Is mirror therapy associated with progressive muscle relaxation more effective than mirror therapy alone in reducing phantom limb pain in patients with lower limb amputation?

Mirror therapy is a widely used treatment for phantom limb pain (PLP) relief in patients with limb loss. Less common is progressive muscle relaxation (PMR), used mostly in other medical conditions (psychological, terminal cancer pain, etc). The purpose of this study is to evaluate the efficacy of a mirror therapy preceded by PMR intervention compared to mirror therapy preceded by unguided generic relaxation-mirror therapy in patients with lower limb amputation suffering from PLP. This pilot study was a single-blind, controlled, randomized trial. Thirty lower limb amputees suffering from PLP were recruited and randomly assigned to three groups respectively undergoing a PMR-mirror therapy rehabilitative intervention, generic relaxation-mirror therapy, and conventional physiotherapy (ConvPT). Selected items from Prosthesis Evaluation Questionnaire (PEQ) and the Brief Pain Inventory (BPI) were used to test the pain features at the beginning and 1 week after 3 weeks of intervention. A decrease of about 65% was found in the rate and duration of PLP at the PEQ in PMR-mirror therapy with respect to generic relaxation-mirror therapy (about 30%) and ConvPT (about 6%). A decrease of about 90% in intensity (worst and average) of PLP in PMR-mirror therapy when compared to generic relaxation-mirror therapy (about 45%) and ConvPT (about 20%) was found at the BPI. We preliminary concluded, albeit with limitations due to the small sample of patients, that mirror therapy can improve PLP when associated with PMR. Further studies are required to confirm that PMR could be an effective technique for more successful PLP management.

A review of user needs to drive the development of lower limb prostheses.

BACKGROUND: The development of bionic legs has seen substantial improvements in the past years but people with lower-limb amputation still suffer from impairments in mobility (e.g., altered balance and gait control) due to significant limitations of the contemporary prostheses. Approaching the problem from a human-centered perspective by focusing on user-specific needs can allow identifying critical improvements that can increase the quality of life. While there are several reviews of user needs regarding upper limb prostheses, a comprehensive summary of such needs for those affected by lower limb loss does not exist. METHODS: We have conducted a systematic review of the literature to extract important needs of the users of lower-limb prostheses. The review included 56 articles in which a need (desire, wish) was reported explicitly by the recruited people with lower limb amputation (N = 8149). RESULTS: An exhaustive list of user needs was collected and subdivided into functional, psychological, cognitive, ergonomics, and other domain. Where appropriate, we have also briefly discussed the developments in prosthetic devices that are related to or could have an impact on those needs. In summary, the users would like to lead an independent life and reintegrate into society by coming back to work and participating in social and leisure activities. Efficient, versatile, and stable gait, but also support to other activities (e.g., sit to stand), contribute to safety and confidence, while appearance and comfort are important for the body image. However, the relation between specific needs, objective measures of performance, and overall satisfaction and quality of life is still an open question. CONCLUSIONS: Identifying user needs is a critical step for the development of new generation lower limb prostheses that aim to improve the quality of life of their users. However, this is not a simple task, as the needs interact with each other and depend on multiple factors (e.g., mobility level, age, gender), while evolving in time with the use of the device. Hence, novel assessment methods are required that can evaluate the impact of the system from a holistic perspective, capturing objective outcomes but also overall user experience and satisfaction in the relevant environment (daily life).

Effectiveness of graded motor imagery protocol in phantom limb pain in amputed patient: Protocol of a randomized clinical trial.

OBJECTIVE: The aim of this study is to analyse the effectiveness of the Graded Motor Imagery (GraMI) protocol in phantom limb pain in amputee patients. MATERIALS AND METHODS: A randomised clinical trial will be conducted, with two parallel groups and simple blinding, and a phenomenological study with semi-structured interviews. People over the age of 18, with amputation of one limb, with a minimum score of 3 on the visual analogue scale of pain, who are pharmacologically stable and have been discharged from hospital, will be recruited. An initial assessment, a post-intervention assessment (9 weeks) and a follow-up assessment (12 weeks post-intervention) will be performed, in which pain, quality of life, functionality and psychological aspects will be assessed. The aim of the qualitative study is to find out about the experience of living with phantom limb pain and to identify the satisfaction with the intervention. A descriptive, univariate and bivariate quantitative statistical analysis will be performed using the SPSS program, with a 95% confidence level and a statistical significance level of p < 0.05. The qualitative analysis will be carried out using the Atlas.ti 8.0 program, where the different interviews will be analysed, coded and categorised. DISCUSSION: The GraMI protocol allows the patient to work on motor learning through brain reorganisation, analytical movements, sensory stimulation, and functional activities. In addition, it can help to standardise the use of graded motor imagery in future studies and in clinical practice with this patient profile. TRIAL REGISTRATION: NCT05083611.

