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.

Rehabilitation of high upper limb amputees after Targeted Muscle Reinnervation.

STUDY DESIGN: This is a Delphi study based on a scoping literature review. INTRODUCTION: Targeted muscle reinnervation (TMR) enables patients with high upper limb amputations to intuitively control a prosthetic arm with up to six independent control signals. Although there is a broad agreement regarding the importance of structured motor learning and prosthetic training after such nerve transfers, to date, no evidence-based protocol for rehabilitation after TMR exists. PURPOSE OF THE STUDY: We aimed at developing a structured rehabilitation protocol after TMR surgery after major upper limb amputation. The purpose of the protocol is to guide clinicians through the full rehabilitation process, from presurgical patient education to functional prosthetic training. METHODS: European clinicians and researchers working in upper limb prosthetic rehabilitation were invited to contribute to a web-based Delphi study. Within the first round, clinical experts were presented a summary of recent literature and were asked to describe the rehabilitation steps based on their own experience and scientific evidence. The second round was used to refine these steps, while the importance of each step was rated within the third round. RESULTS: Experts agreed on a rehabilitation protocol that consists of 16 steps and starts before surgery. It is based on two overarching principles, namely the necessity of multiprofessional teamwork and a careful selection and education of patients within the rehabilitation team. Among the different steps in therapy, experts rated the training with electromyographic biofeedback as the most important one. DISCUSSION: Within this study, a first rehabilitation protocol for TMR patients based on a broad experts' consensus and relevant literature could be developed. The detailed steps for rehabilitation start well before surgery and prosthetic fitting, and include relatively novel interventions as motor imagery and biofeedback. Future studies need to further investigate the clinical outcomes and thereby improve therapists' practice. CONCLUSION: Graded rehabilitation offered by a multiprofessional team is needed to enable individuals with upper limb amputations and TMR to fully benefit from prosthetic reconstruction. LEVEL OF EVIDENCE: Low.

A scoping review of current non-pharmacological treatment modalities for phantom limb pain in limb amputees.

PURPOSE: Phantom limb pain (PLP) is a chronic neuropathic pain condition of a missing limb following amputation. Pain management is multi-modal, including various non-pharmacological therapies. The purpose of this scoping review was to investigate the evidence surrounding current non-pharmacological treatment modalities for PLP and provide insight into their clinical feasibility. METHOD: A systematic search was conducted using four databases (Medline, Embase, PsychInfo, and CINAHL) following the PRISMA-ScR method. Results from papers meeting the inclusion criteria were charted to summarize findings, demographics, and use of neuroimaging. RESULTS: A total of 3387 papers were identified, and full texts of 142 eligible papers were assessed. Eleven treatment modalities for PLP were identified with varying levels of evidence. Overall, there were 25 RCTs, 58 case reports, and 59 a combination of pilot, quasi-experimental, observational, and other study designs. CONCLUSIONS: Currently, the evidence surrounding most treatment modalities is limited and only a fraction of studies are supported by strong evidence. The findings of this review demonstrated a clear need to conduct more rigorous research with diverse study designs to better understand which modalities provide the most benefit and to incorporate neuroimaging to better determine the neural correlates of PLP and mechanisms of various treatments.Implications for RehabilitationPhantom limb pain (PLP) is a prevalent and debilitating condition following amputation and health care professionals should incorporate an evidence-based pain management protocol into their rehabilitation program.There exist a number of different non-pharmacological therapies to address PLP, however the scientific rigor and levels of evidence vary across modalities.Prescription of interventions for PLP should consider individual patient differences, accessibility to the patient, and quite possibly, a multi-modal approach, particularly for those who also experience residual limb pain.Imagery-based therapies provide the highest level of current evidence based on robust and large randomized control trials, are readily accessible, and are thus most recommended for relief of PLP.

