subjects
aged between 28 years and 63 years had PLP following
amputation of a lower limb. The results were impressive; in
8 of the 10 patients, PLP disappeared after 1 minute or 2
minutes typically at the beginning of the session. Two
patients reported partial reduction of PLP.
Finally, in 1989 [19], a detailed case study of TENS
applied to the contralateral lower leg in a case of PLP
was described. This is the only study in which the
placebo effect was compared directly with contralateral
TENS stimulation to study the efficacy of this treatment
for PLP. In this experiment, the researchers alternated
and combined baseline (placebo) with bilateral ear
(auricular) stimulation and contralateral TENS. During the
placebo session, no stimulation was carried out. This
session was performed in such a way that the partici-
pant believed that electric stimulation was delivered
using a very low intensity. The results showed that TENS
applied to the contralateral limb was significantly more
effective than placebo in helping to reduce the intensity
of phantom sensations. Stimulation of the outer ears did
not produce a significant decrease in phantom
sensations.
Although differing in details and follow-up, the five men-
tioned previous studies employed similar methodology
with promising results. None, however, differentiated
among PLP, phantom limb sensation (PLS), and stump
pain (SP), and no distinction was made among fre-
quency, intensity, and duration of the different pains.
Finally, minimal theoretical explanation was provided to
explain the potential mechanisms underpinning the
intervention.
To replicate and extend previous studies by including
improved controlled conditions, two new patients with
chronic PLP were evaluated. The aims were to 1) establish
the effectiveness of TENS when applied to those selective
areas on the intact contralateral limb that mirrored the felt
location on the phantom limb; 2) characterize the fre-
quency, intensity, and duration of the pain throughout the
intervention period; and, finally, 3) document the differen-
tial effectiveness of the intervention on PLS, PLP, and SP
at follow-up.
134
Case Reports and Assessments
Although several patients were considered, only two
patients were considered, given the inclusion/exclusion
criteria. Inclusion criteria: Patients had to have PLP for a
minimum period of 1 year with little or minimal improve-
ment in the perception of PLP since amputation. In terms
of exclusion criteria, subjects had to be adults (aged
between 18 and 60) without psychiatric diagnosis and no
previous psychiatric history. Eight patients with PLP were
originally identified, but only four of these met the
inclusion/exclusion criteria. Two of these subsequently
agreed to participate in the study.
Same assessment methods were used with both patients.
However, as the first participant (FG) had suffered upper
limb amputation and the second (SL) suffered above-knee
amputation, the Gronigen Questionnaire [20] was adapted
for use with a lower limb amputation. The adaptation was
carried out by simply substituting the word “arm” with the
word “leg.” Moreover, as SL had never reported SP, these
were not recorded.
Case 1
FG was a 24-year-old man who had suffered a left below-
elbow amputation following a car crash. FG reported PLP
for a period of 12 months, at which time the current
interventions began. His pain started soon after the ampu-
tation of his arm and had not changed significantly. FG
reported a number of symptoms that accompanied his
phantom pain including blurred vision, dizziness, exces-
sive sweating, fatigue, nausea, and skin temperature
change. The pain was located in his left phantom hand,
extending to the tip of his phantom thumb.
As first assessment, FG was coping with his pain by using
painkillers (6 doses of gabapentin—mg 300—a week and
6 doses of tramadol—mg 300—a week). The initial
assessment also discovered that physical factors such as
cold, heat, massage, and changes in the weather
increased his pain as did emotional events such as anger,
fatigue, and frustration.
Case 2
SL was a 38-year-old male who had a transfemoral right
amputation further to a viral infection. SL suffered a motor-
bike accident 10 years before the amputation. Three years
after the accident, he had a fused knee, and 7 years later,
amputation of the leg was necessary due to viral infection.
He reported that his PLP started soon after the amputa-
tion, which had been carried out 23 months before this
study. During that period of time, he claimed that the pain,
while diminished, was uncontrolled. The degree of pain
relief improvement, however, was minimal (and hence, in
accordance with our inclusion criteria).
Pains were localized in the phantom muscle and/or skin.
He also described it as continuous, steady, and constant.
SL described several locations where he felt pain in his