Association Between Changes in Subjective and Objective Measures of Mobility in People With Lower Limb Amputations After Inpatient Rehabilitation.

Functional recovery for people with lower limb amputations is quantified using objective or subjective measures of performance. In this brief report, the prospective relationship between objective and subjective mobility after rehabilitation was evaluated in people with lower limb amputations. Adults undergoing inpatient prosthetic rehabilitation for a first unilateral transtibial or transfemoral level lower limb amputation were recruited. Assessment times: discharge and 4-mo follow-up. Gait velocity and the L Test under single- and dual-task conditions measured objective mobility. The Prosthetic Evaluation Questionnaire (section 4 and question 5b) measured subjective mobility. Paired t tests and Pearson correlation analysis evaluated change over time and the association between mobility types, respectively. Twenty-one people with lower limb amputations (61.6 ± 8.2 yrs) participated. Gait velocity significantly improved (single- and dual-task: P < 0.001). L Test significantly improved for single-task (P = 0.002) but not dual-task conditions. No statistically significant Prosthetic Evaluation Questionnaire changes were observed. One subjective mobility question (sidewalk walking) correlated with objective mobility at follow-up (L Test single- and dual-task: r = -0.77; P < 0.001). Objective mobility improved after discharge; however, subjective reporting had no change. Lack of association may represent a mismatch between quantitative outcomes and subjective self-assessment. Both subjective and objective measures of mobility should be collected to provide a holistic picture of clinical and patient-relevant outcomes in people with lower limb amputations.

Motor imagery ability of patients with lower-limb amputation: exploring the course of rehabilitation effects.

BACKGROUND: Amputation of a lower-limb results in a severe decrease of functional mobility that deeply alters independent living. Motor imagery (MI) refers to the mental representation of an action without engaging its actual execution. The repetitive use of MI has been shown to contribute to promote motor recovery and phantom-limb pain alleviation. AIM: Given the importance of invoking accurate images to benefit from MI practice, and considering the link between motor capacities and MI, the present study investigated the effect of a rehabilitation program on MI ability in patients with lower-limb amputation. DESIGN: Observational and longitudinal study. SETTING: Patients recruited from the Amputation program at the Institut de Réadaptation en Déficience Physique de Québec (IRDPQ), in Quebec City, Canada. POPULATION: Patients with trans-tibial or transfemoral amputation, following a rehabilitation program as outpatients. METHODS: MI ability of the patients was measured at three different time points along the course of physical therapy. RESULTS: The data revealed a positive effect of the rehabilitation program on MI accuracy of locomotor tasks, and greater MI vividness and accuracy for single-joint movements that patients were still able to physically perform. CONCLUSIONS: These findings suggest that MI abilities and actual motor performance are mirrored in a congruent fashion. CLINICAL REHABILITATION IMPACT: Therapists should consider this critical aspect when including MI practice in rehabilitation programs among patients with lower-limb amputation.

Arte reabilitação em mulheres amputadas utilizando o mito de Pandora como recurso facilitador de autoestima e qualidade de vida / Art rehabilitation in amputee women with Pandora's myth as a self-esteem and quality of life facilitator resource

