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Canadian Journal of Pain = Revue... 2023Graded Motor Imagery (GMI) is a non-invasive and inexpensive therapy used to treat Phantom Limb Pain (PLP) by sequentially activating motor networks in such a way that... (Review)
Review
INTRODUCTION
Graded Motor Imagery (GMI) is a non-invasive and inexpensive therapy used to treat Phantom Limb Pain (PLP) by sequentially activating motor networks in such a way that movement and pain are unpaired. The objective of this systematic review was to critically appraise relevant data on the efficacy of GMI and its components for reducing PLP and disability in amputees.
METHODS
We searched 11 electronic databases for controlled trials investigating GMI and its components in amputees with PLP from inception until February 2023. Two reviewers independently screened studies and extracted relevant data. Study-level data were entered using the inverse variance function of the Review Manager 5 and pooled with the random effects model.
RESULTS
Eleven studies with varying risk of bias were eligible. No eligible study considered left/right judgement tasks in isolation. Studies showed no effect for imagined movements, but positive effects were seen for GMI [weighted mean difference: -21.29 (95%CI: -31.55, -11.02), I= 0%] and mirror therapy [weighted mean difference: -8.55 (95%CI: -14.74, -2.35, I= 61%]. A comparison of mirror therapy versus sham showed no difference [weighted mean difference: -4.43 (95%CI: -16.03, 7.16), I= 51%].
CONCLUSION
Our findings suggest that GMI and mirror therapy may be effective for reducing PLP. However, this conclusion was drawn from a limited body of evidence, and the certainty of the evidence was very low. Therefore, rigorous, high-quality trials are needed to address the gap in the literature and inform practice.
PubMed: 37214633
DOI: 10.1080/24740527.2023.2188899 -
Plastic and Reconstructive Surgery Feb 2024It is estimated that by 2050, a total of 3.6 million patients will be living with an amputation in the United States. The objective of this systematic review is to...
BACKGROUND
It is estimated that by 2050, a total of 3.6 million patients will be living with an amputation in the United States. The objective of this systematic review is to evaluate the effect of targeted muscle reinnervation (TMR) on pain and physical functioning in amputees.
METHODS
A literature search was performed on PubMed, Embase, and MEDLINE up to November 28, 2021. Clinical studies assessing the outcomes of TMR (pain, prosthesis control, life quality, limb function, and disability) were included.
RESULTS
Thirty-nine articles were included. The total number of patients who underwent TMR was 449, and 716 were controls. Mean follow-up was 25 months. A total of 309 (66%) lower-limb and 159 (34%) upper-limb amputations took place in the TMR group, the most common being below-knee amputations (39%). The control group included a total of 557 (84%) lower-limb and 108 (16%) upper-limb amputations; the greatest proportion being below-knee amputations in this group as well (54%). Trauma was the most common indication for amputation. Phantom limb pain scores were lower by 10.2 points for intensity ( P = 0.01), 4.67 points for behavior ( P = 0.01), and 8.9 points for interference ( P = 0.09). Similarly, residual limb pain measures were lower for cases for intensity, behavior, and interference, but they failed to reach significance. Neuroma symptoms occurred less frequently, and functional and prosthesis control outcomes improved following TMR.
CONCLUSION
The literature evidence suggests that TMR is a promising therapy for improving pain, prosthesis use, and functional outcomes after limb amputation.
Topics: Humans; Amputation, Surgical; Artificial Limbs; Lower Extremity; Muscle, Skeletal; Muscles; Phantom Limb
PubMed: 37104493
DOI: 10.1097/PRS.0000000000010598 -
PM & R : the Journal of Injury,... Nov 2023Nerve pain frequently develops following amputations and peripheral nerve injuries. Two innovative surgical techniques, targeted muscle reinnervation (TMR) and... (Review)
Review
OBJECTIVE
Nerve pain frequently develops following amputations and peripheral nerve injuries. Two innovative surgical techniques, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNI), are rapidly gaining popularity as alternatives to traditional nerve management, but their effectiveness is unclear.
LITERATURE SURVEY
A review of literature pertaining to TMR and RPNI pain results was conducted. PubMed and MEDLINE electronic databases were queried.