phantom right leg, with the most painful points being the
top of the shin just below the knee and the top of his right
foot matching the area of the extensor digitorum brevis
muscle.
Method
The intervention period consisted of 3 months of con-
tralateral TENS stimulation, using five variables that were
monitored before, during, and after the trial. Patients were
instructed to apply four rubber electrodes connected to
the TENS stimulator to their contralateral limb at precise
point(s) corresponding to the maximum pain each time
they felt pain for a period not exceeding 60 minutes. Each
machine delivered a constant source of electric stimula-
tion with a frequency of 80 Hz and a pulse width of 50.
The intensity (ampere) of the stimulation was regulated by
each participant individually. Patients were instructed to
regulate the machine until they experienced strong, but
not painful, stimulation. The variables measured before,
during, and after the trial period were:
• PLP,
• PLS,
• SP,
• Overall use of prostheses (measured in hours), and
• Number of coping strategies used.
PLP, PLS, and SP were measured for intensity, duration,
and frequency. The study design comprised five sequen-
tial different stages.
1. Pre-assessment—involving a preliminary questionnaire
(McGill Comprehensive Pain Questionnaire—part A
only) [21] sent to the participant before first formal
appointment; this assessment was carried out to
collect important screening information such as the
quality and quantity of PLP and PLS, the location of
their pain, etc.
2. Preliminary baseline assessment was completed
during the first appointment. This comprised a base-
line of the five mentioned variables. The assessment
was completed using the following semi-structured
interview and questionnaires:
• The Comprehensive Pain Questionnaire interview
guide—part B [21];
• The Cambridge Phantom Limb Profile (CPLP) [22];
this is a questionnaire concerning PLP, PLS, and SP.
For each variable, intensity, frequency, and duration
of the phenomenon were assessed using rating
scales varying from 0 to 5;
• The Groningen Questionnaire: Problems after Arm
Amputation (GQPAA) [20], a questionnaire assessing
PLS, PLP, SP, the use of prostheses, and also rating
the intensity, duration, and frequency of those
variables;
• The 13 visual analog scales (VAS), measuring PLP,
PLS, SP, the use of prostheses, and coping strate-
gies. This offered the possibility to measure those
same variables using a continuous scale moving
from 0 to 10.
Contralateral Stimulation of Phantom Pain
Further screening information was also obtained. As part
of this assessment, we provided participants with the
opportunity to report any changes regarding the quality
and quantity of their PLP since amputation.
3. Start of intervention that lasted 3 months—TENS treat-
ment. This treatment stage started a week after the
baseline assessment was obtained. Participants used
TENS on their contralateral limb. Training was pro-
vided. Patients were instructed to apply the TENS
each time the pain occurred to the contralateral sites
where the phantom pain was experienced on the
amputated limb for a period not exceeding 60 minutes.
During the period of the active intervention, the sub-
jects met with the researcher four times, where the
CPLP [22], GQPAA [20], and 13 VAS were com-
pleted. The assessments carried out during this
stage were administrated at regular intervals of 3
weeks. However, as the treatment stage started a
week after the baseline measures were completed,
the time interval between baseline and first treat-
ment assessment was 4 weeks.
4. Extended assessment at the end of the 3 months
treatment period; the assessments described in
stages 1 and 2 were repeated. During this assess-
ment, further information regarding how PLP, PLS, and
SP changed in time were also collected.
5. Follow-up: 1 year following end of intervention, partici-
pants were contacted for a follow-up interview. During
the interview, the CPLP, GQPAA, and 13 VAS were
completed.
Results
PLP
PLP was evaluated at six different stages and involved
evaluations of frequency, intensity, and duration. The first
assessments served as a stable baseline, three assess-
ments were carried out during the treatment, an interim
assessment at the end of the 3 months intervention, and
finally, the last assessment 1 year from the end of the
intervention (follow-up). Frequency of the PLP involved a
combined measure of the following three measures: VAS
(0–10); CPLP (0–4); and GQPAA (0–6). This aggregate
score was generated by transforming the results of the
two rating scales to a continuous variable score using
proportional mathematical transformations and adding
these to the VAS score. These scores were subsequently
averaged to obtain a more reliable measure of the variable
under observation. Similar results were obtained for inten-
sity of PLP. As CPLP and GQPAA did not contain rating
scales to estimate the duration of each episode, duration
was measured using a VAS only.
Figure 1 shows how both patients rated frequency, inten-
sity, and duration of their PLP (dashed lines = patient SL;
solid lines = patient FG). In the case of FG, the ratings for
frequency, intensity, and duration of PLP consistently
decreased during intervention and 1-year follow-up. This
figure also shows that the frequency and duration of PLP
for SL had also clearly decreased by comparison with the
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8
Degrees of phantom limb pain

7
6
5
Intensity FG
4
Intensity SL
3
2
1
Figure 1 Changes on the three
0
1 2 3 4 5 6 different indexes of phantom
12 limb pain (PLP) in time. Point 1
Degrees of phantom limb pain

