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Interviewer: For patients who have lost a limb, phantom limb pain is a very real and very painful condition. And what exactly is it, and how is it treated?

Today, we're joined by two specialists who really treat this kind of condition. Dr. Colby Hansen is Director of Amputee Program at the Craig H. Neilsen Rehabilitation Hospital, and Spencer Thompson, a doctor of physical therapy and a board-certified specialist in neurological physical therapy specializing in the treatment of amputees.

Now, when we're starting to first kind of understand what phantom limb pain is, why don't we go with that question to begin with? Dr. Hansen, what exactly is phantom pain?

Dr. Hansen: Phantom pain is the perception of pain in a limb that has been amputated. For someone who has lost their leg, they may still feel painful sensations as if they are coming from the missing leg, the missing foot, the missing ankle, etc.

Interviewer: What exactly causes that? And correct me if I'm wrong, there are no nerves there to be creating that pain, are there?

Dr. Hansen: Well, it's a good question. Pain signals obviously have to originate from the site of pain, and then travel through the nervous system up to the spinal cord, and then up to the brain.

And in our brain, we have essentially a map that represents signals that pertain to every part of our body. And so, even though we may have lost a limb, we haven't lost that map in our brain. And so it can still perceive signals going to that part of the brain, which may be then perceived as coming from the missing part of the body.

In addition to that, the residual nerve in the remaining part of the limb that would have gone to that part of the limb is still there, and it can also send signals originating from there up to the brain which can be perceived as pain.

Interviewer: And how severe is this pain?

Dr. Hansen: It's very different from person to person. There are some people who may not feel pain, but they may feel the sensation of their limb. We call that phantom limb sensation. And then there are people who may have very severe phantom limb pain, and then there are going to be those who have perhaps only very mild or very intermittent phantom pain experiences.

Interviewer: I want to shift over to Spencer Thompson. Spencer, when you work with these patients, as an outsider, it's a little confusing, right? If someone has a twisted ankle, a physical therapist works on that twisted ankle, right? In this situation, it seems more that there is a neurological almost perceptual type pain happening. How exactly as a physical therapist do you help patients with this condition?

Dr. Thompson: I think understanding first how frequent it's happening for them gives understanding to how to best treat it. But one of the ways that I've found that's an easy way, that's not medication so it doesn't really have any systemic effects on the patient, is something called mirror therapy.

Like Dr. Hansen talked about, that pathway, that map is already in their brain, and sometimes that system gets ramped up where it feels like . . . sometimes people feel like their foot is twisted or contorted in a certain position, or they get those zaps of pain. Because that part of their leg is missing, what we want to do is train the brain in the sense that that part of their limb actually can move without pain. And the way we do that is with the mirror.

Interviewer: Is it a special mirror?

Dr. Thompson: No. I tell people to just buy a door mirror at Walmart for $15 or whatever. What you do is you put that mirror in between your legs. And you can do this with an arm as well, right? But you want to in a sense block your amputated side. And the mirror is going to show the reflection of the intact limb, whether that's the arm or whether that's the leg.

When I teach this to patients, what I tell them to do is their whole focus needs to be on the reflection of that intact leg, so that reflection is covering the leg, their amputated side. It looks like when they're looking over there . . . Say the left leg is amputated, I have the mirror on that left side, but it's showing the reflection of my right leg in that mirror, so when I'm looking in the mirror, it looks like that's actually my left leg, if that makes sense.

Interviewer: Oh, wow. Okay.

Dr. Thompson: Then, what I do, or what we tell patients . . . I work a lot with more lower limb, so I'll just describe what you do for lower limb, but it could be the same for upper limb type of thing.

I tell them, "I want you to keep your whole focus on that mirror, of that reflection of the intact limb, because we want to train your brain that is there, that it can move without pain." And then I teach them to move that ankle up and down, move it in and out, move it through circles in all directions, spell the alphabet with that ankle, kick the leg in and out, move the hip up and down, in and out. Any type of movement like that that can be moved through a pain-free movement, you're sending signals to the brain that that leg can move without pain.

Interviewer: The leg that is not there?

Dr. Thompson: The leg that is not there, but by looking at that reflection, you're sending input into the brain telling the brain that that leg can move without pain.