METHODOLOGY
Studies were included if pain outcomes were assessed after TMR or RPNI in the upper or lower extremity, both for prophylaxis performed at the time of amputation and for treatment of postamputation pain. Data were extracted for evaluation.
SYNTHESIS
Seventeen studies were included, with 14 evaluating TMR (366 patients) and three evaluating RPNI (75 patients). Of these, one study was a randomized controlled trial. Nine studies had a mean follow-up time of at least 1 year (range 4-27.6 months). For pain treatment, TMR and RPNI improved neuroma pain in 75%-100% of patients and phantom limb pain in 45%-80% of patients, averaging a 2.4-6.2-point reduction in pain scores on the numeric rating scale postoperatively. When TMR or RPNI was performed prophylactically, many patients reported no neuroma pain (48%-100%) or phantom limb pain (45%-87%) at time of follow-up. Six TMR studies reported Patient-Reported Outcomes Measurement Information System (PROMIS) scores assessing pain intensity, behavior, and interference, which consistently showed a benefit for all measures. Complication rates ranged from 13% to 31%, most frequently delayed wound healing.
CONCLUSIONS
Both TMR and RPNI may be beneficial for preventing and treating pain originating from peripheral nerve dysfunction compared to traditional techniques. Randomized trials with longer term follow-up are needed to directly compare the effectiveness of TMR and RPNI with traditional nerve management techniques.
Topics: Humans; Phantom Limb; Amputation, Surgical; Neurosurgical Procedures; Neuroma; Peripheral Nerves; Muscles; Muscle, Skeletal; Randomized Controlled Trials as Topic
PubMed: 36965013
DOI: 10.1002/pmrj.12972 -
Microsurgery Oct 2023Targeted muscle reinnervation (TMR) is a promising surgical modality for reducing post-amputation pain. We sought to provide a succinct overview of TMR specific to the... (Review)
Review
BACKGROUND
Targeted muscle reinnervation (TMR) is a promising surgical modality for reducing post-amputation pain. We sought to provide a succinct overview of TMR specific to the lower extremity (LE) amputation population.
METHODS
A systematic review was performed per PRISMA guidelines. Ovid MEDLINE, PubMed, and Web of Science were queried for records using various combinations of Medical Subject Heading (MeSH) terms such as "LE "amputation," "below-knee amputation" (BKA), "above-knee amputation" (AKA), and "TMR." Primary outcomes included (1) operative techniques, (2) changes in neuroma, phantom limb pain (PLP), or residual limb pain (RLP), and (3) postoperative complications. Studies were only included if outcomes data were discretely provided for LE patients.
RESULTS
Eleven articles examining 318 patients were identified. Average patient age was 47.5 ± 9.3 years, and most patients were male (n = 246, 77.4%). Eight manuscripts (72.7%) described TMR at the index amputation. The average number of nerve transfers performed per TMR case was 2.1 ± 0.8, and the most commonly employed nerve was the tibial (178/498; 35.7%). Nine (81.8%) articles incorporated patient-reported outcomes after TMR, with common methods including the Numerical Rating Scale (NRS) and questionnaires. Four studies (33.3%) reported functional outcomes such as ambulation ability and prosthesis tolerance. Complications were described in seven manuscripts (58.3%), with postoperative neuroma development being the most common (21/371; 7.2%).
CONCLUSIONS
The application of TMR to LE amputations is effective in reducing PLP and RLP with limited complications. Continued investigations are warranted to better understand patient outcomes specific to anatomic location using validated patient-reported outcome measures (PROM).
PubMed: 36864779
DOI: 10.1002/micr.31030 -
Disability and Rehabilitation Feb 2024To summarize the research on the effectiveness of virtual reality (VR) therapy for the management of phantom limb pain (PLP).
PURPOSE
To summarize the research on the effectiveness of virtual reality (VR) therapy for the management of phantom limb pain (PLP).
METHODS
Three databases (SCOPUS, Ovid Embase, and Ovid MEDLINE) were searched for studies investigating the use of VR therapy for the treatment of PLP. Original research articles fulfilling the following criteria were included: (i) patients 18 years and older; (ii) all etiologies of amputation; (iii) any level of amputation; (iv) use of immersive VR as a treatment modality for PLP; (v) self-reported objective measures of PLP before and after at least one VR session; (vi) written in English.