Comportamiento del dolor fantasma en pacientes amputados en Cárdenas. Periodo 2015-2019 / Phantom pain behavior in amputated patients in Cardenas. Period 2015-2019

RESUMEN Introducción: la amputación es un procedimiento quirúrgico y la incapacidad como consecuencia se puede considerar una entidad clínica. Toda respuesta a la amputación es altamente individual. Entre el 40 y 80 % de los amputados manifiestan dolor de la zona amputada o dolor de miembro fantasma. Entre todos los problemas que se pueden presentar tras la cirugía este es uno de los más graves. Objetivo: determinar el comportamiento del dolor fantasma en la población amputada en Cárdenas y la mejoría clínica de los síntomas con los diferentes tratamientos. Periodo comprendido entre 1-1-2015 al 31-12-2019. Materiales y métodos: se realizó un estudio descriptivo de corte transversal en el Hospital General "Julio Miguel Aristegui Villamil" de Cárdenas, en el período comprendido del 1-1-2015 al 31-12-2019. Con el fin de evaluar las variables clínicas y demográficas de pacientes con antecedentes de amputación unilateral de miembro y que acudieron al cuerpo de guardia y/o consultas externas de Ortopedia y Traumatología, de Angiológica y Cirugía Vascular por presentar dolor fantasma. Resultados: con respecto a la mejoría de los síntomas y del propio dolor fantasma, según la escala de evaluación del dolor (EVA), se demostró que hubo alivio muy discreto y en un 96 % de los pacientes se presentó persistencia de los mismos. Conclusiones: los resultados fueron insatisfactorios, a pesar de los tratamientos utilizados en el estudio (AU).

ABSTRACT Introduction: amputation is a surgical procedure and disability as its consequence can be considered a clinical entity. Any response to amputation is highly individual. Between 40 and 80% of amputees refer pain in the amputated area or phantom limb pain, and among all the problems that can occur after surgery, this is one of the most serious. Objective: to determine the behavior of phantom pain in the amputated population in Cárdenas from January 1st 2015 to December 31st 2019 and the clinical improvement of symptoms with the different treatments applied. Materials and methods: a descriptive cross-sectional study was conducted in the General Hospital Julio Miguel Aristegui Villamil of Cárdenas in the period from January 1st 2015 to December 31st 2019, with the aim of evaluating the clinical and demographic variables of patients with antecedents of unilateral limb amputation who attended the emergency department or outpatient Orthopedics and Traumatology, and Angiology and Vascular Surgery consultations for presenting phantom pain. Results: regarding the improvement of the symptoms and the phantom pain itself, according to the pain evaluation scale (VAS), it was shown that there was very discreet relief and its persistence in 96% of the patients. Conclusions: unsatisfactory results are observed instead of the treatments used in the study (AU).

Functional rehabilitation of a person with transfemoral amputation through guided motor imagery: a case study.

Background: Motor imagery (MI) is a mental technique, absent of physical movement, to foster movement patterns and relieve pain via a training model enacting the brain before the body. This case study assessed MI's efficacy in decreasing phantom limb pain and attaining functional gait and balance after lower extremity amputation. Description: The participant was a 71-year-old female with a transfemoral amputation seven years prior. She required a standard walker for ambulation. The participant underwent three sessions per week for four weeks of MI intervention, with immediate, post-test, and 1-week retention testing involving subjective and functional assessments. Intervention sessions involved quiet sitting with eyes closed while listening to the MI script. The scripts focused on functional movement patterns and tasks that were relevant to the participant, such as walking, balancing, and reaching. Each session's script focused on a different task. These scripts guided her through proper action and biomechanics of the skills to imagine herself moving safely and functionally. Outcomes: Short Form Berg Balance Scale and Tinetti Performance Oriented Mobility Assessment scores demonstrated clinically important and sustained improvement. Further, the participant reported decreased phantom limb pain and could walk a short distance independently for the first time in seven years. Discussion: MI is a time- and cost-effective, low-risk treatment option that decreased phantom pain and improved balance and functional gait in an individual with an amputation. The use of MI as an intervention for the rehabilitation of persons with amputation must be further examined.

Sensitivity to temporal parameters of intraneural tactile sensory feedback.