A amputação é um evento traumático que repercute intensamente na vida da pessoa acometida. A dificuldade em lidar com a nova realidade pode contribuir negativamente para a autoestima e reabilitação do indivíduo, afetando a sua qualidade de vida. A Arteterapia por meio dos recursos expressivos pode ser um canal facilitador e promotor de aspectos resilientes para a superação do trauma. Objetivo: Averiguar a influência da Arteterapia na autoestima e qualidade de vida em mulheres amputadas. Grupo formado por 8 mulheres amputadas, entre 35 a 65 anos. Método: Divididos em 2 grupos (4 indivíduos no grupo de intervenção e 4 indivíduos no grupo controle). Instrumentos de avaliação: WHOQOL- Bref (World Health Organization Quality of Life), Escala de Autoestima Rosemberg (EAR), o Desenho da Figura Humana e Relatos das Participantes. As atividades foram desenvolvidas com base no mito de Pandora, em 11 oficinas arteterapêuticas com 1 hora de duração, uma vez por semana no setor de Arte-Reabilitação, AACD ­ Ibirapuera, São Paulo. Resultados: Estatisticamente não foram observadas diferenças significantes entre os momentos inicial e final para os domínios de Whoqol Bref e EAR, em ambos os grupos; porém, o grupo intervenção apresenta um movimento de melhora na autoestima, especialmente no quesito autodepreciação. Qualitativamente foram observadas através do discurso das participantes melhorias de autoestima e possibilidade de melhoria na qualidade de vida das participantes. Conclusão: A arteterapia, junto com a equipe interdisciplinar, pode contribuir positivamente para o processo de reabilitação em mulheres amputadas ajudando a promover a autoestima e qualidade de vida.

Amputation is a traumatic event that has serious repercussions on the amputee's life. The difficulty in dealing with the new reality can contribute negatively to self-esteem and rehabilitation, affecting the patient's quality of life. The Art therapy, through its expressive resources, can be a facilitator and provide resilience to overcoming the trauma. Objective: The objective of this study is to investigate the influence of art therapy in self-esteem and quality of life in amputee women. Methods: A group of 8 amputees, aged 35-65 years were divided into 2 groups (4 in the experimental group and 4 in the control group). They were evaluated with the WHOQoL-Bref (World Health Organization Quality of Life), Rosenberg Self-Esteem Scale (RSE), Human Figure Drawing test and the participants' own Reports. The activities, based on the Pandora myth, were developed in 11 art therapy workshops sessions of one hour that were carried out once a week in the Art-Rehabilitation sector off AACD ­ Ibirapuera, São Paulo. Results: There was no statistically significant differences observed between the initial and final assessments of quality of life (WHOQoL-Bref) and RSE domains of both groups, however, the experimental group evidenced a tendency towards the improvement of self-esteem, especially in regards of self-depreciation. Qualitatively, improvements of self-esteem and the possibility of improving the participants' quality of life were also observed. Conclusion: Art Therapy, combined with interdisciplinary care, can contribute positively to the rehabilitation process of amputee women, by helping to promote better self-esteem and quality of life.

Motor sequence learning and intermanual transfer with a phantom limb.

Amputees with phantom limb sometimes report vivid experiences of moving their phantom. Is phantom movement only "imaginary", or, instead, it has physiological properties comparable to those pertaining to real movements? To answer this question, we took advantage of the intermanual transfer of sequence learning, occurring when one hand motor skills improve after training with the other hand. Ten healthy controls and two upper-limb amputees (with and without phantom-movement) were recruited. They were asked to perform with the right (intact) hand a fingers-thumb opposition sequence either in Naïve condition or after an active (Real condition) or a mental (Imagery condition) training with the left (phantom) hand. In healthy controls, the results showed different effects after active training (i.e., faster movement duration (MD) with stable accuracy) and after mental training (i.e., increased accuracy with stable MD). Opposite results between moving-phantom case and static-phantom case were found. In the Real condition, after an "active" training with her phantom hand, the moving-phantom case showed a faster performance of the intact hand. This transfer effect was not different from that found in healthy controls, actually performing the active training with an existing hand (Real condition), but, crucially, it was significantly different from both Imagery and Naïve conditions of controls. Contrariwise, in the static phantom case, the performance during the Real condition was significantly different from the Real condition of healthy controls and it was not significantly different from their Imagery and Naïve conditions. Importantly, a significant difference was found when the transfer effect in Real condition was compared between the two phantom cases. Taken together, these findings provide the first evidence that a phantom limb can learn motor skills and transfer them to the intact limb.

Mobility Analysis of AmpuTees (MAAT I): Quality of life and satisfaction are strongly related to mobility for patients with a lower limb prosthesis.

