Feasibility of a traditional and teletreatment approach to mirror therapy in patients with phantom limb pain: a process evaluation performed alongside a randomized controlled trial.

OBJECTIVE: To evaluate the delivery, acceptance and experiences regarding a traditional and teletreatment approach to mirror therapy as delivered in a randomized controlled trial. DESIGN: Mixed methods, prospective study. SETTING: Rehabilitation centres, hospital and private practices. SUBJECTS: Adult patients with phantom pain following lower limb amputation and their treating physical and occupational therapists. INTERVENTIONS: All patients received 4 weeks of traditional mirror therapy (n = 51), followed by 6 weeks of teletreatment (n = 26) or 6 weeks of self-delivered mirror therapy (n = 25). MAIN MEASURES: Patient files, therapist logs, log files teletreatment, acceptance questionnaire and interviews with patients and their therapists. RESULTS: In all, 51 patients and 10 therapists participated in the process evaluation. Only 16 patients (31%) received traditional mirror therapy according to the clinical framework during the first 4 weeks. Between weeks 5 and 10, the teletreatment was used by 14 patients (56%) with sufficient dose. Teletreatment usage decreased from a median number of 31 (weeks 5-10) to 19 sessions (weeks 11-24). Satisfactory teletreatment user acceptance rates were found with patients demonstrating higher scores (e.g. regarding the usefulness to control pain) than therapists. Potential barriers for implementation of the teletreatment perceived by patients and therapists were related to insufficient training and support as well as the frequency of technical problems. CONCLUSION: Traditional mirror therapy and the teletreatment were not delivered as intended in the majority of patients. Implementation of the teletreatment in daily routines was challenging, and more research is needed to evaluate user characteristics that influence adherence and how technology features can be optimized to develop tailored implementation strategies.

Traditional and augmented reality mirror therapy for patients with chronic phantom limb pain (PACT study): results of a three-group, multicentre single-blind randomized controlled trial.

OBJECTIVE:: To compare the effects of traditional mirror therapy (MT), a patient-centred teletreatment (PACT) and sensomotor exercises without a mirror on phantom limb pain (PLP). DESIGN:: Three-arm multicentre randomized controlled trial. SETTING:: Rehabilitation centres, hospital and private practices. SUBJECTS:: Adult patients with unilateral lower limb amputation and average PLP intensity of at least 3 on the 0-10 Numeric Rating Scale (NRS). INTERVENTIONS:: Subjects randomly received either four weeks of traditional MT followed by a teletreatment using augmented reality MT, traditional MT followed by self-delivered MT or sensomotor exercises of the intact limb without a mirror followed by self-delivered exercises. MAIN MEASURES:: Intensity, frequency and duration of PLP and patient-reported outcomes assessing limitations in daily life at baseline, 4 weeks, 10 weeks and 6 months. RESULTS:: In total, 75 patients received traditional MT ( n = 25), teletreatment ( n = 26) or sensomotor exercises ( n = 24). Mean (SD) age was 61.1 (14.2) years and mean (SD) pain intensity was 5.7 (2.1) on the NRS. Effects of MT at four weeks on PLP were not significant. MT significantly reduced the duration of PLP at six months compared to the teletreatment ( P = 0.050) and control group ( P = 0.019). Subgroup analyses suggested significant effects on PLP in women, patients with telescoping and patients with a motor component in PLP. The teletreatment had no additional effects compared to self-delivered MT at 10 weeks and 6 months. CONCLUSION:: Traditional MT over four weeks was not more effective than sensomotor exercises without a mirror in reducing PLP, although significant effects were suggested in some subgroups.

How nursing home residents with dementia respond to the interactive art installation 'VENSTER': a pilot study.