BACKGROUND: Recent studies have shown that neural stimulation can be used to provide artificial sensory feedback to amputees eliciting sensations referred on the amputated hand. The temporal properties of the neural stimulation modulate aspects of evoked sensations that can be exploited in a bidirectional hand prosthesis. METHODS: We previously collected evidence that the derivative of the amplitude of the stimulation (intra-digit temporal dynamics) allows subjects to recognize object compliance and that the time delay among stimuli injected through electrodes implanted in different nerves (inter-digit temporal distance) allows to recognize object shapes. Nevertheless, a detailed characterization of the subjects' sensitivity to variations of intra-digit temporal dynamic and inter-digit temporal distance of the intraneural tactile feedback has not been executed. An exhaustive understanding of the overall potentials and limits of intraneural stimulation to deliver sensory feedback is of paramount importance to bring this approach closer and closer to the natural situation. To this aim, here we asked two trans-radial amputees to identify stimuli with different temporal characteristics delivered to the same active site (intra-digit temporal Dynamic Recognition (DR)) or between two active sites (inter-digit Temporal distance Recognition (TR)). Finally, we compared the results achieved for (simulated) TR with conceptually similar experiments with real objects with one subject. RESULTS: We found that the subjects were able to identify stimuli with temporal differences (perceptual thresholds) larger than 0.25 s for DR and larger than 0.125 s for TR, respectively. Moreover, we also found no statistically significant differences when the subjects were asked to identify three objects during simulated 'open-loop' TR experiments or real 'closed-loop' tests while controlling robotic hand. CONCLUSIONS: This study is a new step towards a more detailed analysis of the overall potentials and limits of intraneural sensory feedback. A full characterization is necessary to develop more advanced prostheses capable of restoring all lost functions and of being perceived more as a natural limb by users.

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.

Mobilising the patient: With emphasis on innovative technologies.

Treatment of trauma patients and fractures has changed dramatically throughout the years. From conservative methods to nowadays various kinds of screws, pins, plates and nails for optimal fixation of fractures. This lead to changes in post-operative management as well, from bedrest to (partial) weight bearing. Some patients however have very limited to no ability to mobilise, such as critical ill patients on the Intensive Care Unit, amputees or spinal cord injured patients. Due to innovations such as hydrotherapy, osseointegrated prosthesis and exoskeletons, even these people can mobilise. Thanks to innovations like these an increasing number of trauma patients are able to fully reintegrate into community life and get back to an active and independent life style.

Electrical stimulation-induced SSSEP as an objective index to evaluate the difference of tactile acuity between the left and right hand.

OBJECTIVE: The objective of this study is to propose an objective index to evaluate the difference of tactile acuity between the left and right hand based on steady-state somatosensory evoked potential (SSSEP). APPROACH: Two kinds of tactile sensations (vibration and pressure) with three levels of intensities (low/medium/high) were evoked on two finger areas of the left or right hand (thumb and index for healthy hands, thumb and index-projected areas for disabled hands) via transcutaneous electrical nerve stimulation (TENS). Three forearm amputees and 13 able-bodied subjects were recruited to discriminate the specific level and area of the applied stimulation. Electroencephalography was adopted to simultaneously record the somatosensory cortex response to TENS. We assessed the discrimination performance (discrimination accuracy rate (AR) and response time (RT)) to quantify the tactile acuity, while the evoked SSSEP was synchronously analyzed. Linear regression analyses were performed between the difference of SSSEP amplitudes and the difference of discrimination performance for the left and right hand stimulation. MAIN RESULTS: Frequency domain analysis revealed that SSSEP amplitude increased with the increase of the stimulation intensity. There were positive correlations between the difference of SSSEP amplitudes and the difference of ARs for the left and right hand stimulation in the sensations of vibration (R 2 = 0.6389 for able-bodied subjects, R 2 = 0.5328 for amputees) and pressure (R 2 = 0.6102 for able-bodied subjects, R 2 = 0.5452 for amputees), respectively. Significance The SSSEP amplitude could be used as an objective index to evaluate the difference of the tactile acuity between the left and right hand and has the potential to be applied in sensory rehabilitation for amputees or stroke patients.

Intraneural sensory feedback restores grip force control and motor coordination while using a prosthetic hand.

