Towards efficient motor imagery interventions after lower-limb amputation.

BACKGROUND: The therapeutic benefits of motor imagery (MI) are now well-established in different populations of persons suffering from central nervous system impairments. However, research on similar efficacy of MI interventions after amputation remains scarce, and experimental studies were primarily designed to explore the effects of MI after upper-limb amputations. OBJECTIVES: The present comparative study therefore aimed to assess the effects of MI on locomotion recovery following unilateral lower-limb amputation. METHODS: Nineteen participants were assigned either to a MI group (n = 9) or a control group (n = 10). In addition to the course of physical therapy, they respectively performed 10 min per day of locomotor MI training or neutral cognitive exercises, five days per week. Participants' locomotion functions were assessed through two functional tasks: 10 m walking and the Timed Up and Go Test. Force of the amputated limb and functional level score reflecting the required assistance for walking were also measured. Evaluations were scheduled at the arrival at the rehabilitation center (right after amputation), after prosthesis fitting (three weeks later), and at the end of the rehabilitation program. A retention test was also programed after 6 weeks. RESULTS: While there was no additional effect of MI on pain management, data revealed an early positive impact of MI for the 10 m walking task during the pre-prosthetic phase, and greater performance during the Timed Up and Go Test during the prosthetic phase. Also, a lower proportion of participants still needed a walking aid after MI training. Finally, the force of the amputated limb was greater at the end of rehabilitation for the MI group. CONCLUSION: Taken together, these data support the integration of MI within the course of physical therapy in persons suffering from lower-limb amputations.

Reappraisal and empathic perspective-taking - More alike than meets the eyes.

Emotion regulation and empathy represent highly intertwined psychological processes sharing common conceptual ground. Despite the wealth of research in these fields, the joint and distinct functional nature and topological features of these constructs have not yet been investigated using the same experimental approach. This study investigated the common and distinct neural correlates of emotion regulation and empathy using a meta-analytic approach. The regions that were jointly activated were then characterized using meta-analytic connectivity modeling and functional decoding of metadata terms. The results revealed convergent activity within the ventrolateral and dorsomedial prefrontal cortex as well as temporal regions. The functional decoding analysis demonstrated that emotion regulation and empathy were related to highly similar executive and internally oriented processes. This synthesis underlining strong functional and neuronal correspondence between emotion regulation and empathy could (i) facilitate greater integration of these two separate lines of literature, (ii) accelerate progress toward elucidating the neural mechanisms that support social cognition, and (iii) push forward the development of a common theoretical framework for these psychological processes essential to human social interactions.

Functional connectivity patterns of trait empathy are associated with age.

Empathy is the capacity to feel and understand others' mental states. In some individuals, there is an imbalance between the affective and cognitive components of empathy, which can lead to deficits. This study investigated the functional connectivity of the anterior insula (AI) and dorsomedial prefrontal cortex (dmPFC), which play key roles in empathy, in covariation with the affective and cognitive subscales of the Interpersonal Reactivity Index (IRI), as a function of age and sex, as an exploratory analysis. Seed-based functional connectivity analyses were performed on 33 healthy participants that were subdivided according to their age (16 adults and 17 adolescents) and sex (16 women and 17 men). Adolescents reported lower cognitive empathy than adults and men less affective empathy than women. The connectivity of the dmPFC and AI, in covariation with the cognitive and affective subscales of empathy, respectively, differed between adolescents and adults, but was similar in men and women. Adolescents had patterns of negative covariations between the regions of interest and many brain regions associated with the default-mode and salience networks. These findings support that lower self-report levels of empathy in certain individuals could be reflected in the functional connectivity patterns of the dmPFC and AI.

Food craving predicts the consumption of highly palatable food but not bland food.

