Strategies for graded motor imagery for clients with phantom limb pain and cognitive impairment.

BACKGROUND: Individuals with amputations often experience phantom limb pain (PLP) that can limit their participation in rehabilitation, prosthesis training, desired activities, and roles. One nonpharmacological rehabilitation intervention for PLP is graded motor imagery (GMI). There are several components to GMI, including right/left discrimination or laterality, motor imagery, sensory retraining, and mirror therapy. Successful implementation of GMI requires a range of cognitive skills, such as attention span, working memory, abstract reasoning, and planning. For individuals with PLP who concurrently display cognitive impairments, GMI protocols can be adapted using strategies derived from clinical practice. OBJECTIVES: The purpose of this technical clinical report was to discuss the application of clinically implemented cognitive compensation techniques to GMI instruction. STUDY DESIGN: Not applicable. METHODS: Clinical expert opinion to explore adaptations for GMI. TECHNIQUE: Graded motor imagery can be an effective tool for pain treatment; however, some clients may need greater clinician support due to existing cognitive difficulties. RESULTS: For clients to be successful, active engagement in learning about and implementing GMI techniques is necessary. CONCLUSIONS: When serving the lifetime amputation care needs of patients with cognitive deficits, we find that targeted learning strategies and accommodations can be helpful when introducing GMI concepts and skill development. Enhanced patient education techniques support client learning.

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.

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.

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.

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.

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.

Efficacy of eye movement desensitization and reprocessing on the phantom limb pain of patients with amputations within a 24-month follow-up.

The aim of this study was to evaluate the efficacy of eye movement desensitization and reprocessing (EMDR) on the phantom limb pain (PLP) of patients with amputations within a 24-month follow-up. This study was a randomized-controlled trial. A total of 60 patients with amputations were selected by a purposive sampling and patients were divided randomly into two experimental and control groups. Samples were assigned through randomized allocation. EMDR therapy was administered individually to the experimental group participants in 12 one-hour sessions over a 1-month period In each session, the patient completed the Subjective Units of Distress Scale and a pain-rating scale before and after the intervention. Follow-up measures were obtained 24 months later for the experimental group. The participants in the control group were measured on the two scales at an initial session and again after 1- and 24-month follow-up. The mean PLP decreased in the experimental group between the first and last sessions and remained so at a 24-month follow-up. No decrease occurred for the control group over the 1- and 24-month period. The differences were statistically significant (P<0.001) according to a repeated-measures analysis of variance. EMDR therapy proved to be a successful treatment for PLP. Because of its efficacy and the fact that the positive effects were maintained at the 24-month follow-up, this therapy is recommended for the treatment of PLP.

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.

Mirror Therapy and Transcutaneous Electrical Nerve Stimulation for Management of Phantom Limb Pain in Amputees - A Single Blinded Randomized Controlled Trial.

BACKGROUND AND PURPOSE: Phantom limb pain (PLP) can be disabling for nearly two thirds of amputees. Hence, there is a need to find an effective and inexpensive treatment that can be self administered. Among the non-pharmacological treatment for PLP, transcutaneous electrical nerve stimulation (TENS) applied to the contralateral extremity and mirror therapy are two promising options. However, there are no studies to compare the two treatments. The purpose of this study is to evaluate and compare mirror therapy and TENS in the management of PLP in subjects with amputation. METHODS: The study was an assessor blinded randomized controlled trial conducted at Physiotherapy Gymnasium of Physical Medicine and Rehabilitation Department, Christian Medical College, Vellore. Twenty-six subjects with PLP consented to participate. An initial assessment of pain using visual analogue scale (VAS) and universal pain score (UPS) was performed by a therapist blinded to the treatment given. Random allocation into Group I-mirror therapy and Group II-TENS was carried out. After 4 days of treatment, pain was re-assessed by the same therapist. The mean difference in Pre and Post values were compared among the groups. The change in pre-post score was analyzed using the paired t test. RESULTS: Participants of Group I had significant decrease in pain [VAS ( p = 0.003) and UPS ( p = 0.001)]. Group II also showed a significant reduction in pain [VAS ( p = 0.003) and UPS ( p = 0.002)]. However, no difference was observed between the two groups [VAS ( p = 0.223 and UPS ( p = 0.956)]. DISCUSSION: Both Mirror Therapy and TENS were found to be effective in pain reduction on a short-term basis. However, no difference between the two groups was found. Substantiation with long-term follow-up is essential to find its long-term effectiveness. Copyright © 2015 John Wiley & Sons, Ltd.

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 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.

[Mirror therapy for the treatment of phantom limb pain after bilateral thigh amputation. A case report]. / Spiegeltherapie zur Behandlung von Phantomschmerzen nach beidseitiger Oberschenkelamputation. Ein Fallbericht.

This case study is the first to report successful treatment of bilateral phantom limb pain (PLP) in a patient with bilateral thigh amputation and inefficacious medical treatment using a protocol of graded interventions including mirror therapy (MT). MT is a common treatment for PLP but requires the induction of a visual illusion of an intact limb in the mirror, usually achieved by mirroring the healthy extremity. Here, we illustrate how application of a unilateral prosthesis sufficed to induce the necessary illusion. After sequential imagery, then lateralization training, which alleviated pain attacks, the patient received a further 3-week treatment of mirror treatment. Pain intensity was reduced by more than 85 %; the number of attacks were decreased by more than 90% per day. The analgesic efficacy lasted until the unexpected death of the patient several months later. This case illustrates the mechanisms of MT through overcoming the sensory incongruences underlying the distorted body schema and its efficacy in patients with bilateral amputation.