OBJECTIVE: Tactile afferents in the human hand provide fundamental information about hand-environment interactions, which is used by the brain to adapt the motor output to the physical properties of the object being manipulated. A hand amputation disrupts both afferent and efferent pathways from/to the hand, completely invalidating the individual's motor repertoire. Although motor functions may be partially recovered by using a myoelectric prosthesis, providing functionally effective sensory feedback to users of prosthetics is a largely unsolved challenge. While past studies using invasive stimulation suggested that sensory feedback may help in handling fragile objects, none explored the underpinning, relearned, motor coordination during grasping. In this study, we aimed at showing for the first time that intraneural sensory feedback of the grip force (GF) improves the sensorimotor control of a transradial amputee controlling a myoelectric prosthesis. APPROACH: We performed a longitudinal study testing a single subject (clinical trial registration number NCT02848846). A stacking cups test (CUP) performed over two weeks aimed at measuring the subject's ability to finely regulate the GF applied with the prosthesis. A pick and lift test (PLT), performed at the end of the study, measured the level of motor coordination, and whether the subject transferred the motor skills learned in the CUP to an alien task. MAIN RESULTS: The results show that intraneural sensory feedback increases the subject's ability in regulating the GF and allows for improved performance over time. Additionally, the PLT demonstrated that the subject was able to generalize and transfer her manipulation skills to an unknown task and to improve her motor coordination. SIGNIFICANCE: Our findings suggest that intraneural sensory feedback holds the potential of restoring functionally effective tactile feedback. This opens up new possibilities to improve the quality of life of amputees using a neural prosthesis.

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.

Mirror therapy for phantom limb and stump pain: a randomized controlled clinical trial in landmine amputees in Cambodia.

Background and aims The aim of the study was to examine the effect of mirror and tactile therapy on phantom and stump pain in patients with traumatic amputations, with particular reference to amputees in low-income communities. Methods The study was conducted with an open, randomized, semi-crossover case-control design in rural Cambodia. A study sample of 45 landmine victims with trans-tibial amputations was allocated to three treatment arms; mirror therapy, tactile therapy, and combined mirror-and-tactile therapy. Non-responders from the mono-therapy interventions were crossed over to the alternative intervention. The intervention consisted of 5 min of treatment every morning and evening for 4 weeks. Endpoint estimates of phantom limb pain (PLP), stump pain, and physical function were registered 3 months after the treatment. Results All three interventions were associated with more that 50% reduction in visual analogue scale (VAS)-rated PLP and stump pain. Combined mirror-tactile treatment had a significantly better effect on PLP and stump pain than mirror or tactile therapy alone. The difference between the three treatment arms were however slight, and hardly of clinical relevance. After treatment, the reduction of pain remained unchanged for an observation period of 3 months. Conclusions The study documents that a 4-week treatment period with mirror and/or tactile therapy significantly reduces PLP and stump pain after trans-tibial amputations. Implications The article reports for the first time a randomized controlled trial of mirror therapy in a homogenous sample of persons with traumatic amputations. The findings are of special relevance to amputees in low-resource communities.

Case Studies in Neuroscience: Sensations elicited and discrimination ability from nerve cuff stimulation in an amputee over time.

The present case study details sensations elicited by electrical stimulation of peripheral nerve axons using an implanted nerve cuff electrode, in a participant with a transhumeral amputation. The participant uses an osseointegrated electromechanical interface, which enables skeletal attachment of the prosthesis and long-term, stable, bidirectional communication between the implanted electrodes and prosthetic arm. We focused on evoking somatosensory percepts, where we tracked and quantified the evolution of perceived sensations in the missing hand, which were evoked from electrical stimulation of the nerve, for over 2 yr. These sensations included small, pointlike areas of either vibration or pushing, to larger sensations over wider areas, indicating the recruitment of a few and many afferents, respectively. Furthermore, we used a two-alternative forced choice paradigm to measure the level of discrimination between trains of brief electrical stimuli, to gauge what the participant could reliably distinguish between. At best, the participant was able to distinguish a 0.5-Hz difference and on average acquired a 3.8-Hz just-noticeable difference at a more stringent psychophysical level. The current work shows the feasibility for long-term sensory feedback in prostheses, via electrical axonal stimulation, where small and relatively stable percepts were felt that may be used to deliver graded sensory feedback. This opens up opportunities for signaling feedback during movements (e.g., for precision grip), but also for conveying more complex cutaneous sensations, such as texture. NEW & NOTEWORTHY We demonstrate the long-term stability and generation of sensations from electrical peripheral nerve stimulation in an amputee, through an osseointegrated implant. We find that perceived tactilelike sensations could be generated for over 2 yr, in the missing hand. This is useful for prosthetic development and the implementation of feedback in artificial body parts.

