Graded motor imagery and its phases for individuals with phantom limb pain following amputation: A scoping review.

OBJECTIVE: Three-phase graded motor imagery (limb laterality, explicit motor imagery, and mirror therapy) has been successful in chronic pain populations. However, when applied to phantom limb pain, an amputation-related pain, investigations often use mirror therapy alone. We aimed to explore evidence for graded motor imagery and its phases to treat phantom limb pain. DATA SOURCES: A scoping review was conducted following the JBI Manual of Synthesis and Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews. Thirteen databases, registers, and websites were searched. REVIEW METHODS: Published works on any date prior to the search (August 2023) were included that involved one or more graded motor imagery phases for participants ages 18+ with amputation and phantom limb pain. Extracted data included study characteristics, participant demographics, treatment characteristics, and outcomes. RESULTS: Sixty-one works were included representing 19 countries. Most were uncontrolled studies (31%). Many participants were male (75%) and had unilateral amputations (90%) of varying levels, causes, and duration. Most works examined one treatment phase (92%), most often mirror therapy (84%). Few works (3%) reported three-phase intervention. Dosing was inconsistent across studies. The most measured outcome was pain intensity (95%). CONCLUSION: Despite the success of three-phase graded motor imagery in other pain populations, phantom limb pain research focuses on mirror therapy, largely ignoring other phases. Participant demographics varied, making comparisons difficult. Future work should evaluate graded motor imagery effects and indicators of patient success. The represented countries indicate that graded motor imagery phases are implemented internationally, so future work could have a widespread impact.

Diagnosis and Treatment of Low Back Pain: Synopsis of the 2021 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline.

ABSTRACT: Low back pain is a significant issue in the US Department of Veterans Affairs and Department of Defense populations as well as the general US population at large. This type of pain can be distressing to those who experience its effects, leading patients to seek relief of their symptoms. In 2022, leadership within the US Department of Veterans Affairs and US Department of Defense approved a joint clinical practice guideline for the management of low back pain. The guideline provides evidence-based recommendations for assessing and managing low back pain. Development of the guideline included a systematic evidence review, which was guided by 12 key questions. A multidisciplinary team, which included clinical stakeholders, reviewed the evidence that was retrieved and developed 39 recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. The scope of the clinical practice guideline is broad; however, the authors have focused on key recommendations that are important for clinicians in the evaluation and nonoperative treatment of low back pain, including pharmacologic therapies and both noninvasive and invasive nonpharmacologic treatments.

The Primary Care Management of Headache: Synopsis of the 2020 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline.

INTRODUCTION: In June of 2020, the U.S. DVA and DoD approved a new joint clinical practice guideline for assessing and managing patients with headache. This guideline provides a framework to evaluate, treat, and longitudinally manage the individual needs and preferences of patients with headache. METHODS: In October of 2018, the DVA/DoD Evidence-Based Practice Work Group convened a guideline development panel that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. RESULTS: The guideline panel developed key questions, systematically searched and evaluated the literature, created a 1-page algorithm, and advanced 42 recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. CONCLUSION: This synopsis summarizes the key features of the guideline in three areas: prevention, assessing and treating medication overuse headache, and nonpharmacologic and pharmacologic management of headache.

Strategies for graded motor imagery for clients with phantom limb pain and cognitive impairment.

BACKGROUND: Individuals with amputations often experience phantom limb pain (PLP) that can limit their participation in rehabilitation, prosthesis training, desired activities, and roles. One nonpharmacological rehabilitation intervention for PLP is graded motor imagery (GMI). There are several components to GMI, including right/left discrimination or laterality, motor imagery, sensory retraining, and mirror therapy. Successful implementation of GMI requires a range of cognitive skills, such as attention span, working memory, abstract reasoning, and planning. For individuals with PLP who concurrently display cognitive impairments, GMI protocols can be adapted using strategies derived from clinical practice. OBJECTIVES: The purpose of this technical clinical report was to discuss the application of clinically implemented cognitive compensation techniques to GMI instruction. STUDY DESIGN: Not applicable. METHODS: Clinical expert opinion to explore adaptations for GMI. TECHNIQUE: Graded motor imagery can be an effective tool for pain treatment; however, some clients may need greater clinician support due to existing cognitive difficulties. RESULTS: For clients to be successful, active engagement in learning about and implementing GMI techniques is necessary. CONCLUSIONS: When serving the lifetime amputation care needs of patients with cognitive deficits, we find that targeted learning strategies and accommodations can be helpful when introducing GMI concepts and skill development. Enhanced patient education techniques support client learning.

Interdisciplinary Pain Neuroscience Continuing Education in the Veterans Affairs: Live Training and Live-Stream With 1-Year Follow-up.

OBJECTIVE: Because of the pain and opioid epidemic in the United States, there is a need to update clinician's knowledge, attitudes, and beliefs regarding persistent pain across health care disciplines. The aim of this study was to determine if health care professionals can positively change their knowledge, attitudes, and beliefs regarding chronic pain, following a pain neuroscience education (PNE) lecture and 1 year follow-up. MATERIALS AND METHODS: A total of 270 health care providers at the Minneapolis Veterans Affairs Health Care System received a 3.5-hour PNE lecture in person or via live-stream. Primary outcomes were the Neurophysiology of Pain Questionnaire (NPQ) and Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) measured before, immediately after, and 1 year after the PNE lecture. At 1 year participants were also asked how the PNE lecture affected their practice. RESULTS: Pain knowledge (NPQ) (P<0.01) and attitudes and beliefs regarding persistent pain (HC-PAIRS) (P<0.01) improved for all providers, with specific improvements across several disciplines. Positive gains in outcomes were equal for in-person attendance, and live-streaming of the lecture. One year later, NPQ and HC-PAIRS gains diminished, yet clinicians reported a large positive impact on daily clinical practice. DISCUSSION: PNE resulted in a positive clinical impact for health care providers treating patients with persistent pain. The mechanism of this effect may be about healthier attitudes and beliefs regarding persistent pain rather than increased knowledge about pain.