The impact of obesity on physical and psychological health is well recognized in the literature with, among others, evidence of alterations in cognition. Indeed, obese populations are characterized by lower executive functions as well as an enhanced food craving. However, the relationship between executive functions and food craving remains unexplored. Moreover, these two variables have also been shown to predict food intake, but studies in the context of obesity are lacking. Thus, this study had two objectives: (1) determining if executive functions and food craving are linked, and (2) examining the predictors of highly palatable food intake and bland food intake. First, it was hypothesized that executive functions would be negatively associated with food craving. Second, it was expected that food craving would predict positively highly palatable food intake but not bland food intake. Third, it was predicted that executive functions would predict negatively highly palatable food intake and positively bland food intake. 48 participants (34 females) with BMIs ranging from 17.9 to 46.4 took part in two experimental sessions. First, executive functions were assessed using the delayed discounting task (impulsivity towards food and money) and the color-word interference test (CWIT; inhibition/flexibility). Second, a cue-induced food craving protocol, with images as well as real food, was administered followed by an ad libitum food intake protocol including both highly palatable and bland food. The inhibition/flexibility condition of the CWIT was significantly and negatively correlated with food craving following induction. Highly palatable food intake was significantly predicted by food craving following induction, but bland food intake was not. This study reveals an association between lower inhibition/flexibility and susceptibility to food craving induction that is of great importance in obesogenic environments. Moreover, this study confirmed the link between food craving and food intake, and showed for the first time a specific contribution of food craving to highly palatable food intake but not to bland food intake, highlighting its potential influence in obesity. This work leads to future research questions regarding the possible benefits of cognitive remediation interventions, as well as interventions aiming at reducing food craving, in weight loss programs. LEVEL OF EVIDENCE: Level IV, quasi-experimental study.

Impact of traumatic brain injury on social cognition in adolescents and contribution of other higher order cognitive functions.

Social cognition impairments can contribute to social participation difficulties following traumatic brain injury (TBI). However, little attention has been given to these impairments during adolescence, a period of life when peer relationships are central. The aim of the current study was to examine the impact of a moderate to severe TBI sustained in adolescence on multiple facets of social cognition. Twenty-three adolescents who had sustained a moderate-to-severe TBI were compared with a group of 23 typically developing peers. The Integrated Social Cognition Battery (mentalising, social knowledge, emotion recognition) and the Interpersonal Reactivity Index were administered, along with non-social cognition tests (selective attention, working memory, executive functions), IQ estimation, and a socio-demographic questionnaire. Adolescents with TBI reported having a significantly lower ability to take other people's perspectives versus controls. They also presented significantly lower levels of mentalising. After controlling for non-social higher-order cognitive variables, the group effect on mentalising remained marginally significant, whereas the effect on perspective taking remained significant. Our findings suggest the presence of primary deficits in social cognition following TBI in adolescence. These deficits could partially underlie the social reintegration difficulties encountered following TBI. A systematic assessment of social cognition in clinical practice is necessary.

Functional MRI examination of empathy for pain in people with schizophrenia reveals abnormal activation related to cognitive perspective-taking but typical activation linked to affective sharing.

BACKGROUND: Schizophrenia is associated with important disturbances in empathy that are related to everyday functioning. Empathy is classically defined as including affective (sharing others' emotions) and cognitive (taking others' cognitive perspectives) processes. In healthy individuals, studies on empathy for pain revealed specific brain systems associated with these sets of processes, notably the anterior middle cingulate (aMCC) and anterior insula (AI) for affective sharing and the bilateral temporoparietal junction (TPJ) for the cognitive processes, but the integrity of these systems in patients with schizophrenia remains uncertain. METHODS: Patients with schizophrenia and healthy controls performed a pain empathy task while undergoing fMRI scanning. Participants observed pictures of hands in either painful or nonpainful situations and rated the level of pain while imagining either themselves (self) or an unknown person (other) in these situations. RESULTS: We included 27 patients with schizophrenia and 21 healthy controls in our analyses. For the pain versus no pain contrast, patients showed overall typical activation patterns in the aMCC and AI, with only a small part of the aMCC showing reduced activation compared with controls. For the other versus self contrast, patients showed an abnormal modulation of activation in the TPJ bilaterally (extending to the posterior superior temporal sulcus, referred to as the TPJ/pSTS). LIMITATIONS: The design included an unnecessary manipulation of the visual perspective that reduced the number of trials for analysis. The sample size may not account for the heterogeneity of schizophrenia. CONCLUSION: People with schizophrenia showed relatively intact brain activation when observing others' pain, but showed abnormalities when asked to take the cognitive perspectives of others.

Empathy in paediatric intensive care nurses part 1: Behavioural and psychological correlates.