Evoked haptic sensations in the hand via non-invasive proximal nerve stimulation.

OBJECTIVE: Haptic perception of a prosthetic limb or hand is a crucial, but often unmet, need which impacts the utility of the prostheses. In this study, we seek to evaluate the feasibility of a non-invasive transcutaneous nerve stimulation method in generating haptic feedback in a transradial amputee subject as well as intact able-bodied subjects. APPROACH: An electrode grid was placed on the skin along the medial side of the upper arm beneath the short head of the biceps brachii, in proximity to the median and ulnar nerves. Varying stimulation patterns were delivered to different electrode pairs, in order to emulate different types of sensations (Single Tap, Press-and-Hold, Double Tap) at different regions of the hand. Subjects then reported the magnitude of sensation by pressing on a force transducer to transform the qualitative haptic perception into a quantitative measurement. MAIN RESULTS: Altering current stimulations through electrode pairs on the grid resulted in repeatable alterations in the percept regions of the hand. Most subjects reported spatial coverage of individual fingers or phalanges, which can resemble the whole hand through different pairs of stimulation electrodes. The different stimulation patterns were also differentiable by all subjects. The amputee subject also reported haptic sensations similar to the able-bodied subjects. SIGNIFICANCE: Our findings demonstrated the capabilities of our transcutaneous stimulation method. Subjects were able to perceive spatially distinct sensations with graded magnitudes that emulated tapping and holding sensation in their hands. The elicitation of haptic sensations in the phantom hand of an amputee is a significant step in the development of our stimulation method, and provides insight into the future adaptation and implementation of prostheses with non-invasive sensory feedback to the users.

Sensory adaptation to electrical stimulation of the somatosensory nerves.

OBJECTIVE: Sensory systems adapt their sensitivity to ambient stimulation levels to improve their responsiveness to changes in stimulation. The sense of touch is also subject to adaptation, as evidenced by the desensitization produced by prolonged vibratory stimulation of the skin. Electrical stimulation of nerves elicits tactile sensations that can convey feedback for bionic limbs. In this study, we investigate whether artificial touch is also subject to adaptation, despite the fact that the peripheral mechanotransducers are bypassed. APPROACH: Using well-established psychophysical paradigms, we characterize the time course and magnitude of sensory adaptation caused by extended electrical stimulation of the residual somatosensory nerves in three human amputees implanted with cuff electrodes. MAIN RESULTS: We find that electrical stimulation of the nerve also induces perceptual adaptation that recovers after cessation of the stimulus. The time course and magnitude of electrically-induced adaptation are equivalent to their mechanically-induced counterparts. SIGNIFICANCE: We conclude that, in natural touch, the process of mechanotransduction is not required for adaptation, and artificial touch naturally experiences adaptation-induced adjustments of the dynamic range of sensations. Further, as it does for native hands, adaptation confers to bionic hands enhanced sensitivity to changes in stimulation and thus a more natural sensory experience.

Effectiveness of mirror therapy, motor imagery, and virtual feedback on phantom limb pain following amputation: A systematic review.

BACKGROUND: Phantom limb pain is reported in 50%-85% of people with amputation. Clinical interventions in treating central pain, such as mirror therapy, motor imagery, or virtual visual feedback, could redound in benefits to amputee patients with phantom limb pain. OBJECTIVES: To provide an overview of the effectiveness of different techniques for treating phantom limb pain in amputee patients. STUDY DESIGN: Systematic review. METHODS: A computerized literature search up to April 2017 was performed using the following databases: PubMed, Scopus, CINAHL, MEDLINE, ProQuest, PEDro, EBSCOhost, and Cochrane Plus. Methodological quality and internal validity score of each study were assessed using PEDro scale. For data synthesis, qualitative methods from the Cochrane Back Review Group were applied. RESULTS: In all, 12 studies met our inclusion criteria, where 9 were rated as low methodological quality and 3 rated moderate quality. All studies showed a significant reduction in pain, but there was heterogeneity among subjects and methodologies and any high-quality clinical trial (PEDro score ≤8; internal validity score ≤5) was not found. CONCLUSION: Mirror therapy, motor imaginary, and virtual visual feedback reduce phantom limb pain; however, there is limited scientific evidence supporting their effectiveness. Future studies should include designs with more solid research methods, exploring short- and long-term benefits of these therapies. Clinical relevance This systematic review investigates the effectiveness of mirror therapy, motor imagery, and virtual visual feedback on phantom limb pain, summarizing the currently published trials and evaluating the research quality. Although these interventions have positive benefits in phantom limb pain, there is still a lack of evidence for supporting their effectiveness.

