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BMC Neurology Oct 2021The objective of the current study is to evaluate the effects of phantom exercises on phantom limb pain, mobility status, and quality of life in lower limb amputees... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
The objective of the current study is to evaluate the effects of phantom exercises on phantom limb pain, mobility status, and quality of life in lower limb amputees treated with mirror therapy and routine physiotherapy.
METHODS
It is a randomized controlled trial in which 24 unilateral lower limb amputees (above and below the knee) were randomly assigned to two equal groups i.e., control group (mirror therapy and conventional physical therapy) and experimental group in which, phantom exercises were given, additionally. Physical therapy included conventional therapeutic exercises while phantom exercises include imagining the movement of the phantom limb and attempting to execute these movements Data were collected at baseline, after 2 and 4 weeks of intervention using VAS (pain), AMP (mobility) and RAND SF-36 Version 1.0 (QOL) questionnaires. All statistical analyses were done with IBM SPSS 25.0 with 95% CI.
RESULTS
Twenty-four amputees (17 males and 7 females) participated in this trial. The Mean age of the participants in experimental and control groups was 45.3 ± 11.1 years and 40.5 ± 12.5 years respectively. After the intervention, the pain (VAS score) was significantly lower in the experimental group (p = 0.003). Similarly, the experimental group demonstrated a significantly better score in the "bodily pain" domain of SF-36 (p = 0.012). Both groups significantly (p < 0.05) improved in other domains of SF-36 and ambulatory potential with no significant (p > 0.05) between-group differences.
CONCLUSIONS
The Addition of phantom exercises resulted in significantly better pain management in lower limb amputees treated with mirror therapy and routine physiotherapy.
TRIAL REGISTRATION
This study is registered in the U.S National Library of Medicine. The clinical trials registration number for this study is NCT04285138 ( ClinicalTrials.gov Identifier) (Date: 26/02/2020).
Topics: Adult; Amputees; Female; Humans; Lower Extremity; Male; Middle Aged; Pain Measurement; Phantom Limb; Quality of Life
PubMed: 34706654
DOI: 10.1186/s12883-021-02441-z -
Agri : Agri (Algoloji) Dernegi'nin... Jul 2022he autonomic nervous system (ANS) controls the heart rate, blood pressure, digestion, respiration, pupillary reactivity, sweating, urination, sexual arousal, and... (Review)
Review
he autonomic nervous system (ANS) controls the heart rate, blood pressure, digestion, respiration, pupillary reactivity, sweating, urination, sexual arousal, and regulates the functions of internal organs. This system provides the homeostasis of the cells, tissues, and organs throughout the body and protects against the disturbances imposed by the external and internal stressors. The ANS has three main divisions: The sympathetic nervous system (SNS), the parasympathetic nervous system (PNS), and the enteric nervous system. In general, the SNS and PNS have opposing effects. Each region belonging to the 'pain matrix' interacts with ANS. The descending system regulates pain and creates a regulatory effect by the contribution of aminergic neurotransmitters. Hypothalamus, amygdala, and periaqueductal gray are the main structures of this regulatory system. Dysfunction of the ANS is frequently observed in pain patients. The SNS induce, facilitate, or potentiate chronic pain. Increased responsiveness of injured sensory nerves to catecholamines, increased expression of α-1 adrenoreceptors on the primary afferent nociceptors and hyperalgesic skin, central sensitization rendering Aβ mechanoreceptors, enhanced discharge and sympathetic sprouting in dorsal root ganglia, central sensitization, and dysfunction of the pain modulation is proposed mechanisms. In this review, the anatomical, physiological and pathological aspects of ANS and pain, and laboratory tests to evaluate autonomic functions will be discussed. Pathophysiological role of ANS in migraine, trigeminal autonomic cephalgias, trigeminal neuralgia, peripheral nerve injuries, small fiber neuropathies, myofascial pain syndrome, fibromyalgia, painful joint diseases, visceral pain, phantom limb pain, complex regional pain syndrome, and spinal cord injury will be discussed.
