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.

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.