10
shows the pretreatment base-
line. Points 2, 3, 4, and 5 show
8
the perception of PLP across
6 Duration FG
the 3 months treatment stage
Duration SL
4 (an assessment every 3 weeks).
2 The time interval between base-
0 line and assessment 1 was,
1 2 3 4 5 6 however, 4 weeks. Point 6
12 shows the perception of PLP at
Degrees of phantom limb pain

10 1-year follow-up. The top graph

8
Frequency FG
shows data regarding the inten-
6 Frequency SL sity of PLP, the middle graph
4 shows the duration, and the
2 bottom graph shows the fre-
0
quency. Dashed lines show the
ss
s

p
e

es

s
se

performance of SL. Solid lines

-u
lin

se

s
se
ss

w
as
se

as

llo
ta

as
Ba

d
d

Fo
1s

3r

show the performances of FG.

2n

4t

original baseline. Moreover, these changes were main- (solid lines), the graph shows that the frequency, intensity,
tained at the 1-year follow-up. Although the intensity of and duration of PLS had significantly decreased. These
PLP for SL showed decreases in comparison with the changes were maintained at 12 months. There were no
original baseline, the changes reported were marginal. In changes in the number of words (“itching,” “abnormal
the case of SL, all three measures consistently decreased shape,” and “cold”) selected to describe PLS across
prior to their complete elimination during the third planned assessments, suggesting that the quality of sensations
assessment. has not changed.

PLS In the case of SL (dashed lines), the results show a con-

stant continuous decrement in the perception of PLS.
To better understand changes in PLS, four different mea- Although intensity, duration, and frequency continuously
sures were employed: 1) frequency, 2) intensity, 3) dura- decreased across time, these changes are relatively small
tion, and 4) the number of describing words used. when compared with changes showed by the same par-
Frequency was assessed using the same procedure as ticipants for PLP. Again, the words used by SL to describe
PLP. Intensity was measured by combining the results of the PLS did not change across time.
the rating scale in GQPAA with the results of a new VAS,
whereas duration of PLS was simply assessed using a SP
single rating scale. Finally, the number of words used to
describe PLS was measured by asking the participant to As with the previous two variables, frequency, intensity,
select some of the words from a list presented in the and duration of each episode were measured. To rate the
GQPAA. frequency and intensity of SP, the GQPAA and two differ-
ent VAS (one for intensity and the other for frequency)
Figure 2 charts the changes for PLS during the 3-month were used. The two rating scales were transformed and
treatment and at the 1-year follow-up. For patient FG averaged as previously described for other variables. To

136
 Contralateral Stimulation of Phantom Pain

Degrees of phantom sensations

6

4 Intensity SL
3 Intensity FG

0
1 2 3 4 5 6

Figure 2 Changes on the three Degrees of phantom sensations 9

8
different indexes of phantom
7
limb sensations (PLS) in time.
6
Point 1 shows the pretreatment
5 Duration FG
baseline. Points 2, 3, 4, and 5
4 Duration SL
show the perception of PLS 3
across the 3 months treatment 2
stage (an assessment every 3 1
weeks). The time interval 0
between baseline and assess- 1 2 3 4 5 6
Degrees of phantom sensations

ment 1 was, however, 4 weeks. 8

Point 6 shows the perception of 7
6
PLS at 1-year follow-up. The
5
top graph shows data regarding Frequency FG
4
Frequency SL
the intensity of PLS, the middle 3
graph shows the duration, and 2
1
the bottom graph shows the fre-
0
quency. Dashed lines show the
s

ss
ss

ss

p
e

es

-u
lin

se
se

se

performance of SL. Solid lines

ss

w
se

as
as

as

llo
ta
Ba

Fo
h
d

d
1s

4t

show the performances of FG.

2n

3r

measure duration of the episodes of SP, a single VAS was
used. Figure 3 shows the changes during the 3-month
treatment and at the 1-year follow-up for FG (solid lines).
SL never reported SP. Data regarding SL SP is not con-
sequently reported in this graph. The graph clearly shows
that FG’s frequency, intensity, and duration of SP had
decreased and were maintained at the 1-year follow-up.
Overall Use of Prostheses
No changes regarding overall use of the prostheses was
recorded for both patients during the trial and at 1-year
follow-up.
Number of Coping Strategies
Finally, the numbers of coping strategies used by partici-
pants across the trial and at 1-year follow-up were evalu-
ated. Three VAS were used, for PLP, PLS, and SP
consecutively. Figure 4 shows the changes during the
3-month intervention and at 1-year follow-up.
For FG (solid lines), it can be seen that while the overall use
of coping strategies did not change across time for PLP
and PLS, the use of coping strategies for SP decreased,
keeping with the continuous decrement in frequency,
intensity, and duration of SP. In the case of SL (dashed
lines), the graph shows that the number of coping strat-
egies did not change over time, and one can assume that
coping strategies did not play any significant role in rela-
tion to the previous mentioned changes in PLP and PLS.
Discussion
Overall, observation on the five key factors showed that
FG experienced a functional improvement in both the
experience and management of PLP, PLS, and SP,
despite initial reporting that his PLP was stable in the year