RESULTS
A total of 15 studies were included for analysis. Fourteen studies reported decreases in objective pain scores following a single VR session or a VR intervention consisting of multiple sessions. Moreover, combining VR with tactile stimulation had a larger beneficial effect on PLP compared with VR alone.
CONCLUSIONS
Based on the current literature, VR therapy has the potential to be an effective treatment modality for the management of PLP. However, the low quality of studies, heterogeneity in subject population and intervention type, and lack of data on long-term relief make it difficult to draw definitive conclusions.IMPLICATION FOR REHABILITATIONVirtual reality (VR) therapy has emerged as a new potential treatment option for phantom limb pain (PLP) that circumvents some limitations of mirror therapy.VR therapy was shown to decrease PLP following a single VR session as well as after an intervention consisting of multiple sessions.The addition of vibrotactile stimuli to VR therapy may lead to larger decreases in PLP scores compared with VR therapy alone.
Topics: Humans; Phantom Limb; Amputation, Surgical; Treatment Outcome; Pain Management; Virtual Reality
PubMed: 36724203
DOI: 10.1080/09638288.2023.2172222 -
Innovations in Clinical Neuroscience 2022To evaluate the literature on the effectiveness of virtual reality (VR)- and augmented reality (AR)-based treatments for phantom limb pain (PLP) in postamputation or... (Review)
Review
OBJECTIVE
To evaluate the literature on the effectiveness of virtual reality (VR)- and augmented reality (AR)-based treatments for phantom limb pain (PLP) in postamputation or brachial plexus avulsion (BPA) populations.
METHODS
Multiple databases were queried in July 2021 with the keywords "virtual reality," "augmented reality," and "phantom limb pain." Included studies utilized VR or AR to treat PLP with outcome measurement. Two independent reviewers assessed methodological quality using the Physiotherapy Evidence Databsae (PEDro) Scale and the Methodological Index for Nonrandomized Studies (MINORS) scoring. Studies were separated into immersive and nonimmersive AR/VR systems, with further categorization according to the specific methodologies used.
RESULTS
Of 110 results from the database queries, 20 publications met the inclusion criteria. There was one unblinded, randomized, control trial (RCT), one single-blinded, randomized, crossover trial (RCxT), three comparative case series, 13 noncomparative case series, and two case reports. Seven of the 20 studies were classified as nonimmersive. Six studies reported decreased PLP after AR/VR treatments, of which four reported significant reductions. One study reported a reduction in PLP with no significant difference from control conditions. Thirteen of the 20 studies were classified as immersive AR/VR. Twelve studies reported decreased PLP after AR/VR treatments, of which eight reported significant reductions. One study found no change in PLP, compared to baseline.
CONCLUSION
The number of studies using AR/VR in PLP treatment has expanded since a 2017 review on the topic. The majority of these studies offer support for the efficacy of treating PLP with AR/VR-based treatments. Research has expanded on the customization, outcome measurements, and statistical analysis of AR/VR treatments. While results are promising, most publications remain at the case series level, and clinical indications should be cautioned. With improvements in the quality of evidence, there remain avenues for further investigations, including increased sampling, randomization, optimization of treatment duration, and comparisons to alternative therapies.
PubMed: 36591552
DOI: No ID Found -
Hand (New York, N.Y.) Jun 2024Upper and lower limb amputations are frequently associated with phantom limb pain (PLP). Recently, virtual reality (VR) and augmented reality (AR) have been reported as... (Review)
Review
Upper and lower limb amputations are frequently associated with phantom limb pain (PLP). Recently, virtual reality (VR) and augmented reality (AR) have been reported as a potential therapy of PLP. We have conducted a systematic review of literature to evaluate the efficacy of VR and AR in managing PLP. Four databases were searched: PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Web of Science. We utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for our organization. The initial search resulted in 164 results. After title, abstract, and full-text screening, 9 studies were included. One study was of good quality and 8 studies were of fair to poor quality. Seven studies utilized VR and 2 studies utilized AR. The number of treatment sessions ranged from 1 to 28 and the duration ranged from 10 minutes to 2 hours. Several pain scales were used to evaluate PLP pre- and postintervention including Numeric Rating Scale, Pain Rating Index, McGill Pain Questionnaire, and Visual Analog Scale. All the studies reported improvement of PLP on one or more of pain scales after one or more sessions of VR or AR. Despite the promising results reported by literature, we cannot recommend using VR or AR for PLP. Most of the studies are of poor design and have limited sample size with high bias levels. Therefore, no substantial evidence can be derived from them. However, we do believe further research with high-quality randomized controlled trials should take place to increase the knowledge of the potential advantages.