Topics: Autonomic Nervous System; Fibromyalgia; Heart Rate; Humans; Male; Phantom Limb; Somatoform Disorders
PubMed: 35792695
DOI: 10.14744/agri.2021.43078 -
Revista Da Associacao Medica Brasileira... Nov 2017The consequences of chronic pain and associated disabilities to the patient and to the health care system are well known. Medication is often the first treatment of... (Review)
Review
The consequences of chronic pain and associated disabilities to the patient and to the health care system are well known. Medication is often the first treatment of choice for chronic pain, although side effects and high costs restrict long-term use. Inexpensive, safe and easy to self-administer non-pharmacological therapies, such as mirror therapy, are recommended as adjuncts to pain treatment. The purpose of this review is to describe the principles of use of mirror therapy so it can be incorporated into a health care delivery. The physiological rationale of mirror therapy for the management of pain and the evidence of clinical efficacy based on recent systematic reviews are also discussed. Mirror therapy, whereby a mirror is placed in a position so that the patient can view a reflection of a body part, has been used to treat phantom limb pain, complex regional pain syndrome, neuropathy and low back pain. Research evidence suggests that a course of treatment (four weeks) of mirror therapy may reduce chronic pain. Contraindications and side effects are few. The mechanism of action of mirror therapy remains uncertain, with reintegration of motor and sensory systems, restored body image and control over fear-avoidance likely to influence outcome. The evidence for clinical efficacy of mirror therapy is encouraging, but not yet definitive. Nevertheless, mirror therapy is inexpensive, safe and easy for the patient to self-administer.
Topics: Amputees; Chronic Pain; Humans; Pain Management; Phantom Limb; Physical Therapy Modalities; Treatment Outcome
PubMed: 29451665
DOI: 10.1590/1806-9282.63.11.1000 -
Physiotherapy Dec 2020To investigate whether graded motor imagery (GMI) is effective for reducing phantom limb pain (PLP) in people who have undergone limb amputations. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To investigate whether graded motor imagery (GMI) is effective for reducing phantom limb pain (PLP) in people who have undergone limb amputations.
DESIGN
A single-blinded randomised, controlled trial.
SETTING
Physiotherapy out-patient departments in three secondary level hospitals in Cape Town, South Africa.
PARTICIPANTS
Twenty-one adults (≥18 years) who had undergone unilateral upper or lower limb amputations and had self-reported PLP persisting beyond three months.
INTERVENTIONS
A 6-week GMI programme was compared to routine physiotherapy. The study outcomes were evaluated at baseline, 6 weeks, 3 months and 6 months.
OUTCOME MEASURES
The pain severity scale of the Brief Pain Inventory (BPI) was used to assess the primary outcome - PLP. The pain interference scale of the BPI and the EuroQol EQ-5D-5L were used to assess the secondary outcomes - pain interference with function and health-related quality of life (HRQoL) respectively.
RESULTS
The participants in the experimental group had significantly greater improvements in pain than the control group at 6 weeks and 6 months. Further, the participants in the experimental group had significantly greater improvements than the control group in pain interference at all follow-up points. There was no between-group difference in HRQoL.
CONCLUSION
The results of the current study suggest that GMI is better than routine physiotherapy for reducing PLP. Based on the significant reduction in PLP and pain interference within the participants who received GMI, and the ease of application, GMI may be a viable treatment for treating PLP in people who have undergone limb amputations.
CLINICAL TRIAL REGISTRATION NUMBER
(PACTR201701001979279).
Topics: Aged; Female; Humans; Imagery, Psychotherapy; Male; Middle Aged; Pain Management; Pain Measurement; Phantom Limb; Physical Therapy Modalities; Quality of Life; Single-Blind Method; South Africa
PubMed: 31992445
DOI: 10.1016/j.physio.2019.06.009 -
Neurologia Oct 2022Phantom limb pain (PLP) is a type of neuropathic pain that affects the territory of an amputated limb or other surgically removed body parts. Between 60% and 90% of... (Review)
Review
INTRODUCTION
Phantom limb pain (PLP) is a type of neuropathic pain that affects the territory of an amputated limb or other surgically removed body parts. Between 60% and 90% of amputees suffer from PLP during follow-up. There are a range of therapeutic options for PLP, both pharmacological (gabapentin, amitriptyline, tricyclic antidepressants, etc) and non-pharmacological (transcutaneous electrical nerve stimulation, hypnosis, acupuncture, etc). A widely accepted hypothesis considers PLP to be the consequence of postamputation cortical reorganisation. New treatment approaches, such as mirror therapy (MT), have been developed as a result of Ramachandran's groundbreaking research in the 1990s. This review analyses the current evidence on the efficacy of MT for treating PLP.