You can try it yourself, even if you're not an amputee. It's a little trippy at first. When the patients try it, they're like, "That feels so weird." But it's cool.

The biggest kicker with it is it takes consistency. Any time you're training the brain for something, it takes a lot of repetition, it takes consistency, it takes effort.

There's research out there. There are more research studies that need to be done to continue to prove efficacy of this, but protocols that I recommend is doing it for 5 or 10 minutes every day for 4 to 6 weeks.

And people that I've seen that have committed to that, there's a variety of results. Some people, it doesn't work. Some people, it does.

Some people feel like the edge of their phantom pain is taken off. We call it telescoping. The phantom pain may be on the distal end of their leg, in their foot. But sometimes that pain travels up, so it's not necessarily in their foot. It kind of travels up a little bit, and it's not as intense.

And some people, it helps out quite a bit. Or if they have an intense phantom pain session, they do it, and it just kinds of melts that pain away.

But biggest thing I would say is . . . I talk to people, and I'm like, "Have you tried mirror therapy?" They're like, "Yeah. I tried it, but it didn't work." When I kind of explore a little bit more, I find out that they haven't really done it on a consistent basis. They've tried it four or five times and it didn't really maybe have the effect they wanted, and so they stopped doing it.

And so my biggest thing was if you really want to see if it works, give it a shot, but be consistent with it. Shoot for every day. Put a timer on your phone for five minutes and be consistent with it and see what happens.

Interviewer: Now, Dr. Hansen, I guess I'm just a bit of a layperson here, but a $15 mirror that you can get at a big box store can significantly help with your pain. What exactly is happening, I guess, in the brain, in the nerves, with this therapy to have it work?

Dr. Hansen: Yeah, it's a good question. I think the simplest way to maybe try to conceptualize what's going on here is we have obviously five senses, right? Touch, smell, taste. Vision is one of our strongest senses and drives some of that pathway to that part of the brain represented by that missing limb. I think we can start to replace some of those pain signals going there with healthy, normal-feeling normal movement type of signals going there.

When we can have this visual input that's looking as if we're looking at our missing limb and that it's there, and if we can harness that input, which is very strong, to then do some of those things that Spencer was mentioning, move the phantom limb through the mirror in these different ways and not reconnect but sort of drive some of that pathway to that part of the brain represented by that missing limb, I think we can start to replace some of those pain signals going there with healthy, normal-feeling, normal movement type of signals going there.

Interviewer: Dr. Hansen, say there is a listener who either they themselves have an amputated limb or there's a loved one with an amputated limb, and they are dealing with some of these phantom sensations, phantom pain. Where do they start? Is it a general practitioner, is it a specialist, is it a physical therapist? If they need some help, where do they go?

Dr. Hansen: Good question. I would say the place to go is a high-level rehabilitation center that sees a lot of these complex types of patients. There may be some sort of small community rehab centers that don't see this very often. Usually at bigger centers, not just academic medical centers, although most academic medical centers should have the expertise. I am a rehabilitation physician, but not all rehabilitation physicians do amputee care. Sometimes orthopedic surgeons may do amputee care and do a very good job.

But I would say you start by looking for a large medical center that sees and treats complex rehabilitation types of patients, and then likely you'd be plugged into hopefully an amputee clinic at our institution run by myself as a rehabilitation doctor, but also that incorporates other expertise, like physical therapy or rehabilitation psychology, etc.

Interviewer: Spencer, for a patient who might be dealing with this kind of pain, what is something that you tell either them or their loved ones about what they can expect with working with a physical therapist to treat this condition?

Dr. Thompson: PTs, I think sometimes people think we're just mean people, that we just like to . . . We have this tagline that's "PT stands for pain and torture." I mean, yes, it does take work and sometimes pain, just like working through anything to improve, but we're here as huge advocates for you. We're on your team. PTs, our goal is to help improve your daily function and mobility and to get you back to living life to its fullest.

I would say for patients, give yourself some grace, some compassion. You've been through a lot. Your body has been through some significant changes. Just take a minute and breathe and just acknowledge all that you've been through and all the . . .

I tell all patients that I think the media sometimes does the amputee population a disservice in some aspects, because we see all these Olympians that are doing these amazing things, which is awesome that they are, but people sometimes have this expectation of, "Once I get my prosthetic limb, I'm going to be out running, doing all these amazing things." But the media doesn't also show the phantom limb pain that people experience or just the different trials that they do experience.