BACKGROUND: While rehabilitation professionals are historically trained to place emphasis on the restoration of mobility following lower limb amputation, changes in healthcare dynamics are placing an increased emphasis on the limb loss patient's quality of life and general satisfaction. Thus, the relationship between these constructs and mobility in the patient with lower limb loss warrants further investigation. OBJECTIVES: To determine the relationship between mobility of the patient with lower limb loss and both (1) general satisfaction and (2) quality of life. STUDY DESIGN: Retrospective chart analysis. METHODS: A retrospective chart review of the Prosthetic Limb Users Survey of Mobility and the Prosthesis Evaluation Questionnaire-Well-Being subsection. Pearson correlations were used to test relationships. RESULTS: Data from 509 patients with a lower limb prosthesis were included. Mobility was found to be positively correlated with quality of life ( r = 0.511, p < 0.001, 95% confidence interval (0.443, 0.569)) and general satisfaction ( r = 0.475, p < 0.001, 95% confidence interval (0.403, 0.542)), as well as their arithmetic mean (i.e. Prosthesis Evaluation Questionnaire-Well-Being) ( r = 0.533, p < 0.001, 95% confidence interval (0.466, 0.592)). CONCLUSION: This study provides evidence of a strong positive correlation between mobility and both quality of life and general satisfaction. Thus, in the holistic care of a patient with lower limb loss, maximizing mobility would correlate with greater quality of life and general satisfaction. Clinical relevance There is growing emphasis on the quality of life and general satisfaction experienced by patients undergoing prosthetic rehabilitation. The results of this study underscore the importance of providing prosthetic rehabilitation that maximizes the patient's mobility, noting that these individuals also report greater quality of life and general satisfaction.

Psychological and Physical Health in Military Amputees During Rehabilitation: Secondary Analysis of a Randomized Controlled Trial.

BACKGROUND: Service members who have experienced combat trauma with resulting amputation are at risk for compromised quality of life postamputation. Monitoring mental and physical health in amputees returning from the war is of paramount importance. This study examined changes in physical and mental health-related quality of life in service members following traumatic unilateral, transtibial amputation (TTA) during a 12-week period of rehabilitation before and after receiving a prosthesis. METHOD: This study is a secondary analysis from a randomized controlled trial (RCT) of military service members starting Military Amputee Rehabilitation Program (MARP) following a traumatic TTA. The study examined change in SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores as two aspects of health-related quality of life. Forty-four injured service members, aged 19 to 46, were recruited into the RCT. Participants were randomized into 12 weeks of MARP plus home neuromuscular electrical stimulation therapy (n = 23) or MARP alone (N = 21) and compared at baseline, 6, and 12 weeks on: SF-36 PCS and MCS scores. Linear mixed models examined time and group differences and their interaction for the MCS and PCS scores. A multivariate mixed model tested whether MCS and PCS scores differed. RESULTS: For the combined rehabilitation cohort, MCS did not differ over 12 weeks (p = 0.27) with scores at week 0 of M = 56.7 (SD = 11.9) and at week 12 of M = 52.7 (SD = 11.4), similar to healthy controls (age = 25-34, M = 51.0, SD = 7.6). Scores did not differ between treatment groups (p = 0.28) with no group by time interaction (p = 0.34). The MCS significantly declined over time (p = 0.05) after adjustment for covariates. PCS improved over 12 weeks (p < 0.0001) in the total rehabilitation group with scores at week 0 of M = 34.0 (SD = 8.1) to M = 41.8 (SD = 8.4) at week 12, significantly lower than healthy controls (age = 25-34, M = 54.1, SD = 6.6). Scores did not differ between treatment groups (p = 0.89), and there was no group by time interaction (p = 0.34). An interaction between the PCS and MCS was observed such that the PCS improved over time, whereas the MCS did not significantly change (p = 0.0005). DISCUSSION: War-injured transtibial amputees are at risk for compromised quality of life during rehabilitation. Self-perceived physical health improved as might be expected from rehabilitation. Self-perceived mental health did not. During rehabilitation, physical healing, psychological adjustment, and lifestyle adaptation are occurring simultaneously. However, more attention may need to be directed toward mental health during rehabilitation.

Osseointegration for Lower-Limb Amputation: A Systematic Review of Clinical Outcomes.