AIM: To determine if differences exist between paediatric intensive care nurses and allied health professionals in empathy, secondary trauma, burnout, pain exposure and pain ratings of self and others. Early and late career differences were also examined. BACKGROUND: Nurses are routinely exposed to patient pain expression. This work context may make them vulnerable to adverse outcomes such as desensitization to patient pain or a compromise in personal well-being. DESIGN: Cross-sectional study. METHODS: Data were collected from a convenience sample of paediatric intensive care nurses (n = 27) and allied health professionals (n = 24), from September 2014-June 2015, at a Canadian health centre. Both groups completed one demographic and three behavioural scales. Participants underwent fMRI while rating the pain of infant and adult patients in a series of video clips. Data were analyzed using parametric and non-parametric methods. fMRI results are reported in a second paper. RESULTS: Nurses were significantly more likely to be exposed to pain at work than allied health professionals and scored significantly higher on dimensions of empathy, secondary trauma and burnout. Nurses scored their own pain and the pain of infant and adult patients, higher than allied health participants. Less experienced nurses had higher secondary trauma and burnout scores than more experienced nurses. CONCLUSIONS: Paediatric intensive care work demands, such as patient pain exposure, may be associated with nurse's higher report of empathy and pain in self and others, but also with higher levels of secondary trauma and burnout, when compared with allied health professionals.

Empathy in paediatric intensive care nurses part 2: Neural correlates.

AIMS: To determine if there are brain activity differences between paediatric intensive care nurses and allied health professionals during pain intensity rating tasks and test whether these differences are related to the population observed (infant or adult) and professional experience. BACKGROUND: The underestimation of patients' pain by healthcare professionals has generally been associated with patterns of change in neural response to vicarious pain, notably reduced activation in regions associated with affective sharing and increased activation in regions associated with regulation, compared with controls. Paediatric nurses, however, have recently been found to provide higher estimates of infants' pain in comparison to allied health controls, suggesting that changes in neural response of this population might be different than other health professionals. DESIGN: Cross-sectional study. METHODS: Functional MRI data were acquired from September 2014-June 2015 and used to compare changes in brain activity in 27 female paediatric care nurses and 24 allied health professionals while rating the pain of infants and adults in a series of video clips. RESULTS: Paediatric nurses rated infant and adult pain higher than allied health professionals, but the two groups' neural response only differed during observation of infant pain; paediatric nurses mainly showed significantly less activation in the medial prefrontal cortex (linked to cognitive empathy) and in the left anterior insula and inferior frontal cortex (linked to affective sharing). CONCLUSIONS: Patterns of neural activity to vicarious pain may vary across healthcare professions and patient populations and the amount of professional experience might explain part of these differences.

Anodal transcranial direct current stimulation enhances the effects of motor imagery training in a finger tapping task.

Motor imagery (MI) training and anodal transcranial direct current stimulation (tDCS) applied over the primary motor cortex can independently improve hand motor function. The main objective of this double-blind, sham-controlled study was to examine whether anodal tDCS over the primary motor cortex could enhance the effects of MI training on the learning of a finger tapping sequence. Thirty-six right-handed young human adults were assigned to one of three groups: (i) who performed MI training combined with anodal tDCS applied over the primary motor cortex; (ii) who performed MI training combined with sham tDCS; and (iii) who received tDCS while reading a book. The MI training consisted of mentally rehearsing an eight-item complex finger sequence for 13 min. Before (Pre-test), immediately after (Post-test 1), and at 90 min after (Post-test 2) MI training, the participants physically repeated the sequence as fast and as accurately as possible. An anova showed that the number of sequences correctly performed significantly increased between Pre-test and Post-test 1 and remained stable at Post-test 2 in the three groups (P < 0.001). Furthermore, the percentage increase in performance between Pre-test and Post-test 1 and Post-test 2 was significantly greater in the group that performed MI training combined with anodal tDCS compared with the other two groups (P < 0.05). As a potential physiological explanation, the synaptic strength within the primary motor cortex could have been reinforced by the association of MI training and tDCS compared with MI training alone and tDCS alone.

Repeated exposure to vicarious pain alters electrocortical processing of pain expressions.

Repeated exposure to others in pain has been shown to bias vicarious pain perception, but the neural correlates of this effect are currently not known. The current study therefore aimed at measuring electrocortical responses to facial expressions of pain following exposure to expressions of pain. To this end, a between-subject design was adopted. Participants in the Exposure group were exposed to facial expressions of intense pain, while the participants in the Control group were exposed to neutral expressions before performing the same pain detection task. As in previous studies, participants in the Exposure group showed a significantly more conservative bias when judging facial expressions pain, meaning that they were less inclined to judge moderate pain expressions as painful compared to participants in the Control group. Event-related potential analyses in response to pain or neutral expressions indicated that this effect was related to a relative decrease in the central late positive potential responses to pain expressions. Furthermore, while the early N170 response was not influenced by repeated exposure to pain expressions, the P100 component showed an adaptation effect in the Control group only. These results suggest that repeated exposure to vicarious pain do not influence early event-related potential responses to pain expressions but decreases the late central positive potential. These results are discussed in terms of changes in the perceived saliency of pain expressions following repeated exposure.