And so don't compare yourself to what's shown in the media. Just take it a day at a time. You're going to have good days, you're going to have days that are harder, but just be patient with yourself and just know that day-by-day, it's going to get better.

There is hope. There's help out there. There are great resources. We run an amputee support group here through the University of Utah that I run. There's a company called the Amputee Coalition. There's support out there. You're not alone in this. Talk to other people that get it, talk to professionals that understand, and I think just build your team around you that can help support you, and be patient and give yourself grace in this healing process.

Interviewer: You're wondering if you should let you kids play contact sports that could lead to concussion injury. What are some of the things that you should discuss and think about? We'll find out from concussion expert Dr. Colby Hansen next on The Scope.

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Interviewer: Dr. Colby Hansen is a concussion expert at University of Utah Orthopedic Center's concussion clinic. Ultimately, I think the question that every parent would want to know given the stories and a lot of talk about concussions in the media, is it still safe or is it safe for my kids to play sports? I suppose you get that question a lot know a days.

Dr. Hansen: I do. I would say, yes, it's totally appropriate for kids to play sports.

Interviewer: Even football.

Dr. Hansen: Yes.

Interviewer: Which seems to be . . . is that the highest risk of a concussion, that sport?

Dr. Hansen: Football is right up there. There are others that are near it - hockey, things like rugby, soccer not too far behind, wrestling.

Interviewer: So it's still safe in, your opinion, for kids to play sports.

Dr. Hansen: I think you have to ask yourself the question, "What is the value of my kid in playing sports?" which I think are numerous.

Interviewer: Maybe basketball would be a better option than football? Where should a parent stand on that?

Dr. Hansen: If we talk about football specifically. Yes, football has some risk to it. Might there be an appropriate age where it's best to start to engaging in football and maybe a younger age where they shouldn't? I don't know. I am not really going to comment on that or try to pretend to be the expert or sounding board for that.

Interviewer: Is there research going on right now or research that would point to an answer to that question?

Dr. Hansen: Well, I know that some groups are interested in taking measures to reduce the number of impacts that people sustain playing a contact sport, like football. There are visible things that people who watch football might see as being measures in that regard - reducing the number of kick-off plays, increasing the number of touch-backs that occur, rules to prevent helmet-to-helmet or targeting types of collisions.

In the background there are lots of efforts to try to educate athletes, and coaches in proper tackling techniques. There are even rules now that are coming down limiting the number of contact practices in full pads, in full gear, to reduce the amount of contact that's sustained over the course of the season.

Those are, I think, appropriate measures. I don't know that we know exactly what's an acceptable amount of collisions to sustain. I think a lot of it eventually comes back to educating coaches, educating parents, educating athletes.

Where I see, perhaps, the biggest problem is when the initial injury may occur and it's not recognized. Instead of taking the kid out of play and observing them or even just making them sit out the rest of that practice or game, there is a tendency to, I think, brush it off. Whether it's on the part of the coach or the athlete, I think, sometimes both at fault, and just rush them out there, and say, "You're okay, let's go at it." That's where you're at risk.

Interviewer: Is that one of the most dangerous things that can happen? You sustain a concussion type head injury, and you go get one immediately right after that?

Dr. Hansen: Exactly.

Interviewer: That's where problems really start arising.

Dr. Hansen: Yeah. There's a saying that goes around in the concussion world, "When in doubt, sit him out." I think that is totally appropriate, there's nothing wrong with that. Is it, perhaps, on the conservative side? Sure. But I think it may well prevent some of these other complications that arise when it's not recognized and then what you have is a situation where kids are, perhaps, sustaining multiple, subsequent collisions over the course of a game or perhaps a few practices. It starts to add up.

Interviewer: Let's go down that path for a second. Are there lasting effects that can occur from those multiple sustained injuries if enough recovery time in between doesn't happen?

Dr. Hansen: I would say yes. From animal model data, and what we see from following players over time in some studies that have done that over the course of a season, if not given adequate recovery time, I think that certainly is a huge risk factor, maybe one of the biggest, for prolonged problems and symptoms that, unfortunately, in a few instances, may not go away.