The goal of this study was (1) to determine whether and how nursing home residents with dementia respond to the interactive art installation in general and (2) to identify whether responses change when the content type and, therefore, the nature of the interaction with the artwork changes. The interactive art installation 'VENSTER' evokes responses in nursing home residents with dementia, illustrating the potential of interactive artworks in the nursing home environment. Frequently observed responses were naming, recognizing or asking questions about depicted content and how the installation worked, physically gesturing towards or tapping on the screen and tapping or singing along to the music. It seemed content matters a lot. When VENSTER is to be used in routine care, the choice of a type of content is critical to the intended experience/usage in practice. In this study, recognition seemed to trigger memory and (in most cases) a verbal reaction, while indistinctness led to asking for more information. When (initially) coached by a care provider, residents actively engaged physically with the screen. Responses differed between content types, which makes it important to further explore different types of content and content as an interface to provide meaningful experiences for nursing home residents. Implications for rehabilitation VENSTER can facilitate different types of responses ranging from verbal reactions to active physical engagement. The choice of a type of content is critical to the intended experience/usage in practice. Activating content seems suitable for use as a meaningful experience during the spare time in between existing activities or therapy. Sessions with interactive content are short (avg. 30 mins) and intense and can therefore potentially be used as an activating therapy, activity or exercise. In order to actively engage residents with dementia, the role of the care provider seems very important.

Design and Development of a Telerehabilitation Platform for Patients With Phantom Limb Pain: A User-Centered Approach.

BACKGROUND: Phantom limb pain is a frequent and persistent problem following amputation. Achieving sustainable favorable effects on phantom limb pain requires therapeutic interventions such as mirror therapy that target maladaptive neuroplastic changes in the central nervous system. Unfortunately, patients' adherence to unsupervised exercises is generally poor and there is a need for effective strategies such as telerehabilitation to support long-term self-management of patients with phantom limb pain. OBJECTIVE: The main aim of this study was to describe the user-centered approach that guided the design and development of a telerehabilitation platform for patients with phantom limb pain. We addressed 3 research questions: (1) Which requirements are defined by patients and therapists for the content and functions of a telerehabilitation platform and how can these requirements be prioritized to develop a first prototype of the platform? (2) How can the user interface of the telerehabilitation platform be designed so as to match the predefined critical user requirements and how can this interface be translated into a medium-fidelity prototype of the platform? (3) How do patients with phantom limb pain and their treating therapists judge the usability of the medium-fidelity prototype of the telerehabilitation platform in routine care and how can the platform be redesigned based on their feedback to achieve a high-fidelity prototype? METHODS: The telerehabilitation platform was developed using an iterative user-centered design process. In the first phase, a questionnaire followed by a semistructured interview was used to identify the user requirements of both the patients and their physical and occupational therapists, which were then prioritized using a decision matrix. The second phase involved designing the interface of the telerehabilitation platform using design sketches, wireframes, and interface mock-ups to develop a low-fidelity prototype. Heuristic evaluation resulted in a medium-fidelity prototype whose usability was tested in routine care in the final phase, leading to the development of a high-fidelity prototype. RESULTS: A total of 7 categories of patient requirements were identified: monitoring, exercise programs, communication, settings, background information, log-in, and general requirements. One additional category emerged for therapists: patient management. Based on these requirements, patient and therapist interfaces for the telerehabilitation platform were developed and redesigned by the software development team in an iterative process, addressing the usability problems that were reported by the users during 4 weeks of field testing in routine care. CONCLUSIONS: Our findings underline the importance of involving the users and other stakeholders early and continuously in an iterative design process, as well as the need for clear criteria to identify critical user requirements. A decision matrix is presented that incorporates the views of various stakeholders in systematically rating and prioritizing user requirements. The findings and lessons learned might help health care providers, researchers, software designers, and other stakeholders in designing and evaluating new teletreatments, and hopefully increase the likelihood of user acceptance.

Development of a Clinical Framework for Mirror Therapy in Patients with Phantom Limb Pain: An Evidence-based Practice Approach.

OBJECTIVE: To describe the development and content of a clinical framework for mirror therapy (MT) in patients with phantom limb pain (PLP) following amputation. METHODS: Based on an a priori formulated theoretical model, 3 sources of data collection were used to develop the clinical framework. First, a review of the literature took place on important clinical aspects and the evidence on the effectiveness of MT in patients with phantom limb pain. In addition, questionnaires and semi-structured interviews were used to analyze clinical experiences and preferences of physical and occupational therapists and patients suffering from PLP regarding the application of MT. All data were finally clustered into main and subcategories and were used to complement and refine the theoretical model. RESULTS: For every main category of the a priori formulated theoretical model, several subcategories emerged from the literature search, patient, and therapist interviews. Based on these categories, we developed a clinical flowchart that incorporates the main and subcategories in a logical way according to the phases in methodical intervention defined by the Royal Dutch Society for Physical Therapy. In addition, we developed a comprehensive booklet that illustrates the individual steps of the clinical flowchart. CONCLUSIONS: In this study, a structured clinical framework for the application of MT in patients with PLP was developed. This framework is currently being tested for its effectiveness in a multicenter randomized controlled trial.