An augmented reality home-training system based on the mirror training and imagery approach.

Mirror training and movement imagery have been demonstrated to be effective in treating several clinical conditions, such as phantom limb pain, stroke-induced hemiparesis, and complex regional pain syndrome. This article presents an augmented reality home-training system based on the mirror and imagery treatment approaches for hand training. A head-mounted display equipped with cameras captures one hand held in front of the body, mirrors this hand, and displays it in real time in a set of four different training tasks: (1) flexing fingers in a predefined sequence, (2) moving the hand into a posture fitting into a silhouette template, (3) driving a "Snake" video game with the index finger, and (4) grasping and moving a virtual ball. The system records task performance and transfers these data to a central server via the Internet, allowing monitoring of training progress. We evaluated the system by having 7 healthy participants train with it over the course of ten sessions of 15-min duration. No technical problems emerged during this time. Performance indicators showed that the system achieves a good balance between relatively easy and more challenging tasks and that participants improved significantly over the training sessions. This suggests that the system is well suited to maintain motivation in patients, especially when it is used for a prolonged period of time.

Development of a neurotechnological system for relieving phantom limb pain using transverse intrafascicular electrodes (TIME).

Phantom limb pain (PLP) is a chronic condition that develops in the majority of amputees. The underlying mechanisms are not completely understood, and thus, no treatment is fully effective. Based on recent studies, we hypothesize that electrical stimulation of afferent nerves might alleviate PLP by giving sensory input to the patient if nerve fibers can be activated selectively. The critical component in this scheme is the implantable electrode structure. We present a review of a novel electrode concept to distribute highly selective electrode contacts over the complete cross section of a peripheral nerve to create a distributed activation of small nerve fiber ensembles at the fascicular level, the transverse intrafascicular multichannel nerve electrode (TIME). The acute and chronic implantations in a small animal model exhibited a good surface and structural biocompatibility as well as excellent selectivity. Implantation studies on large animal models that are closer to human nerve size and anatomical complexity have also been conducted. They proved implant stability and the ability to selectively activate nerve fascicles in a limited proximity to the implant. These encouraging results have opened the way forward for human clinical trials in amputees to investigate the effect of selective electrical stimulation on PLP.

Imaginative resonance training (IRT) achieves elimination of amputees' phantom pain (PLP) coupled with a spontaneous in-depth proprioception of a restored limb as a marker for permanence and supported by pre-post functional magnetic resonance imaging (fMRI).

Non-pharmacological approaches such as mirror therapy and graded motor imagery often provide amelioration of amputees' phantom limb pain (PLP), but elimination has proved difficult to achieve. Proprioception of the amputated limb has been noted in studies to be defective and/or distorted in the presence of PLP, but has not, apparently, been researched for various stages of amelioration up to the absence of PLP. Previous studies using functional magnetic resonance imaging (fMRI) suggested that pathological cortical reorganisation after amputation may be the underlying neurobiological correlate of PLP. We report two cases of permanent elimination of PLP after application of imaginative resonance training. The patients, 69 years and 84 years old, reported freedom from PLP together with in-depth achievement of proprioception of a restored limb at the end of the treatment, which may thus be taken as an indication of permanence. Pre/post fMRI for the first case showed, against a group of healthy controls, analogous changes of activation in the sensorimotor cortex.

Using a virtual integration environment in treating phantom limb pain.

The Revolutionizing Prosthetics 2009 program conducted by the Defense Advanced Research Projects Agency (DARPA) has resulted in a Virtual Integration Environment (VIE) that provides a common development platform for researchers and clinicians that design, model and build prosthetic limbs and then integrate and test them with patients. One clinical need that arose during the VIE development was a feature to easily create and model animations that represent patient activities of daily living (ADLs) and simultaneously capture real-time surface EMG activity from the residual limb corresponding to the ADLs. An application of this feature is being made by the Walter Reed Military Amputee Research Program (MARP) where they are utilizing the VIE to investigate methods of reducing upper extremity amputee phantom limb pain (PLP).

Training with virtual visual feedback to alleviate phantom limb pain.

BACKGROUND: Performing phantom movements with visual virtual feedback, or mirror therapy, is a promising treatment avenue to alleviate phantom limb pain. However the effectiveness of this approach appears to vary from one patient to another. OBJECTIVE: To assess the individual response to training with visual virtual feedback and to explore factors influencing the response to that approach. METHODS: Eight male participants with phantom limb pain (PLP) resulting from either a traumatic upper limb amputation or a brachial plexus avulsion participated in this single case multiple baseline study. Training was performed 2 times per week for 8 weeks where a virtual image of a missing limb performing different movements was presented and the participant was asked to follow the movements with his phantom limb. RESULTS: Patients reported an average 38% decrease in background pain on a visual analog scale (VAS), with 5 patients out of 8 reporting a reduction greater than 30%. This decrease in pain was maintained at 4 weeks postintervention in 4 of the 5 participants. No significant relationship was found between the long-term pain relief and the duration of the deafferentation or with the immediate pain relief during exposure to the feedback. CONCLUSIONS: These results support the use of training with virtual feedback to alleviate phantom limb pain. Our observations suggest that between-participant differences in the effectiveness of the treatment might be related more to a difference in the susceptibility to the virtual visual feedback, than to factors related to the lesion, such as the duration of the deafferentation.