DEVELOPMENT
We performed a literature review of publications registered from 2012 to 2017 on the CINAHL, Cochrane, Scopus, and PubMed (including Medline) databases Using the descriptors "phantom limb‿ and "mirror therapy.‿ We identified 115 publications addressing MT in PLP. Of these, 17 (15%) contributed useful information for pooled analysis.
CONCLUSIONS
MT seems to be effective in relieving PLP, reducing the intensity and duration of daily pain episodes. It is a valid, simple, and inexpensive treatment for PLP. The methodological quality of most publications in this field is very limited, highlighting the need for additional, high-quality studies to develop clinical protocols that could maximise the benefits of MT for patients with PLP.
Topics: Humans; Phantom Limb; Mirror Movement Therapy; Amputees; Transcutaneous Electric Nerve Stimulation; Pain Management
PubMed: 30447854
DOI: 10.1016/j.nrl.2018.08.003 -
European Journal of Pain (London,... Jan 2023Phantom limb pain (PLP) concerns >50% of amputees and has a negative impact on their rehabilitation, mental health and quality of life. Mirror therapy (MT) is a... (Review)
Review
Effect of mirror therapy in the treatment of phantom limb pain in amputees: A systematic review of randomized placebo-controlled trials does not find any evidence of efficacy.
BACKGROUND AND OBJECTIVE
Phantom limb pain (PLP) concerns >50% of amputees and has a negative impact on their rehabilitation, mental health and quality of life. Mirror therapy (MT) is a promising strategy, but its effectiveness remains controversial. We performed a systematic review to: (i) evaluate the effectiveness of MT versus placebo in reducing PLP, and (ii) determine MT effect on disability and quality of life.
DATABASES AND DATA TREATMENT
We selected randomized-controlled trials in five databases (Medline, Cochrane Library, CINAHL, PEDro and Embase) that included patients with unilateral lower or upper limb amputation and PLP and that compared the effects on PLP of MT versus a placebo technique. The primary outcome was PLP intensity changes and the secondary outcomes were PLP duration, frequency, patients' disability and quality of life.
RESULTS
Among the five studies included, only one reported a significant difference between the MT group and control group, with a positive MT effect at week 4. Only one study assessed MT effect on disability and found a significant improvement in the MT group at week 10 and month 6.
CONCLUSIONS
Our systematic review did not allow concluding that MT reduces PLP and disability in amputees. This lack of strong evidence is probably due to (i) the low methodological quality of the included studies, and (ii) the lack of statistical power. Future trials should include a higher number of patients, increase the number and frequency of MT sessions, have a long-term follow-up and improve the methodological quality.
SIGNIFICANCE
Recent meta-analyses concluded that MT is effective for reducing phantom limb pain. Conversely, the present systematic review that included only studies with the best level of evidence did not find any evidence about its effectiveness for this condition. We identified many ways to improve future randomized-controlled trials on this topic: increasing the number of participants, reducing the intra-group heterogeneity, using a suitable placebo and intensifying the MT sessions and frequency.
Topics: Humans; Phantom Limb; Quality of Life; Mirror Movement Therapy; Amputees; Pain Management; Randomized Controlled Trials as Topic
PubMed: 36094758
DOI: 10.1002/ejp.2035 -
NeuroImage Sep 2020Following arm amputation the region that represented the missing hand in primary somatosensory cortex (S1) becomes deprived of its primary input, resulting in changed... (Review)
Review
Following arm amputation the region that represented the missing hand in primary somatosensory cortex (S1) becomes deprived of its primary input, resulting in changed boundaries of the S1 body map. This remapping process has been termed 'reorganisation' and has been attributed to multiple mechanisms, including increased expression of previously masked inputs. In a maladaptive plasticity model, such reorganisation has been associated with phantom limb pain (PLP). Brain activity associated with phantom hand movements is also correlated with PLP, suggesting that preserved limb functional representation may serve as a complementary process. Here we review some of the most recent evidence for the potential drivers and consequences of brain (re)organisation following amputation, based on human neuroimaging. We emphasise other perceptual and behavioural factors consequential to arm amputation, such as non-painful phantom sensations, perceived limb ownership, intact hand compensatory behaviour or prosthesis use, which have also been related to both cortical changes and PLP. We also discuss new findings based on interventions designed to alter the brain representation of the phantom limb, including augmented/virtual reality applications and brain computer interfaces. These studies point to a close interaction of sensory changes and alterations in brain regions involved in body representation, pain processing and motor control. Finally, we review recent evidence based on methodological advances such as high field neuroimaging and multivariate techniques that provide new opportunities to interrogate somatosensory representations in the missing hand cortical territory. Collectively, this research highlights the need to consider potential contributions of additional brain mechanisms, beyond S1 remapping, and the dynamic interplay of contextual factors with brain changes for understanding and alleviating PLP.