The PACT trial: PAtient Centered Telerehabilitation: effectiveness of software-supported and traditional mirror therapy in patients with phantom limb pain following lower limb amputation: protocol of a multicentre randomised controlled trial.

INTRODUCTION: Non-pharmacological interventions such as mirror therapy are gaining increased recognition in the treatment of phantom limb pain; however, the evidence in people with phantom limb pain is still weak. In addition, compliance to self-delivered exercises is generally low. The aim of this randomised controlled study is to investigate the effectiveness of mirror therapy supported by telerehabilitation on the intensity, duration and frequency of phantom limb pain and limitations in daily activities compared to traditional mirror therapy and care as usual in people following lower limb amputation. METHOD: A three-arm multi-centre randomised controlled trial will be performed. Participants will be randomly assigned to care as usual, traditional mirror therapy or mirror therapy supported by telerehabilitation. During the first 4 weeks, at least 10 individual sessions will take place in every group. After the first 4 weeks, participants will be encouraged to perform self-delivered exercises over a period of 6 weeks. Outcomes will be assessed at 4 and 10 weeks after baseline and at 6 months follow-up. The primary outcome measure is the average intensity of phantom limb pain during the last week. Secondary outcome measures include the different dimensions of phantom limb pain, pain-related limitations in daily activities, global perceived effect, pain-specific self-efficacy, and quality of life. DISCUSSION: Several questions concerning the study design that emerged during the preparation of this trial will be discussed. This will include how these questions were addressed and arguments for the choices that were made.

Use of movement imagery in neurorehabilitation: researching effects of a complex intervention.

Since the beginning of the new millennium, the use of mental practice and movement imagery within several medical professions in rehabilitation and therapy has received an increased attention. Before this introduction in healthcare, the use of movement imagery was mainly researched in sports science. Mental practice is a complex intervention. When a complex intervention is applied in a new target group or population, the intervention is most likely needed to be adjusted, developed, and evaluated. Recently, a dissertation has been published in which the researchers describe their efforts to transfer the use of movement imagery in sports to rehabilitation. This study reports two aspects from this research project: (a) What did the researcher do? (b) What do the results mean for future research? First, however, some background information is given, in which the use of movement imagery in athletes is discussed.

Rehabilitation with mental practice has similar effects on mobility as rehabilitation with relaxation in people with Parkinson's disease: a multicentre randomised trial.

QUESTIONS: Is mental practice embedded in standard physiotherapy compared with relaxation embedded in standard physiotherapy more effective at improving mobility tasks in people with Parkinson's disease in the community? Does disease severity influence the treatment effect? DESIGN: A multicentre randomised controlled trial. PARTICIPANTS: People with Parkinson's disease. INTERVENTION: During a six-week intervention period, both groups received physiotherapy as usual with the addition of either mental practice (experimental group) or relaxation (control group). Imagery skills were taught using a four-step protocol. Movement imagery (in thought) and the performance of motor activities were combined. OUTCOME MEASURES: Outcomes were assessed at six weeks and three months with: the patient- and therapist-perceived effect on walking performance (visual analogue scale), the Timed Up and Go test, and the 10 m Walk test. Primary analysis was performed using intention-totreat and was repeated as a per-protocol analysis, and as a sub-group analysis of participants with Hoehn and Yahr stage of less than 3. Generalised estimating equations were used to analyse effects. RESULTS: 47 participants were assigned to the control (n = 22) and experimental (n = 25) groups. No effect in favour of the mental practice intervention on any outcome measure could be detected at any of the measurement points. In the sub-group analysis of participants with milder disease, the experimental group improved more than the control group but this was not statistically significant. CONCLUSION: In this study, we did not find differences between embedded mental practice and relaxation with current standard of care. TRIAL REGISTRATION: Nederlands Trial Register: NTR1735.

Feasibility of a mental practice intervention in stroke patients in nursing homes; a process evaluation.

