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Neurorehabilitation and Neural Repair Aug 2021Phantom limb pain (PLP) is a frequent complication in amputees, which is often refractory to treatments. We aim to assess in a factorial trial the effects of... (Randomized Controlled Trial)
Randomized Controlled Trial
Phantom limb pain (PLP) is a frequent complication in amputees, which is often refractory to treatments. We aim to assess in a factorial trial the effects of transcranial direct current stimulation (tDCS) and mirror therapy (MT) in patients with traumatic lower limb amputation; and whether the motor cortex plasticity changes drive these results. In this large randomized, blinded, 2-site, sham-controlled, 2 × 2 factorial trial, 112 participants with traumatic lower limb amputation were randomized into treatment groups. The interventions were active or covered MT for 4 weeks (20 sessions, 15 minutes each) combined with 2 weeks of either active or sham tDCS (10 sessions, 20 minutes each) applied to the contralateral primary motor cortex. The primary outcome was PLP changes on the visual analogue scale at the end of interventions (4 weeks). Motor cortex excitability and cortical mapping were assessed by transcranial magnetic stimulation (TMS). We found no interaction between tDCS and MT groups ( = 1.90, = .13). In the adjusted models, there was a main effect of active tDCS compared to sham tDCS (beta coefficient = -0.99, = .04) on phantom pain. The overall effect size was 1.19 (95% confidence interval: 0.90, 1.47). No changes in depression and anxiety were found. TDCS intervention was associated with increased intracortical inhibition (coefficient = 0.96, = .02) and facilitation (coefficient = 2.03, = .03) as well as a posterolateral shift of the center of gravity in the affected hemisphere. MT induced no motor cortex plasticity changes assessed by TMS. These findings indicate that transcranial motor cortex stimulation might be an affordable and beneficial PLP treatment modality.
Topics: Adult; Combined Modality Therapy; Double-Blind Method; Evoked Potentials, Motor; Female; Humans; Male; Middle Aged; Mirror Movement Therapy; Motor Cortex; Phantom Limb; Transcranial Magnetic Stimulation; Treatment Outcome; Young Adult
PubMed: 34060934
DOI: 10.1177/15459683211017509 -
The Cochrane Database of Systematic... Jun 2023Amputation is described as the removal of an external part of the body by trauma, medical illness or surgery. Amputations caused by vascular diseases (dysvascular... (Review)
Review
BACKGROUND
Amputation is described as the removal of an external part of the body by trauma, medical illness or surgery. Amputations caused by vascular diseases (dysvascular amputations) are increasingly frequent, commonly due to peripheral arterial disease (PAD), associated with an ageing population, and increased incidence of diabetes and atherosclerotic disease. Interventions for motor rehabilitation might work as a precursor to enhance the rehabilitation process and prosthetic use. Effective rehabilitation can improve mobility, allow people to take up activities again with minimum functional loss and may enhance the quality of life (QoL). Strength training is a commonly used technique for motor rehabilitation following transtibial (below-knee) amputation, aiming to increase muscular strength. Other interventions such as motor imaging (MI), virtual environments (VEs) and proprioceptive neuromuscular facilitation (PNF) may improve the rehabilitation process and, if these interventions can be performed at home, the overall expense of the rehabilitation process may decrease. Due to the increased prevalence, economic impact and long-term rehabilitation process in people with dysvascular amputations, a review investigating the effectiveness of motor rehabilitation interventions in people with dysvascular transtibial amputations is warranted.
OBJECTIVES
To evaluate the benefits and harms of interventions for motor rehabilitation in people with transtibial (below-knee) amputations resulting from peripheral arterial disease or diabetes (dysvascular causes).
SEARCH METHODS
We used standard, extensive Cochrane search methods. The latest search date was 9 January 2023.
SELECTION CRITERIA
We included randomised controlled trials (RCT) in people with transtibial amputations resulting from PAD or diabetes (dysvascular causes) comparing interventions for motor rehabilitation such as strength training (including gait training), MI, VEs and PNF against each other.
DATA COLLECTION AND ANALYSIS
We used standard Cochrane methods. Our primary outcomes were 1. prosthesis use, and 2.
ADVERSE EVENTS
Our secondary outcomes were 3. mortality, 4. QoL, 5. mobility assessment and 6. phantom limb pain. We use GRADE to assess certainty of evidence for each outcome.