Topics: Adult; Amputation, Surgical; Amputees; Brain; Brain Mapping; Female; Humans; Male; Middle Aged; Pain; Phantom Limb; Somatosensory Cortex
PubMed: 32428706
DOI: 10.1016/j.neuroimage.2020.116943 -
Prosthetics and Orthotics International Jun 2018Phantom 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... (Comparative Study)
Comparative Study 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.
Topics: Amputation, Surgical; Amputees; Artificial Limbs; Feedback; Female; Humans; Imagery, Psychotherapy; Male; Pain Management; Pain Measurement; Phantom Limb; Prosthesis Fitting; Quality of Life; Treatment Outcome; Virtual Reality Exposure Therapy
PubMed: 29153043
DOI: 10.1177/0309364617740230 -
Annals of Surgery Aug 2019To compare targeted muscle reinnervation (TMR) to "standard treatment" of neuroma excision and burying into muscle for postamputation pain. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To compare targeted muscle reinnervation (TMR) to "standard treatment" of neuroma excision and burying into muscle for postamputation pain.
SUMMARY BACKGROUND DATA
To date, no intervention is consistently effective for neuroma-related residual limb or phantom limb pain (PLP). TMR is a nerve transfer procedure developed for prosthesis control, incidentally found to improve postamputation pain.
METHODS
A prospective, randomized clinical trial was conducted. 28 amputees with chronic pain were assigned to standard treatment or TMR. Primary outcome was change between pre- and postoperative numerical rating scale (NRS, 0-10) pain scores for residual limb pain and PLP at 1 year. Secondary outcomes included NRS for all patients at final follow-up, PROMIS pain scales, neuroma size, and patient function.
RESULTS
In intention-to-treat analysis, changes in PLP scores at 1 year were 3.2 versus -0.2 (difference 3.4, adjusted confidence interval (aCI) -0.1 to 6.9, adjusted P = 0.06) for TMR and standard treatment, respectively. Changes in residual limb pain scores were 2.9 versus 0.9 (difference 1.9, aCI -0.5 to 4.4, P = 0.15). In longitudinal mixed model analysis, difference in change scores for PLP was significantly greater in the TMR group compared with standard treatment [mean (aCI) = 3.5 (0.6, 6.3), P = 0.03]. Reduction in residual limb pain was favorable for TMR (P = 0.10). At longest follow-up, including 3 crossover patients, results favored TMR over standard treatment.
CONCLUSIONS
In this first surgical RCT for the treatment of postamputation pain in major limb amputees, TMR improved PLP and trended toward improved residual limb pain compared with conventional neurectomy.
TRIAL REGISTRATION
NCT02205385 at ClinicalTrials.gov.
Topics: Adult; Amputation, Surgical; Amputees; Female; Follow-Up Studies; Humans; Male; Muscle, Skeletal; Nerve Transfer; Neuroma; Pain Measurement; Pain, Postoperative; Phantom Limb; Prospective Studies; Plastic Surgery Procedures; Single-Blind Method
PubMed: 30371518
DOI: 10.1097/SLA.0000000000003088 -
Scandinavian Journal of Pain Oct 2018Background 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... (Randomized Controlled Trial)
Randomized Controlled Trial
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.
Topics: Amputees; Cambodia; Case-Control Studies; Cross-Over Studies; Female; Humans; Imagery, Psychotherapy; Male; Middle Aged; Pain Management; Phantom Limb; Touch
PubMed: 30207289
DOI: 10.1515/sjpain-2018-0042