Real-time modulation of visual feedback on human full-body movements in a virtual mirror: development and proof-of-concept.

BACKGROUND: Virtual reality (VR) provides interactive multimodal sensory stimuli and biofeedback, and can be a powerful tool for physical and cognitive rehabilitation. However, existing systems have generally not implemented realistic full-body avatars and/or a scaling of visual movement feedback. We developed a "virtual mirror" that displays a realistic full-body avatar that responds to full-body movements in all movement planes in real-time, and that allows for the scaling of visual feedback on movements in real-time. The primary objective of this proof-of-concept study was to assess the ability of healthy subjects to detect scaled feedback on trunk flexion movements. METHODS: The "virtual mirror" was developed by integrating motion capture, virtual reality and projection systems. A protocol was developed to provide both augmented and reduced feedback on trunk flexion movements while sitting and standing. The task required reliance on both visual and proprioceptive feedback. The ability to detect scaled feedback was assessed in healthy subjects (n = 10) using a two-alternative forced choice paradigm. Additionally, immersion in the VR environment and task adherence (flexion angles, velocity, and fluency) were assessed. RESULTS: The ability to detect scaled feedback could be modelled using a sigmoid curve with a high goodness of fit (R2 range 89-98%). The point of subjective equivalence was not significantly different from 0 (i.e. not shifted), indicating an unbiased perception. The just noticeable difference was 0.035 ± 0.007, indicating that subjects were able to discriminate different scaling levels consistently. VR immersion was reported to be good, despite some perceived delays between movements and VR projections. Movement kinematic analysis confirmed task adherence. CONCLUSIONS: The new "virtual mirror" extends existing VR systems for motor and pain rehabilitation by enabling the use of realistic full-body avatars and scaled feedback. Proof-of-concept was demonstrated for the assessment of body perception during active movement in healthy controls. The next step will be to apply this system to assessment of body perception disturbances in patients with chronic pain.

Facial representations of complex affective states combining pain and a negative emotion.

Pain is rarely communicated alone, as it is often accompanied by emotions such as anger or sadness. Communicating these affective states involves shared representations. However, how an individual conceptually represents these combined states must first be tested. The objective of this study was to measure the interaction between pain and negative emotions on two types of facial representations of these states, namely visual (i.e., interactive virtual agents; VAs) and sensorimotor (i.e., one's production of facial configurations). Twenty-eight participants (15 women) read short written scenarios involving only pain or a combined experience of pain and a negative emotion (anger, disgust, fear, or sadness). They produced facial configurations representing these experiences on the faces of the VAs and on their face (own production or imitation of VAs). The results suggest that affective states related to a direct threat to the body (i.e., anger, disgust, and pain) share a similar facial representation, while those that present no immediate danger (i.e., fear and sadness) differ. Although visual and sensorimotor representations of these states provide congruent affective information, they are differently influenced by factors associated with the communication cycle. These findings contribute to our understanding of pain communication in different affective contexts.

Biological postural oscillations during facial expression of pain in virtual characters modulate early and late ERP components associated with empathy: A pilot study.

There is a surge in the use of virtual characters in cognitive sciences. However, their behavioural realism remains to be perfected in order to trigger more spontaneous and socially expected reactions in users. It was recently shown that biological postural oscillations (idle motion) were a key ingredient to enhance the empathic response to its facial pain expression. The objective of this study was to examine, using electroencephalography, whether idle motion would modulate the neural response associated with empathy when viewing a pain-expressing virtual character. Twenty healthy young adults were shown video clips of a virtual character displaying a facial expression of pain while its body was either static (Still condition) or animated with pre-recorded human postural oscillations (Idle condition). Participants rated the virtual human's facial expression of pain as significantly more intense in the Idle condition compared to the Still condition. Both the early (N2-N3) and the late (rLPP) event-related potentials (ERPs) associated with distinct dimensions of empathy, affective resonance and perspective-taking, respectively, were greater in the Idle condition compared to the Still condition. These findings confirm the potential of idle motion to increase empathy for pain expressed by virtual characters. They are discussed in line with contemporary empathy models in relation to human-machine interactions.

Dispositional empathy modulates vicarious effects of dynamic pain expressions on spinal nociception, facial responses and acute pain.