BACKGROUND: Traditional socket prostheses are not a viable option for all lower-limb prosthetic users. Discomfort, pain in the residual limb, and problems related to the fit of the socket are common and have been shown to negatively impact quality of life and mobility. Osseointegrated or bone-anchored prosthetic implants have evolved over the past 2 decades as a promising alternative for patients who are experiencing substantial issues with socket prostheses. METHODS: A review of the literature was performed to identify studies focusing on the evolution, clinical outcomes, success rates, and complications of osseointegrated lower-limb prostheses. Articles were summarized according to the implant type, amputation level, and study characteristics, with rating of the Level of Evidence. Information on patient selection criteria, outcomes, and complications was extracted. RESULTS: Fourteen articles (with Level-II, III, or IV evidence) met the inclusion criteria. Infection and soft-tissue irritation at the stoma were the most common complications. It is evident that, over the years, changes in implant design, surgical technique, perioperative and postoperative care, and rehabilitation protocols have resulted in improvements in functional outcomes and health-related quality of life, and reduction in rates of complications. CONCLUSIONS: Osseointegration for limb amputation has become an established clinical treatment option for persons with lower-limb amputation not tolerating traditional socket prostheses. Osseointegration could provide substantial benefits regarding function and quality of life for appropriately selected patients who accept the documented risks. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

[Psychotherapies for the Treatment of Phantom Limb Pain]. / Uso de psicoterapias como tratamiento del dolor de miembro fantasma.

INTRODUCTION: The phantom limb pain has been described as a condition in which patients experience a feeling of itching, spasm or pain in a limb or body part that has been previously amputated. Such pain can be induced by a conflict between the representation of the visual and proprioceptive feedback of the previously healthy limb. The phantom limb pain occurs in at least 42 to 90% of amputees. Regular drug treatment of phantom limb pain is almost never effective. METHODS: A systematic review of the literature was conducted in Medline and Cochrane using the MESH terms "phantom limb pain" and "psychotherapy", published in the last 10 years, in English and Spanish, finding 49 items. After reviewing the abstracts, 25 articles were excluded for not being related to the objective of the research. Additionally cross references of included articles and literature were reviewed. OBJECTIVES: To describe the psychotherapies used in the management of phantom limb pain, their effectiveness and clinical application reported in the literature. AIMS: The mechanisms underlying phantom limb pain were initially explained, as were the published studies on the usefulness of some psychotherapies such as mirror visual feedback and immersive virtual reality, visual imagery, desensitization and reprocessing eye movements and hypnosis. CONCLUSIONS: The phantom limb pain is a complex syndrome that requires pharmacological and psychotherapeutic intervention. The psychotherapies that have been used the most as adjuvants in the treatment of phantom limb pain are mirror visual feedback, desensitization and reprocessing eye movements, imagery and hypnosis. Studies with more representative samples, specifically randomized trials are required.

Non-pharmacological conservative therapy for phantom limb pain: A systematic review of randomized controlled trials.

The aim of this manuscript was to investigate the effectiveness of conservative therapy for phantom limb pain (PLP). In this systematic review, CINAHL, AMED, the Cochrane database of systematic reviews, PEDro, psychology and behavioral sciences collection, and MEDLINE were systematically searched for appropriate randomized controlled trials (RCTs). Selected papers were assessed for risk of bias, and evidence was graded using the GRADE approach. Twelve RCTs met initial inclusion/exclusion criteria, of which five were of sufficient quality for final inclusion. There is conflicting evidence from two RCTs for the effectiveness of electromagnetic shielding limb liners on pain in the short term. There is limited evidence supporting the effectiveness of both hypnosis in the short term and graded motor imagery (GMI) in the short-to-medium term. Additionally, there is limited evidence that a single session of mirror therapy has no immediate effect on PLP. Limb liner discomfort was the only adverse effect identified. This review identifies a range of conservative therapies, many of which demonstrate preliminary evidence of potential with respect to clinically worthwhile effects above control interventions and few, if any, adverse effects. However, there is a paucity of high-quality evidence upon which to make any firm clinical conclusions.

Suffering of Traumatic Amputees in Spain: Meaning, Spirituality, and Biomedicine.

Amputation is a traumatic incident that entails a chain of psychological, physical, and social events. The objectives of the study are to describe the beliefs and the philosophies of life related to the experience of suffering of traumatic amputees, analyze the importance of biomedical care, and describe other forms of care used.

Acupuncture for the treatment of phantom limb syndrome in lower limb amputees: a randomised controlled feasibility study.