Interviewer: What's your advice to a parent that has a kid in a sport that can lead to concussion or multiple concussions? Do you have children?

Dr. Hansen: I do.

Interviewer: And as a parent and an expert on concussions what's your strategy on this? What's your thought?

Dr. Hansen: My kids aren't, frankly, interested too much in those types of sports.

Interviewer: Does that make you a little happy on some level?

Dr. Hansen: So that takes some of the pressure off.

Interviewer: Nobody got a concussion in band.

Dr. Hansen: Exactly. I would say it's appropriate to allow kids to play in sanctioned sports, if there are sanctioned leagues and things out there. I think it's appropriate to make sure that the kids have the correct and correct fitting safety equipment. I think a lot of it comes back to the education piece. If an accident occurs, which there is often times not much you can do to prevent an accident, that you manage that appropriately.

Now there gets to be a point where if somebody sustains a number of injuries where you many have to re-think that. Unfortunately, we don't have the magic answer to what's acceptable. How many is too many? We frankly don't know the answer to that question. It should raise some concern if you're starting to have repeat injuries and cause you to re-think that whole issue.

That too, I think comes back to where it may be helpful to talk to a specialist in this area to help you think through those types of questions. Even understanding that even we may not have a definitive answer based on absolute proven scientific research.

Interviewer: And that's something you do at the concussion clinic here at University of Utah Health Care. You'll have consultations, you do some base-line testing, I saw. You consult with sports teams, that sort of thing to help. So, information, knowledge really the most powerful thing right now.

Dr. Hansen: Yeah, I think that's a huge, huge part to what we do. When is it okay to get back to playing? What's appropriate to kind of think about or do we need to maybe think about maybe switching sports altogether? Or any number of things.

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Interviewer: The Will Smith movie "Concussion" focuses on a condition called Chronic Traumatic Encephalopathy. Dr. Colby Hansen is from the University of Utah Orthopedic Center Concussion Clinic. Dr. Hansen, tell me about this condition.

Dr. Hansen: Well, I think in general there's still so much for us as a scientific community and as a medical community to understand about this entity that is highlighted in the movie, chronic traumatic encephalopathy. I mean, it seems pretty clear that trauma is a common denominator, but we don't know to what degree genetics may play into this, to what degree other types of issues may play into it, either mental health disorders or whatnot. We don't know at what amount of exposure to trauma people are put at risk. Just frankly, there's a lot to tease out before we start being over-reactionary and pulling the plug on sports and things of that nature.

Interviewer: The condition that they're talking about in the movie, what exactly is that?

Dr. Hansen: Chronic traumatic encephalopathy is really a diagnosis that can only be made postmortem or after death by autopsy. What some of these researchers are seeing are abnormal collections of clumps of protein called tau that has also been linked to other degenerative diseases like Alzheimer's dementia. They've seen these under the microscope of some of these former athletes, and there's really no denying that they've seen this. So now they're in a phase of trying to characterize are there maybe certain areas of the brain where you get this kind of collection more than others, to what degree does this correlate with known behaviors or symptoms that the patient was experiencing while they were alive, and then ultimately trying to make the link back to the sport or the activity that they were engaged in. People would generally feel or believe that not every football player who progressed through to the NFL has this disorder, so who does and who doesn't and what are the differentiating factors between who does and who doesn't.

Interviewer: Do people that don't play football develop this disease?

Dr. Hansen: At least in terms of the case series, the group at Boston led by Dr. Ann McKee, who's a neuro pathologist there, has studied the most brains and they are not exclusively football players. This disorder was originally described many, many years ago, many decades ago, in boxers, and was termed Dementia Pugilistica which literally means "boxer's dementia." We would assume that the common denominator is trauma, but we don't know much beyond that. How much trauma, at what age the trauma occurred, there's even a lot of debate now not in just concussions, but just the repeated impacts that don't necessarily produce a clear, observable concussion.

At the end of the day there is so much for us to learn, to understand, about not only the impacts of a single concussion and how is the best way to manage it, how is the best way to assess it, but of course the long-term ramifications of concussions and repeated concussions in the health of our athletes and anybody who's active.

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Interviewer: Going to find out what to expect when you go to the University of Utah orthopedic center concussion clinic. That's next on The Scope.