Pain communication is thought to promote automatic vicarious self-protective responses as well as empathic concern towards others' suffering. This duality was recently highlighted in a study showing that highly empathic individuals display increased vicarious facilitation of low-level pain processing (nociceptive flexion reflex, NFR) combined with an unexpected reduced facilitation of self-pain perception (pain ratings) while viewing static pictures evoking pain in others. The present study sought to test further the moderating effects of dispositional empathy on vicarious responses induced by viewing dynamic pain expressions. Twenty-four healthy volunteers viewed 1-s videos showing different levels of pain expression before noxious electric shocks were delivered to the sural nerve. Viewing stronger pain expressions generally increased shock-pain unpleasantness ratings, the amplitude of the NFR, and facial responses (corrugator muscle) to the noxious stimulation. However, self-pain ratings (intensity and unpleasantness) increased less or were reduced following clips of pain expression in individuals scoring higher on the Empathy Quotient. These results suggest that vicarious processes facilitate low-level defensive responses, while the experience of self-pain and the associated negative affect may be partly tuned-down by higher-order empathic processes.

Mentalizing in first-episode psychosis.

Mentalizing deficits have often been observed in people with schizophrenia and a few recent studies suggest that such deficits are also present in patients with first episode psychosis (FEP). It is not clear, however, whether these mentalizing deficits in FEP can be accounted for by underlying processes such as social cue recognition, social knowledge and general reasoning. In this study, we assessed mentalizing abilities in 31 people with FEP and 31 matched controls using a novel, comprehensive mentalizing task validated through the present study. We also assessed social cue recognition, social knowledge and non-social (or general) reasoning performance in the same participants in order to determine if the mentalizing deficits in FEP can be at least partly explained by performance in these three underlying processes. Overall, the mentalizing task revealed the greatest impairment in FEP, an impairment that remained significant even after controlling for social cue recognition, social knowledge and non-social reasoning performance. Interestingly, non-social reasoning and social knowledge were both shown to contribute to mentalizing performance. In addition, social cognition measures were linked to social functioning in the FEP group, with the strongest correlation observed with mentalizing performance. Taken together, these results show that mentalizing is an aspect of social cognition that is particularly affected in FEP and might contribute to functional impairments in these patients. These deficits could be a prime target for cognitive remediation in FEP, and our results suggest that this could be done either directly or through improvement of related social and non-social cognitive skills such as social knowledge and general reasoning.

Clients in Simulated Teletherapy via Videoconference Compensate for Altered Eye Contact When Evaluating Therapist Empathy.

Eye contact is frequently associated with an increased perception of empathy and telepresence, but the currently used videoconferencing (VC) technologies diminish the possibility of naturally conveying eye contact. This study compared the empathy, telepresence, and eye gaze patterns of clients in simulated VC teletherapy sessions where eye contact was altered or facilitated. Forty-two would-be clients met with one of four therapists in training for one 20-min simulated teletherapy session taking place via VC. The session either altered or facilitated eye contact perception by manipulating the positioning of the webcams and of the clients in their chair. Eye-tracking data focusing on the eyes, face, and general body regions of interest were obtained for 25 clients. The results show that facilitating eye contact in VC did not increase the clients' perceptions of empathy or telepresence. However, empathy was associated with greater time spent looking at the eyes and faces of the therapists, but only in the sessions facilitating eye contact. We suggest that clients successfully rely on other verbal and nonverbal cues to detect therapist empathy when eye contact is altered in teletherapy sessions.

Modulation of the response to a somatosensory stimulation of the hand during the observation of manual actions.

Observation of hand movements has been repeatedly demonstrated to increase the excitability of the motor cortical representation of the hand. Little attention, however, has been devoted to its effect on somatosensory processing. Movement execution is well known to decrease somatosensory cortical excitability, a phenomenon termed 'gating'. As executed and observed actions share common cortical representations, we hypothesized that action observation (hand movements) should also modulate the cortical response to sensory stimulation of the hand. Seventeen healthy subjects participated in these experiments in which electroencephalographic (EEG) recordings of the somatosensory steady-state response (SSSR) were obtained. The SSSR provides a continuous measure of somatosensory processing. Recordings were made during a baseline condition and five observation conditions in which videos showed either a: (1) hand action; (2) passive stimulation of a hand; (3) static hand; (4) foot action; or (5) static object. The method employed consisted of applying a continuous 25 Hz vibratory stimulation to the index finger during the six conditions and measuring potential gating effects in the SSSR within the 25 Hz band (corresponding to the stimulation frequency). A significant effect of condition was found over the contralateral parietal cortex. Observation of hand actions resulted in a significant gating effect when compared to baseline (average gating of 22%). Observation of passive touch of the hand also gated the response (17% decrease). In conclusion, the results show that viewing a hand performing an action or being touched interferes with the processing of somatosensory information arising from the hand.