BACKGROUND: Post amputation, the complication of phantom limb pain (PLP) is prevalent and difficult to manage. This study aimed to determine whether it was feasible and acceptable to undertake a definitive multicentred randomised controlled trial assessing the effectiveness of acupuncture for treating lower limb amputees with PLP. METHODS: A mixed-methods embedded design, including a randomised controlled trial and semistructured interviews, was undertaken. A total of 15 participants with PLP were randomly assigned to receive either eight pragmatic Traditional Chinese Medicine acupuncture treatments and usual care or usual care alone over 4 weeks. Outcome measures were completed at baseline, weekly throughout the study and at 1 month post completion of the study and included: a numerical pain-rating scale, the Short-Form McGill Pain Questionnaire 2, the EQ-5D-5 L, the Hospital Anxiety and Depression Scale, the Perceived Stress Scale 10-item, the Insomnia Severity Index, and the Patient Global Impression of Change. Post completion of the trial, participants in the acupuncture group were interviewed about their experience. Feasibility-specific data were also collected. RESULTS: Of 24 amputees meeting the study inclusion criteria, 15 agreed to participate (recruitment rate 62.50 %). Qualitatively, acupuncture was perceived to be beneficial and effective. Quantitatively, acupuncture demonstrated clinically meaningful change in average pain intensity (raw change = 2.69) and worst pain intensity (raw change = 4.00). Feasibility-specific data identified that before undertaking a definitive trial, recruitment, practitioner adherence to the acupuncture protocol, completion of outcome measures at 1 month follow-up and blinding should be addressed. Appropriate outcome measures were identified for use in a definitive trial. Data were generated for future sample size calculations (effect size 0.64). Allowing for a 20 % dropout rate, a sample size of 85 participants per group would be needed in a future definitive trial. CONCLUSIONS: A future definitive trial may be possible if the areas identified in this study are addressed. As acupuncture may be effective at treating PLP, and as this feasibility study suggests that a definitive trial may be possible, a multicentred trial with adequate sample size and blinding is now needed. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02126436 , registered on 4 September 2014.

The effects of graded motor imagery and its components on phantom limb pain and disability in upper and lower limb amputees: a systematic review protocol.

BACKGROUND: Phantom limb pain (PLP) is characterized by the anatomical shifting of neighbouring somatosensory and motor areas into a deafferented cortical area of the brain contralateral to the amputated limb. It has been shown that maladaptive neuroplasticity is positively correlated to the perception of PLP in amputees. Recent studies support the use of graded motor imagery (GMI) and its component to alleviate the severity of PLP and disability. However, there is insufficient collective empirical evidence exploring the effectiveness of these treatment modalities in amputees with PLP. This systematic review will therefore explore the effects of GMI and its individual components on PLP and disability in upper and lower limb amputees. METHODS: We will utilize a customized search strategy to search PubMed, Cochrane Central register of Controlled Trials, MEDLINE, Embase, PsycINFO, PEDro, Scopus, CINAHL, LILACS, DARE, Africa-Wide Information and Web of Science. We will also look at clinicaltrials.gov ( http://www.clinicaltrials.gov/ ), Pactr.gov ( http://www.pactr.org/ ) and EU Clinical trials register ( https://www.clinicaltrialsregister.eu/ ) for ongoing research. Two independent reviewers will screen articles for methodological validity. Thereafter, data from included studies will be extracted by two independent reviewers through a customized pre-set data extraction sheet. Studies with a comparable intervention and outcome measure will be pooled for meta-analysis. Studies with high heterogeneity will be analysed through random effects model. A narrative data analysis will be considered where there is insufficient data to perform a meta-analysis. DISCUSSION: Several studies investigating the effectiveness of GMI and its different components on PLP have drawn contrasting conclusions regarding the efficacy and applicability of GMI in clinical practice. This systematic review will therefore gather and critically appraise all relevant data, to generate a substantial conclusion and recommendations for clinical practice and research on this subject. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016036471.

The effects of mirror therapy on pain and motor control of phantom limb in amputees: A systematic review.