MAIN RESULTS
We included two RCTs with a combined total of 30 participants. One study evaluated MI combined with physical practice of walking versus physical practice of walking alone. One study compared two different gait training protocols. The two studies recruited people who already used prosthesis; therefore, we could not assess prosthesis use. The studies did not report mortality, QoL or phantom limb pain. There was a lack of blinding of participants and imprecision as a result of the small number of participants, which downgraded the certainty of the evidence. We identified no studies that compared VE or PNF with usual care or with each other. MI combined with physical practice of walking versus physical practice of walking (one RCT, eight participants) showed very low-certainty evidence of no difference in mobility assessment assessed using walking speed, step length, asymmetry of step length, asymmetry of the mean amount of support on the prosthetic side and on the non-amputee side and Timed Up-and-Go test. The study did not assess adverse events. One study compared two different gait training protocols (one RCT, 22 participants). The study used change scores to evaluate if the different gait training strategies led to a difference in improvement between baseline (day three) and post-intervention (day 10). There were no clear differences using velocity, Berg Balance Scale (BBS) or Amputee Mobility Predictor with PROsthesis (AMPPRO) in training approaches in functional outcome (very low-certainty evidence). There was very low-certainty evidence of little or no difference in adverse events comparing the two different gait training protocols.
AUTHORS' CONCLUSIONS
Overall, there is a paucity of research in the field of motor rehabilitation in dysvascular amputation. We identified very low-certainty evidence that gait training protocols showed little or no difference between the groups in mobility assessments and adverse events. MI combined with physical practice of walking versus physical practice of walking alone showed no clear difference in mobility assessment (very low-certainty evidence). The included studies did not report mortality, QoL, and phantom limb pain, and evaluated participants already using prosthesis, precluding the evaluation of prosthesis use. Due to the very low-certainty evidence available based on only two small trials, it remains unclear whether these interventions have an effect on the prosthesis use, adverse events, mobility assessment, mortality, QoL and phantom limb pain. Further well-designed studies that address interventions for motor rehabilitation in dysvascular transtibial amputation may be important to clarify this uncertainty.
Topics: Humans; Phantom Limb; Amputation, Surgical; Walking; Peripheral Arterial Disease; Diabetes Mellitus
PubMed: 37276273
DOI: 10.1002/14651858.CD013711.pub2 -
BMJ Military Health Apr 2022Amputations result from trauma, war, conflict, vascular diseases and cancer. Phantom limb pain (PLP) is a potentially debilitating form of chronic pain affecting around... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Amputations result from trauma, war, conflict, vascular diseases and cancer. Phantom limb pain (PLP) is a potentially debilitating form of chronic pain affecting around 100 million amputees across the world. Mirror therapy and virtual reality (VR) are two commonly used treatments, and we evaluated their respective success rates.
METHODS
A meta-analysis and systematic review was undertaken to investigate mirror therapy and VR in their ability to reduce pain levels. A mean difference (MD) model to compare group pain levels pretreatment and post-treatment via aggregating these results from numerous similar studies was employed. Meta-analysis was conducted using RevMan (V.5.4) and expressed in MD for visual analogue scale (VAS) score.
RESULTS
A total of 15 studies met our search criteria; they consisted of eight mirror therapy with 214 participants and seven VR including 86 participants, totalling 300 participants. Mean age ranged from 36 to 63 years, 77% male, of which 61% were lower body amputees. Both led to a VAS reduction (mirror therapy mean reduction VAS score was 2.54, 95% CI 1.42 to 3.66; p<0.001; VR 2.24, 95% CI 1.28 to 3.20; p<0.001). There was no statistically significant difference in pain alleviation between mirror therapy and VR (p=0.69).
CONCLUSIONS
Mirror therapy and VR are both equally efficacious in alleviating PLP, but neither is more effective than the other. However, due to small sample size and limited number of studies, factors such as gender, cause of amputation, site of limb loss or length of time from amputation, which may influence treatment success, could not be explored.
Topics: Adult; Amputees; Female; Humans; Male; Middle Aged; Mirror Movement Therapy; Phantom Limb; Virtual Reality; Virtual Reality Exposure Therapy
PubMed: 35042760
DOI: 10.1136/bmjmilitary-2021-002018 -
International Journal of Rehabilitation... Jun 2023Mirror therapy is a widely used treatment for phantom limb pain (PLP) relief in patients with limb loss. Less common is progressive muscle relaxation (PMR), used mostly... (Randomized Controlled Trial)
Randomized Controlled Trial
Is mirror therapy associated with progressive muscle relaxation more effective than mirror therapy alone in reducing phantom limb pain in patients with lower limb amputation?