Topics: Humans; Phantom Limb; Augmented Reality; Pain Measurement; Virtual Reality; Pain Management; Amputation, Surgical; Virtual Reality Exposure Therapy
PubMed: 36341580
DOI: 10.1177/15589447221130093 -
Healthcare (Basel, Switzerland) Oct 2022(1) Background: Patients diagnosed with chronic pain suffer from long-term pain, which negatively affects their daily lives and mental health. Virtual reality (VR)... (Review)
Review
(1) Background: Patients diagnosed with chronic pain suffer from long-term pain, which negatively affects their daily lives and mental health. Virtual reality (VR) technologies are considered a therapeutic tool to manage pain perception and mental health conditions. This systematic review aimed to appraise the efficacy of VR in improving pain intensity, anxiety, depression and mood among patients with chronic pain; (2) Methods: Five electronic databases were systematically searched using the terms representing VR and chronic pain. Quality assessment was conducted using Cochrane Collaboration's tool and Newcastle-Ottawa scale; (3) Results: Seventeen peer-reviewed articles were included in this review. It was found that VR was able to reduce pain intensity in patients with phantom limb pain, chronic headache, chronic neck pain and chronic low-back pain. The effects of VR on the improvement of anxiety, depression and mood were not determined due to the inadequate amount of clinical evidence; (4) Conclusions: VR, especially immersive VR, improves pain outcomes and its effects may vary depending on the approach and study design. More research is still needed to investigate the clinical use of VR in patients with chronic pain.
PubMed: 36292493
DOI: 10.3390/healthcare10102047 -
Biomedicines Oct 2022Peripheral nerve stimulation (PNS) has been utilized for over 50 years with accumulating evidence of efficacy in a variety of chronic pain conditions. The level and... (Review)
Review
Peripheral nerve stimulation (PNS) has been utilized for over 50 years with accumulating evidence of efficacy in a variety of chronic pain conditions. The level and strength of evidence supporting the use of PNS for peripheral neuropathic pain remains unclear. The purpose of this review is to synthesize data from prospective studies on the efficacy of PNS for neuropathic pain as it pertains to pain intensity, neurological deficits/neuropathy (e.g., weakness, sensory deficits, gait/balance), and other secondary outcomes (quality of life, satisfaction, emotional functioning, and adverse events). In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, this review identified articles from MEDLINE(R), EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus. Overall, per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, pooled results demonstrate very low quality or low quality of evidence supporting modest to substantial improvement in pain and neurological function after PNS implantation for treatment of peripheral neuropathic pain. PNS for phantom limb pain was the only indication that had moderate level evidence. Future prospective and well-powered studies are warranted to assess the efficacy of PNS for peripheral neuropathic pain.
PubMed: 36289867
DOI: 10.3390/biomedicines10102606 -
Cureus Aug 2022While amputation techniques have improved over time, questions remain around how to best treat neuromas and severed nerves in the amputee population, specifically for... (Review)
Review
While amputation techniques have improved over time, questions remain around how to best treat neuromas and severed nerves in the amputee population, specifically for trauma-related amputees. This systematic review investigates and summarizes outcomes following targeted muscle reinnervation (TMR) for the trauma-related amputee population. Studies were classified based on primary or secondary TMR and relevant outcomes, including the ability to use a prosthesis, post-TMR opioid use, Patient-Reported Outcomes Measurement Information System (PROMIS) scores for phantom limb pain and residual limb pain, and overall pain resolution/reduction. Following TMR for trauma-related amputation, most patients experienced neuroma pain resolution (86.2%, 95% confidence interval [CI]: 67.2-95.0%) and overall pain reduction/resolution (90.7%, 95% CI: 82.2-95.4%). No differences were seen between primary and secondary TMR. Preliminary evidence indicates that TMR is effective for preventing or treating pain in patients with trauma-related amputation, whether used in the acute or delayed setting.
PubMed: 36176851
DOI: 10.7759/cureus.28474