137
Giuffrida et al.

Degrees of stump pain

9
8
7
6 Frequency FG
5
Intensity FG
4
3 Duration FG
2
1
0

p
e

ss

ss

ss
s

-u
lin

es

se

se

se

w
se

ss

as

llo
as

as
Ba

ta

Fo
d

h
1s

2n

3r

4t
Assessment carried out during the
treatment phase

Figure 3 Changes on the three different indexes of stump pain (SP) in time. Point 1 shows the pretreatment
baseline. Points 2, 3, 4, and 5 show the perception of SP across the 3 months treatment stage (an
assessment every 3 weeks). The time interval between baseline and assessment 1 was, however, 4 weeks.
Point 6 shows the perception of SP at 1-year follow-up. The top graph shows data regarding the intensity of
PLS, the middle graph shows the duration, and the bottom graph shows the frequency. This graph shows
only the data regarding FG as SL never reported SP.

prior to intervention. These improvements were unrelated
to the use of prostheses and/or the use of coping strate-
gies, which remained largely unchanged. At the end of the
3-month intervention trial, FG decided to keep the TENS
equipment and to continue to use it when pain occurred.
However, at the 1-year follow-up, he reported that he had
stopped using the equipment 6 months previously.
Although FG showed a substantial improvement, PLP,
PLS, and SP were not completely eliminated. These
single-case results support those previously reported
[16,19,20], all of which found a significant improvement in
patients treated with contralateral TENS.
SL also showed that contralateral TENS had contributed
to decreasing his perception of PLP and PLS. While SL
showed a greater improvement in PLP (decreased in fre-
quency, intensity, and duration), the improvements in
PLS were more marginal. However, the improvement
achieved was maintained at the 1-year follow-up. SL
kept the TENS machine at the end of the 3-month trial

7
Number of coping strategies

For phantom sensations

6 FG
5 For phantom pain FG

4 For stump pain FG

3
For phantom sensations
2 SL
1 For phantom pain SL

0
Baseline 1st 2nd 3rd 4th Follow-
assess assess assess assess up

Figure 4 The graph shows the number of coping strategies used by each participant in a daily scale
moving from 0 to 10. Coping strategies were calculated separately for phantom limb pain, phantom limb
sensation, and stump pain. Point 1 shows the pretreatment baseline. Points 2, 3, 4, and 5 show the
number of coping strategies across the 3 months treatment stage (an assessment every 3 weeks). The
time interval between baseline and assessment 1 was, however, 4 weeks. Point 6 shows the number of
coping strategies at 1-year follow-up. Dashed lines show the performance of SL. Solid lines show the
performances of FG. SL never reported stump pain. SL often reported not using any conscious coping
strategy.