Mirror therapy is a widely used treatment for phantom limb pain (PLP) relief in patients with limb loss. Less common is progressive muscle relaxation (PMR), used mostly in other medical conditions (psychological, terminal cancer pain, etc). The purpose of this study is to evaluate the efficacy of a mirror therapy preceded by PMR intervention compared to mirror therapy preceded by unguided generic relaxation-mirror therapy in patients with lower limb amputation suffering from PLP. This pilot study was a single-blind, controlled, randomized trial. Thirty lower limb amputees suffering from PLP were recruited and randomly assigned to three groups respectively undergoing a PMR-mirror therapy rehabilitative intervention, generic relaxation-mirror therapy, and conventional physiotherapy (ConvPT). Selected items from Prosthesis Evaluation Questionnaire (PEQ) and the Brief Pain Inventory (BPI) were used to test the pain features at the beginning and 1 week after 3 weeks of intervention. A decrease of about 65% was found in the rate and duration of PLP at the PEQ in PMR-mirror therapy with respect to generic relaxation-mirror therapy (about 30%) and ConvPT (about 6%). A decrease of about 90% in intensity (worst and average) of PLP in PMR-mirror therapy when compared to generic relaxation-mirror therapy (about 45%) and ConvPT (about 20%) was found at the BPI. We preliminary concluded, albeit with limitations due to the small sample of patients, that mirror therapy can improve PLP when associated with PMR. Further studies are required to confirm that PMR could be an effective technique for more successful PLP management.
Topics: Humans; Phantom Limb; Mirror Movement Therapy; Autogenic Training; Single-Blind Method; Pilot Projects; Amputation, Surgical; Amputees; Lower Extremity
PubMed: 37082804
DOI: 10.1097/MRR.0000000000000582 -
Disability and Rehabilitation Dec 2020The aim of this systematic review was to evaluate the effect of immersive and non-immersive interactive virtual reality on pain perception in patients with a clinical...
The aim of this systematic review was to evaluate the effect of immersive and non-immersive interactive virtual reality on pain perception in patients with a clinical pain condition. The following databases were searched from inception: Medline (Ovid), PsychInfo, CINAHL, Cochrane library and Web of Science. Two reviewers screened reports and extracted the data. A third reviewer acted as an arbiter. Studies were eligible if they were randomized controlled trials, quasi-randomized trials, and uncontrolled trials. Crossover and parallel-group designs were included. Risk of bias was assessed for all included studies. Thirteen clinical studies were included. The majority of studies investigated a sample of participants with chronic pain. Six were controlled trials and seven uncontrolled studies. Findings from controlled research suggest that interactive virtual reality may reduce pain associated with ankylosing spondylitis and post-mastectomy, but results are inconsistent for patients with neck pain. Findings from uncontrolled studies suggest that interactive virtual reality may reduce neuropathic limb pain, and phantom limb pain, but had no effect on nonspecific chronic back pain. There is a need for more rigorous randomized control trials in order to conclude on the effectiveness of the use of virtual reality for the management of pain.Implications for rehabilitationInteractive virtual reality has been increasingly used in the rehabilitation of painful conditions.Interactive virtual reality using exergames may promote distraction from painful exercises and reduce pain post-mastectomy and in patients with ankylosing spondylitis.Interactive virtual representation of limbs may reduce neuropathic and phantom limb pain.
Topics: Breast Neoplasms; Exercise Therapy; Female; Humans; Mastectomy; Pain Perception; Virtual Reality
PubMed: 31067135
DOI: 10.1080/09638288.2019.1610803 -
Journal of Anesthesia Jun 2023Phantom limb pain (PLP) is a major cause of physical limitation and disability accounting for about 85% of amputated patients. Mirror therapy is used as a therapeutic... (Randomized Controlled Trial)
Randomized Controlled Trial
PURPOSE AND OBJECTIVES
Phantom limb pain (PLP) is a major cause of physical limitation and disability accounting for about 85% of amputated patients. Mirror therapy is used as a therapeutic modality for patients with phantom limb pain. Primary objective was to study the incidence of PLP at 6 months following below-knee amputation between the mirror therapy group and control group.
METHODS
Patients posted for below-knee amputation surgery were randomized into two groups. Patients allocated to group M received mirror therapy in post-operative period. Two sessions of therapy were given per day for 7 days and each session lasted for 20 min. Patients who developed pain from the missing portion of the amputated limb were considered to have PLP. All patients were followed up for six months and the time of occurrence of PLP and intensity of the pain were recorded among other demographic factors.
RESULTS
A total of 120 patients completed the study after recruitment. The demographic parameters were comparable between the two groups. Overall incidence of phantom limb pain was significantly higher in the control group (Group C) when compared to the mirror therapy (Group M) group [Group M = 7 (11.7%) vs Group C = 17 (28.3%); p = 0.022]. Intensity of PLP measured on the Numerical Rating Scale (NRS) was significantly lower at 3 months in Group M compared to Group C among patients who developed PLP [NRS - median (Inter quartile range): Group M 5 (4,5) vs Group C 6 (5,6); p 0.001].
CONCLUSION
Mirror therapy reduced the incidence of phantom limb pain when administered pre-emptively in patients undergoing amputation surgeries. The severity of the pain was also found to be lower at 3 months in patients who received pre-emptive mirror therapy.