BACKGROUND AND OBJECTIVE: Phantom limb pain (PLP) is a major problem after limb amputation. Mirror therapy (MT) is a non-pharmacological treatment using representations of movement, the efficacy of which in reducing PLP remains to be clarified. Here, we present the first systematic review on MT efficacy in PLP and phantom limb movement (PLM) in amputees (lower or upper limb). METHODS: A search on Medline, Cochrane Database and Embase, crossing the keywords "Phantom Limb" and "Mirror Therapy" found studies which were read and analyzed according the PRISMA statement. RESULTS: Twenty studies were selected, 12 on the subject of MT and PLP, 3 on MT and PLM, 5 on MT and both (PLP and PLM). Among these 20 studies, 5 were randomized controlled trials (163 patients), 6 prospective studies (55 patients), 9 case studies (40 patients) and methodologies were heterogeneous. Seventeen of the 18 studies reported the efficacy of MT on PLP, but with low levels of evidence. One randomized controlled trial did not show any significant effect of MT. As to the effect of MT on PLM, the 8 studies concerned reported effectiveness of MT: 4 with a low level of evidence and 4 with a high level of evidence. An alternative to visual illusion seems to be tactile or auditory stimulation. CONCLUSION: We cannot recommend MT as a first intention treatment in PLP. The level of evidence is insufficient. Further research is needed to assess the effect of MT on pain, prosthesis use, and body representation, and to standardize protocols.

Phantom limb perception interferes with motor imagery after unilateral upper-limb amputation.

A potential contributor to impaired motor imagery in amputees is an alteration of the body schema as a result of the presence of a phantom limb. However, the nature of the relationship between motor imagery and phantom experiences remains unknown. In this study, the influence of phantom limb perception on motor imagery was investigated using a hand mental rotation task by means of behavioral and electrophysiological measures. Compared with healthy controls, significantly prolonged response time for both the intact and missing hand were observed specifically in amputees who perceived a phantom limb during the task but not in amputees without phantom limb perception. Event-related desynchronization of EEG in the beta band (beta-ERD) in central and parietal areas showed an angular disparity specifically in amputees with phantom limb perception, with its source localized in the right inferior parietal lobule. The response time as well as the beta-ERD values were significantly positively correlated with phantom vividness. Our results suggest that phantom limb perception during the task is an important interferential factor for motor imagery after amputation and the interference might be related to a change of the body representation resulting from an unnatural posture of the phantom limb.

The effect of electromagnetic shielding on phantom limb pain: A placebo-controlled double-blind crossover trial.

BACKGROUND: Environmental electromagnetic fields influence biological systems. Evidence suggests these have a role in the experience of phantom limb pain in patients with amputations. OBJECTIVES: This article followed a previous study to investigate the effect of electromagnetic field shielding with a specially designed prosthetic liner. STUDY DESIGN: Randomised placebo-controlled double-blind crossover trial. METHODS: Twenty suitable participants with transtibial amputations, phantom pain at least 1 year with no other treatable cause or pathology were requested to record daily pain, well-being, activity and hours of prosthetic use on pre-printed diary sheets. These were issued for three 2-week periods (baseline, electromagnetic shielding (verum) and visually identical placebo liners - randomly allocated). RESULTS: Thirty-three per cent of the recruited participants were unable to complete the trial. The resulting N was therefore smaller than was necessary for adequate power. The remaining data showed that maximum pain and well-being were improved from baseline under verum but not placebo. More participants improved on all variables with verum than placebo. CONCLUSION: Electromagnetic field shielding produced beneficial effects in those participants who could tolerate the liner. It is suggested that this might be due to protection of vulnerable nerve endings from nociceptive effects of environmental electromagnetic fields. CLINICAL RELEVANCE: Electromagnetic field shielding with a suitable limb/prosthesis interface can be considered a useful technique to improve pain and well-being in patients with phantom limb pain.

The rubber foot illusion.

BACKGROUND: Lower-limb amputation causes the individual a huge functional impairment due to the lack of adequate sensory perception from the missing limb. The development of an augmenting sensory feedback device able to restore some of the missing information from the amputated limb may improve embodiment, control and acceptability of the prosthesis. FINDINGS: In this work we transferred the Rubber Hand Illusion paradigm to the lower limb. We investigated the possibility of promoting body ownership of a fake foot, in a series of experiments fashioned after the RHI using matched or mismatched (vibrotactile) stimulation. The results, collected from 19 healthy subjects, demonstrated that it is possible to elicit the perception of possessing a rubber foot when modality-matched stimulations are provided synchronously on the biological foot and to the corresponding rubber foot areas. Results also proved that it is possible to enhance the illusion even with modality-mismatched stimulation, even though illusion was lower than in case of modality-matched stimulation. CONCLUSIONS: We demonstrated the possibility of promoting a Rubber Foot Illusion with both matched and mismatched stimulation.