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.

Influence of functional task-oriented mental practice on the gait of transtibial amputees: a randomized, clinical trial.

BACKGROUND: Mental practice (MP) through motor imagery is a cognitive training strategy used to improve locomotor skills during rehabilitation programs. Recent works have used MP tasks to investigate the neurophysiology of human gait; however, its effect on functional performance has not been evaluated. In the present study, the influence of gait-oriented MP tasks on the rehabilitation process of gait in transtibial amputees was investigated by assessing the vertical (V), anterior-posterior (AP), and medio-lateral (ML) ground reaction forces (GRFs) and the time duration of the support phase of the prosthetic limb. METHODS: Unilateral transtibial amputees, who were capable of performing motor imagination tasks (MIQ-RS score ≥4), were randomly divided into two groups: Group A (n = 10), who performed functional gait-oriented MP combined with gait training, and Group B (n = 5), who performed non-motor task MP. The MP intervention was performed in the first-person perspective for 40 min, 3 times/week, for 4 weeks. The GRF outcome measures were recorded by a force platform to evaluate gait performance during 4 distinct stages: at baseline (BL), 1 month before the MP session; Pre-MP, 1-3 days before the MP session; Post-MP, 1-3 days after the MP session; and follow-up (FU), 1 month after MP session. The gait variables were compared inter- and intra-group by applying the Mann-Whitney and Friedman tests (alpha = 0.05). RESULTS: All volunteers exhibited a homogenous gait pattern prior to MP intervention, with no gait improvement during the BL and Pre-MP stages. Only Group A showed significant improvements in gait performance after the intervention, with enhanced impact absorption, as indicated by decreased first V and AP peaks; propulsion capacity, indicated by increasing second V and AP peaks; and balance control of the prosthetic limb, indicated by decreasing ML peaks and increasing duration of support. This gait pattern persisted until the FU stage. CONCLUSIONS: MP combined with gait training allowed transtibial amputees to reestablish independent locomotion. Since the effects of MP were preserved after 1 month, the improvement is considered related to the specificity of the MP tasks. Therefore, MP may improve the clinical aspect of gait rehabilitation when included in a training program.

Delaying Ambulation Mode Transition Decisions Improves Accuracy of a Flexible Control System for Powered Knee-Ankle Prosthesis.

Powered lower limb prostheses can assist users in a variety of ambulation modes by providing knee and/or ankle joint power. This study's goal was to develop a flexible control system to allow users to perform a variety of tasks in a natural, accurate, and reliable way. Six transfemoral amputees used a powered knee-ankle prosthesis to ascend/descend a ramp, climb a 3- and 4-step staircase, perform walking and standing transitions to and from the staircase, and ambulate at various speeds. A mode-specific classification architecture was developed to allow seamless transitions at four discrete gait events. Prosthesis mode transitions (i.e., the prosthesis' mechanical response) were delayed by 90 ms. Overall, users were not affected by this small delay. Offline classification results demonstrate significantly reduced error rates with the delayed system compared to the non-delayed system (p < 0.001). The average error rate for all heel contact decisions was 1.65% [0.99%] for the non-delayed system and 0.43% [0.23%] for the delayed system. The average error rate for all toe off decisions was 0.47% [0.16%] for the non-delayed system and 0.13% [0.05%] for the delayed system. The results are encouraging and provide another step towards a clinically viable intent recognition system for a powered knee-ankle prosthesis.