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Interviewer: Let's say something happened to somebody that led to a concussion, whether it's playing football or skiing and took a nasty fall, or maybe even an accident. I've gone to my primary care physician or it's pretty clear that I do have a concussion, and I make an appointment with the concussion clinic. What should I expect after walking in the door?

Dr. Hansen: You'll be evaluated by a specialist in traumatic brain injury. As far as what the evaluation entails it will include a comprehensive look at what types of symptoms you are experiencing, what were the circumstances of the injury, what other medical problems do you have that could contribute in some way to the symptoms you're experiencing. For example, if somebody has a chronic headache disorder already and then they have a head injury, that certainly can affect how they experience their headaches, for example.

We'll want to find out if they've had head injuries before and if so, how did they occur, what was the recovery pattern. Beyond that history gathering, we'll perform a physical examination that looks at a good balance assessment. We know that that is often affected after a head injury. A general neurologic examination which is typically normal. Then, an assessment of how your eyes and vestibular system are working together and maybe provoking or aggravating symptoms.

Those are the main components of our physical exam. Depending on the circumstances there may be other supplementary tests that we do. The ultimate goal is to document what might be aggravating symptoms, what maybe is not back to normal, because in the case of athletes or people who are wishing to return to sports, or otherwise potentially risky activities, it's really important to make sure that you're "100%" before going back out into harms way.

Interviewer: So a lot of basic tests, a lot of questions, some balance tests, but what about some sort of a brain scan?

Dr. Hansen: Brain scans typically aren't very revealing. If you have a severe injury and show acute signs or symptoms that there might be a more serious problem in the brain, people with those sorts of issues usually end up in the emergency room and those appropriate scans are done at that time.

Interviewer: So imaging is not something that you normally would do there at the concussion clinic.

Dr. Hansen: Not typically. Certainly if the story doesn't add up or we're concerned about something else, but I guess I would say that imaging tests don't diagnose a concussion.

Interviewer: What kind of questions should the patient be asking when they're in the clinic? Is there anything in particular they should be actively doing?

Dr. Hansen: If I could put myself in a patient's shoes or in a parent's shoes, and certainly I'm a parent, how do I know when it's safe to go back and play such and such a sport? Or if I'm having symptoms that aren't going away, what can we do about it? It's a tricky process to navigate.

One of the big things that we try to tackle in our clinic is providing adequate education into how to manage this, and adequate support they can then take back to their work environment, their school environment, their coach, or whatever so that they can educate them on what's the right things to do or not to do to help facilitate getting better.

Interviewer: What are some of the treatment options that you might give a patient after they've come in and you've done the diagnosis? You mentioned medications could be one.

Dr. Hansen: Most of medical management of concussion is geared towards symptom management. There's not a pill that cures a concussion. Medications have a role. There are times when the best medicine is just education and helping them understand the right balance between rest and activity, how to scale things back, and how to tailor their daily activities to facilitate recovery. Sometimes we'll get rehabilitative therapies involved, physical therapy if somebody is struggling with a lot of dizziness or vertigo, or even a lot of neck pain sometimes coincides with their concussion.

Interviewer: If I got a concussion it sounds like rest . . . is rest a big part of it? I guess what I'm saying is instead of coming in, why don't I just rest for a few days?

Dr. Hansen: Sometimes that is the trick. We know that about 50% of concussions will spontaneously get better on their own without doing anything particularly special. The important thing in those situations is just making sure that you're not getting back into harms way too soon.

There are however cases research would suggest probably in the ballpark of 20% of patients may still be having problems even a month out from their injury. Continuing to just rest and do nothing there gets to be a point of diminishing returns I guess I would say where that's not helpful and you need to figure out how to balance the right amount of rest with the right amount of activity.

Interviewer: Certainly somebody in that particular category is somebody that you would want to see, if a month has gone by and they've still got symptoms.

Dr. Hansen: Absolutely, yeah. Some guidelines would even argue that anything beyond two weeks may merit a specialist evaluation.

Interviewer: It sounds like if somebody has had no history of having concussions, and has received one, resting for a few days would be fine. They probably don't need to come into the clinic unless those symptoms persist.

Dr. Hansen: Yeah, they probably don't need to come into necessarily our clinic, but it is super important to check in with a healthcare provider.

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