BACKGROUND: Within a multi-centre randomised controlled trial in three nursing homes, a process evaluation of a mental practice intervention was conducted. The main aims were to determine if the intervention was performed according to the framework and to describe the therapists' and participants' experiences with and opinions on the intervention. METHODS: The six week mental practice intervention was given by physiotherapists and occupational therapists in the rehabilitation teams and consisted of four phases: explanation of imagery, teaching patients how to use imagery, using imagery as part of therapy, and facilitating the patient in using it alone and for new tasks. It had a mandatory and an optional part. Data were collected by means of registration forms, pre structured patient files, patient logs and self-administered questionnaires. RESULTS: A total of 14 therapists and 18 patients with stroke in the sub acute phase of recovery were involved. Response rates differed per assessment (range 57-93%). Two patients dropped out of the study (total n = 16). The mandatory part of the intervention was given to 11 of 16 patients: 13 received the prescribed amount of mental practice and 12 practiced unguided outside of therapy. The facilitating techniques of the optional part of the framework were partly used. Therapists were moderately positive about the use of imagery in this specific sample. Although it was more difficult for some patients to generate images than others, all patients were positive about the intervention and reported perceived short term benefits from mental practice. CONCLUSIONS: The intervention was less feasible than we hoped. Implementing a complex therapy delivered by existing multi-professional teams to a vulnerable population with a complex pathology poses many challenges.

Using mental practice in stroke rehabilitation: a framework.

INTRODUCTION: Motor imagery and mental practice are getting increased attention in neurological rehabilitation. Several different mental practice intervention protocols have been used in studies on its effect on recovery in stroke rehabilitation. The content of the intervention protocols itself is rarely discussed or questioned. OBJECTIVE: To give a practical framework of how mental practice could be integrated into therapy, drawing on available evidence and theory. The aim of the treatment programme described is to enhance both the patient's physical performance and their empowerment and self-determination. THE FRAMEWORK: Based on evidence from sports rehabilitation and our own experiences the framework will eventually be evaluated in a randomized controlled trial. Five steps are described to teach and upgrade the patient's imagery technique: (1) assess mental capacity to learn imagery technique; (2) establish the nature of mental practice; (3) teach imagery technique; (4) embed and monitor imagery technique; (5) develop self-generated treatments. The description is not, however, a recipe that should be followed precisely. It leaves enough room to tailor the mental practice intervention to the specific individual possibilities, skills and needs of the patient in accordance with evidence-based practice. DISCUSSION: Different aspects of the described protocol are discussed and compared with experiences from sports and evidence available in rehabilitation.

The effects of mental practice in stroke rehabilitation: a systematic review.

OBJECTIVE: To assess the effects of a mental practice intervention on recovery in stroke patients. DATA SOURCES: A systematic literature search of the Cochrane Database of Systematic Reviews, PubMed/Medline, PsycINFO, Pedro, Rehadat, and RehabTrials was performed by 2 researchers independently. Eligible studies published through August 2005 were selected. STUDY SELECTION: Four randomized controlled trials (RCTs), 1 controlled clinical trial (CCT), 2 patient series, and 3 case reports that investigated the effects of a mental practice intervention on recovery of stroke patients were included. DATA EXTRACTION: The selected RCTs and CCT were assessed on a methodologic quality rating scale. Important characteristics and outcomes were extracted and summarized. Results and characteristics from the patient series and case reports were only provided if they added information. DATA SYNTHESIS: Included studies differed clearly from one another with regard to patient characteristics, intervention protocol, and outcome measures. Four different mental practice strategies were used. Most tasks involved mentally rehearsing movements of the arm. Intervention periods varied from 2 to 6 weeks, frequencies ranged from multiple sessions per day to 3 times a week. Studies were limited in size. Power could not be increased by pooling or meta-analysis because studies were not comparable. Three of the 4 RCTs were of reasonable methodologic quality. There was some evidence that mental practice as an additional therapy intervention had positive effects on recovery of arm function after stroke. Two mental practice techniques appeared to be effective-tape instruction and self-regulation. Results from the single case studies indicate that mental practice is also promising for improvement of leg function. CONCLUSIONS: No definite conclusions could be drawn except that further research, using clear definitions of the content of mental practice and standardized measurement of outcome, are needed.