Assessment of empathy in first-episode psychosis and meta-analytic comparison with previous studies in schizophrenia.

Empathy is a multidimensional construct that relies on affective and cognitive component processes. A few studies have reported impairments of both cognitive and affective empathy components in patients with schizophrenia. It is, however, not known whether these difficulties are already present at psychosis onset. The affective and cognitive components of empathy were thus assessed in 31 patients with first-episode psychosis (FEP) and 31 matched healthy controls using the Interpersonal Reactivity Index (IRI). Our results were then compared to previous studies of empathy in patients with more chronic schizophrenia via a meta-analysis. In addition, we also assessed the relationship between empathy ratings, Mentalizing performance and clinical symptoms. Contrary to what has been reported in people with more chronic schizophrenia, the IRI ratings did not significantly differ between FEP and controls in our study, though a trend was observed for the Personal distress scale. For the Perspective taking scale, our meta-analysis revealed a significantly lower effect size in this study with FEP patients relative to previous schizophrenia studies. In the FEP group, the IRI ratings were not related to positive, negative or general psychopathology symptoms, but a significant relationship emerged between the Liebowitz Social Anxiety Scale and Perspective taking (negative correlation). In addition, a significant positive correlation was observed between the Empathic concern subscale and our theory of mind task. This study supports the idea that the cognitive component of empathy is less affected in patients with first-episode psychosis relative to patients with more chronic schizophrenia, and the impairments reported in previous reports with more chronic populations should be interpreted in light of a possible deterioration of this cognitive skill. The findings also provide some insight into the relationship between empathy and clinical symptoms such as social anxiety.

The study of social cognition with neuroimaging methods as a means to explore future directions of deficit evaluation in schizophrenia?

This article discusses the important advances in a recent field of science dealing with the brain processes implicated in understanding social situations and interacting with others. Many behavioral studies on schizophrenia have shown the impairment of these processes and their preferential relation with disorganization and negative syndromes. Brain imaging is a powerful method to identify brain systems participating in these processes in healthy subjects and will be used increasingly to study mental disorders such as schizophrenia. A few preliminary studies have opened this field of research and allowed for the drawing of some limited conclusions. We emphasize the importance of developing an integrated neurocognitive framework to account for the multifaceted nature of social cognition deficits in schizophrenia. Inspired by contemporary models of empathy and social cognition that identify different components such as shared representation, mentalizing, self/other distinction, we show how schizophrenia affects these components at the behavioral and functional levels. We also outline the interest of this model to understand putative abnormalities of contextual integration within the area of mentalization. Finally, we discuss how specialized measures of brain functions during the performance of these precisely defined mental processes might be used as outcome predictors.

Decreasing phantom limb pain through observation of action and imagery: a case series.

BACKGROUND: Phantom limb pain is often resistant to treatment. Techniques based on visual-kinesthetic feedback could help reduce it. OBJECTIVE: The objective of the current study was to test if a novel intervention combining observation and imagination of movements can reduce phantom limb pain. METHODS: This single-case multiple baseline study included six persons with upper or lower limb phantom pain. Participants' pain and imagery abilities were assessed by questionnaires. After a 3-5-week baseline, participants received a two-step intervention of 8 weeks. Intervention 1 was conducted at the laboratory with a therapist (two sessions/week) and at home (three sessions/week); and Intervention 2 was conducted at home only (five times/week). Interventions combined observation and imagination of missing limb movements. Participants rated their pain level and their ease to imagine daily throughout the study. RESULTS: Time series analyses showed that three participants rated their pain gradually and significantly lower during Intervention 1. During Intervention 2, additional changes in pain slopes were not significant. Four participants reported a reduction of pain greater than 30% from baseline to the end of Intervention 2, and only one maintained his gains after 6 months. Group analyses confirmed that average pain levels were lower after intervention than at baseline and had returned to baseline after 6 months. Social support, degree of functionality, and perception of control about their lives prior to the intervention correlated significantly with pain reduction. CONCLUSIONS: Persons with phantom limb pain may benefit from this novel intervention combining observation and motor imagery. Additional studies are needed to confirm our findings, elucidate mechanisms, and identify patients likely to respond.