138

as he considered it beneficial. However, at the 1-year
follow-up, he reported having ceased to use the
machine systematically.
Although the current case studies show that both partici-
pants improved following contralateral TENS treatment,
we cannot rule out the contribution played by an inadvert-
ent placebo effect, and/or paying regular attention to their
phantom limb—although the latter was more likely to be
associated with an increase in pain.
Contralateral Limb Stimulation and PLP
Despite limited number of studies, the current study,
together with previous reports, suggests that contralateral
stimulation of PLP represents a promising intervention in
need of further evaluation. Working back from the clinical
findings to a theoretical explanation, however, is not
immediately obvious. Animal models highlight changes to
the dorsal horn of the spinal cord following amputation.
These changes lead to central sensitization, comprising
enduring changes in the responsiveness of synapses of
the dorsal horn of the spinal cord [23]. This can result in a
reorganization of the spinal cord sensory map [24] such
that receptive fields on the skin close to the amputated
limb shift into regions of the spinal cord previously occu-
pied by the limb. However, because spinal anesthesia
does not prevent PLP [25], it would appear that such
spinal cord changes do not provide the full picture.
Supraspinal changes have been extensively employed to
explain the origins and maintenance of PLP [26]. More-
over, amputation of the finger of an owl monkey produced
up to 2 mm “invasion” of contiguous areas into the cortical
representation of the amputated finger [26]. The most
commonly studied supraspinal changes following limb
amputation in humans using functional imaging and
behavioral studies have shown evidence of extensive
remappings of the contralateral somatosensory cortex
and thalamus [27,28]. Support for remapping comes from
studies using functional magnetic resonance imaging and
magnetoencephalography. An investigation of cortical
reorganization in 13 upper limb amputees has found evi-
dence that the area of the brain representing an ampu-
tated part of the body could be used by the neighboring
cortical areas [29]. Similarly, several cases in which, fol-
lowing arm amputation, a precise topographically orga-
nized map of the amputated hand was identified on the
ipsi-amputational face and shoulder have been reported
[27]. These findings were subsequently confirmed and
extended in studies that showed that the original topo-
graphic and apparently exclusive ipsi-amputational-
referred sensations could change with time [28,30]. Within
a year, in patients who suffered a limb amputation, multiple
areas on the contra-amputational side of the face were
now able to elicit referred sensations in the phantom limb,
implying that homotopic regions of primary somatosen-
sory cortex were linked between the hemispheres [28,30].
Animal research also showed that plasticity induced in one
hemisphere, in the form of receptive field expansion
brought about by small peripheral denervation, was mir-
Contralateral Stimulation of Phantom Pain
rored in the other hemisphere without such neurons dis-
playing any responsiveness to stimulation of the ipsilateral
body surface [31].
It has been previously suggested [27] that this extensive
cortical/subcortical remapping may affect the functionality
of the gate control system for moderating pain [32]. The
process of remapping could alter this, amplifying painful
sensations associated to the missing limb. The theory
that remapping is associated with PLP was also dis-
cussed in a study [32] in which it was argued that the lack
of afferent signals caused by the amputation affects the
neuromatrix triggering abnormal firing in substitution.
Consequently [32], TENS works because it replaces or
substitutes for the lack of afferent signals. In the case of
contralateral stimulation, topographically relevant afferent
signals from the intact limb accessed through trancallosal
fibers linking up homotopic parts of the brain activate
cortical areas representing the de-afferenated limb.
Assuming that a key source of PLP is caused by the lack
of appropriate afferent signals, then it would appear that
reinstating the missing lateral inhibition even for a short
period might help alleviate or prevent the pain. This is
realized by stimulating the relevant homotopic area of the
body contralateral to the missing limb, i.e., by stimulating
the areas on the intact limb that approximates to the pain
felt in the phantom. This account assumes that inputs
help reinstate the lateral inhibition normally generated
from stimulating a homotopic ipsilateral body surface. In
support of this speculation, there is literature reporting
contralateral responses to unilateral lesions and/or stimu-
lations. A review of 18 studies where a unilateral lesion(s)
caused contralateral effects [33] showed that contralat-
eral responses to unilateral neurological lesions were
common between species and have been reported in
rats, guinea pigs, frogs, cats, mice, and ferrets. This phe-
nomenon was considered to be mediated via neurological
mechanisms that cross through the spinal cord [33].
Although the two sides of the spinal cord have been
traditionally described as being functionally independent,
there are three main lines of research that suggest that
this is not the case [34–36].
In 2000 [37], it was suggested that because phantom pain
was, in part, a response to the discrepancy between
vision and proprioception, MVF could act by restoring the
congruence between motor output and sensory input. It is
possible that contralateral stimulation works by changing
previous cortical reorganization with corresponding reduc-
tion of pain. In particular, contralateral stimulation results
from the way in which precise topographical activations
compensate for the lack of afferent signals by reinstating
(albeit temporarily) normal lateral inhibition on the ipsilat-
eral side. Following the previously mentioned review [33],
we speculate that the stimulation caused by contralateral
stimulation could initially activate the contralateral spinal
cord and subsequently reinstate (even partially) the lack of
afferent signals given by the amputated limb. This mecha-
nism could then offer a feedback that would prevent the
perception of PLP. Systematic research is therefore
needed to test the validity of this speculation.
139
Giuffrida et al.
Our results, together with those previous studies
reviewed, show that there is sufficient clinical evidence to
warrant further more rigorous evaluation and suggest that
in the future, this promising technique warrants a more
definitive and larger randomized, observer-blinded trial of
contralateral stimulation vs stump stimulation to establish
its potential efficacy.
Acknowledgments
The authors acknowledge the cooperation of ALAC,
Rookwood Hospital, Cardiff and Vale NHS Trust, and the
Medical Research Council.
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