TRIAL REGISTRATION
This prospective study was registered in the clinical trial registry of India.
TRIAL REGISTRATION NUMBER
CTRI/2020/07/026488.
Topics: Humans; Phantom Limb; Mirror Movement Therapy; Prospective Studies; Amputation, Surgical; Amputees
PubMed: 36809505
DOI: 10.1007/s00540-023-03173-9 -
Therapeutic Advances in Chronic Disease 2022To evaluate the effectiveness of any form of physiotherapy intervention for the management of central neuropathic pain (cNeP) due to any underlying cause.
OBJECTIVES
To evaluate the effectiveness of any form of physiotherapy intervention for the management of central neuropathic pain (cNeP) due to any underlying cause.
METHODS
Multiple databases were searched from inception until August 2021. Randomised controlled trials evaluating physiotherapy interventions compared to a control condition on pain among people with cNeP were included. Methodological quality and the quality of evidence were assessed using the Physiotherapy Evidence Database Scale and the Grading of Recommendations, Assessment, Development, and Evaluation tool, respectively.
RESULTS
The searches yielded 2661 studies, of which 23 randomised controlled trials met the inclusion criteria and were included in the meta-analyses. Meta-analyses of trials examining non-invasive neurostimulation revealed significant reductions in pain severity due to spinal cord injury (SCI; standardised mean difference (SMD): -0.59 (95% confidence interval [CI]: -1.07, -0.11), = 0.02) and phantom limb pain (weighted mean difference (WMD): -1.57 (95% CI: -2.85, -0.29), = 0.02). The pooled analyses of trials utilising acupuncture, transcutaneous electrical nerve stimulation (TENS), and mirror therapy showed significant reductions in pain severity among individuals with stroke (WMD: -1.46 (95% CI: -1.97, -0.94), < 0.001), multiple sclerosis (SMD: -0.32 (95% CI: -0.57, -0.06), = 0.01), and phantom limb pain (SMD: -0.74 (95% CI: -1.36, -0.11), = 0.02), respectively. Exercise was also found to significantly reduce pain among people with multiple sclerosis (SMD: -1.58 (95% CI: -2.85, -0.30), = 0.02).
CONCLUSION
Evidence supports the use of non-invasive neurostimulation for the treatment of pain secondary to SCI and phantom limb pain. Beneficial pain management outcomes were also identified for acupuncture in stroke, TENS in multiple sclerosis, and mirror therapy in phantom limb pain.
PubMed: 35356293
DOI: 10.1177/20406223221078672 -
The Orthopedic Clinics of North America Apr 2022The effective management of peripheral nerves in amputation surgery is critical to optimizing patient outcomes. Nerve-related pain after amputation is common, maybe a... (Review)
Review
The effective management of peripheral nerves in amputation surgery is critical to optimizing patient outcomes. Nerve-related pain after amputation is common, maybe a source of dissatisfaction and functional impairment, and should be considered in all amputees presenting with pain and dysfunction. While traction neurectomy or transposition has long been the standard of care, both regenerative peripheral nerve interface (RPNI) and targeted muscle reinnervation (TMR) have emerged as promising techniques to improve neuroma-related and phantom pain. A multi-disciplinary and multi-modal approach is essential for the optimal management of amputees both acutely and in the delayed or chronic setting.
Topics: Amputation, Surgical; Extremities; Humans; Nerve Transfer; Peripheral Nerves; Phantom Limb
PubMed: 35365260
DOI: 10.1016/j.ocl.2022.01.002 -
Journal of Neurology, Neurosurgery, and... May 2022Phantom limb pain (PLP) impacts the majority of individuals who undergo limb amputation. The PLP experience is highly heterogenous in its quality, intensity, frequency... (Review)
Review
Phantom limb pain (PLP) impacts the majority of individuals who undergo limb amputation. The PLP experience is highly heterogenous in its quality, intensity, frequency and severity. This heterogeneity, combined with the low prevalence of amputation in the general population, has made it difficult to accumulate reliable data on PLP. Consequently, we lack consensus on PLP mechanisms, as well as effective treatment options. However, the wealth of new PLP research, over the past decade, provides a unique opportunity to re-evaluate some of the core assumptions underlying what we know about PLP and the rationale behind PLP treatments. The goal of this review is to help generate consensus in the field on how best to research PLP, from phenomenology to treatment. We highlight conceptual and methodological challenges in studying PLP, which have hindered progress on the topic and spawned disagreement in the field, and offer potential solutions to overcome these challenges. Our hope is that a constructive evaluation of the foundational knowledge underlying PLP research practices will enable more informed decisions when testing the efficacy of existing interventions and will guide the development of the next generation of PLP treatments.
PubMed: 35609964
DOI: 10.1136/jnnp-2021-328428