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Mirror Therapy in the Rehabilitation of Lower-Limb Amputation
Abstract
Mirror box therapy and its development (immersive virtual reality) is used in pain therapy and in rehabilitation of people with amputation affected by phantom limb-related phenomena. It allows patients to view a reflection of their anatomical limb in the visual space occupied by their phantom limb. There are only limited reports of its possible side effects.
We retrospectively reviewed the existence of side effects or adverse reactions in a group of 33 nonselected patients with phantom limb-related phenomena.
Nineteen reported confusion and dizziness, 6 reported a not clearly specified sensation of irritation, and 4 refused to continue the treatment. Only 4 of the 33 patients did not have any complaints.
Possible reasons for this large number of side effects could be the lack of selection of patients and the fact that the mirror box therapy was paralleled by a conventional rehabilitation approach targeted to the use of a prosthesis. Warnings on the need to select patients, with regard to their psychologic as well as clinical profile (including time from amputation and clinical setting), and possible conflicting mechanisms between mirror box therapy and conventional therapies are presented.
... (2) any diagnosed psychological disorder that could restrain the ability to concentrate during the therapy [23]; (3) residual limb pain [26]; (4) infectious or systematic diseases [27,28]; (5) neuropathic pain except PLP [29]; (6) severe mental disorder, neglect syndrome, visual spatial hemineglect, confusion, or dizziness [29]. ...
... (2) any diagnosed psychological disorder that could restrain the ability to concentrate during the therapy [23]; (3) residual limb pain [26]; (4) infectious or systematic diseases [27,28]; (5) neuropathic pain except PLP [29]; (6) severe mental disorder, neglect syndrome, visual spatial hemineglect, confusion, or dizziness [29]. ...
... The exercise program consisted of stretching, strengthening, and isometric exercises and prosthetic training (range of movement, mobility, balance training, sit-tostand) depending on the amputation level and evaluation output. Routine physiotherapy involved a 35-minute session once a day, 5 days per week for 4 weeks [29]. The subjects were instructed to note their performance, specifying the type, period, and rate of recurrence [26]. ...
Introduction
The study objective was to determine the effect of conventional physiotherapy treatment with and without mirror therapy on phantom limb pain and psychosocial adjustment to amputation among prosthesis wearers.
Methods
It was a randomized controlled trial. Data were collected in the Physiotherapy Department of the Pakistan Society for the Rehabilitation of the Disabled, Lahore, and University of Lahore teaching hospital, Lahore. Overall, 36 participants with unilateral lower extremity traumatic amputation and phantom limb pain were recruited.
Results
At baseline, the experimental and control groups were comparable for both Numeric Pain Rating Scale (6.17 ± 1.80 and 6.33 ± 1.74) and psychosocial adjustment of the Trinity Amputation and Prosthesis Experience Scales, i.e. general adjustment (19.22 ± 2.39 and 19.67 ± 2.76), adjustment to limitation (12.78 ± 4.36 and 11.72 ± 3.69), and social adjustment (20.22 ± 1.83 and 20.05 ± 2.87). At the end of the 4th week, a significant reduction in pain was observed (2.27 ± 1.17 and 4 ± 1.37). Changes were recorded in general adjustment (22.27 ± 2.63 and 21.89 ± 2.21) and adjustment to limitation (19.67 ± 2.54 and 16.00 ± 3.97) but no significant difference was seen in social adjustment (22.67 ± 1.90 and 21.89 ± 1.99).
Conclusions
Mirror therapy combined with routine physical therapy is a beneficial approach and shows better results in mitigating phantom limb pain and in psychosocial adjustment to the prosthesis than routine physical therapy alone.
... These have never been compared and researched. Adverse effects are only rarely mentioned (Table 2) [7,10,11,[14][15][16] and are by no means thoroughly researched [4]. Only 1 article based on retrospective evaluation of patient records specifically discusses the frequent adverse effects of MVF experienced during treatment, which resulted in withdrawal from MVF [16]. ...
... Adverse effects are only rarely mentioned (Table 2) [7,10,11,[14][15][16] and are by no means thoroughly researched [4]. Only 1 article based on retrospective evaluation of patient records specifically discusses the frequent adverse effects of MVF experienced during treatment, which resulted in withdrawal from MVF [16]. ...
... Chan et al, 2007 [10] Two brief grief reactions Grünert-Plüss et al, 2008 [7] Pain increase possible Casale et al, 2009 [16] Dizziness, irritation, uneasiness Kawashima and Mita, 2009 [11] Client vomited after an increasing feeling of nausea during the first session Darnall and Li, 2012 [14] Boredom, increased depression, increase in phantom limb awareness, and phantom limb pain predetermined level of group consensus [18,19]. A number of advantages contributed to the choice of the Delphi Method in this study: feeding back the experts' responses from previous rounds validates and enlarges the data, and rapid clarification can be obtained [20]. ...
MVF (mirror therapy) is practised worldwide in very different ways to alleviate phantom pain; no study has compared these variations yet or researched risk and harm.
To establish usage and justification of a generally accepted MVF treatment plan after amputation, to explore occurrence and handling of side effects, and to increase knowledge on contributing factors.
Experiential knowledge of 13 experienced practitioners from six countries and five professions was explored with a three round Delphi technique.
Experience with the use of five different treatment plans was described of which one has never been mentioned in the literature: an intense one-off plan where the illusion was carefully set up before the patient was left to the experience with no interference, resolving pain as well as side effects. In the four known treatment plans, the expectations of response time varied which influenced the definition of responders/non-responders, the set-ups, control and use of material reflected the professional background of the practitioners. Contraindications were also defined according to the professional confidence to deal with the side effects. Side effects were reported including emotional reactions, pain increase, sensory changes, freezing of the phantom limb, and dizziness and sweating. The attitude toward and the handling of side effects varied in patients as in practitioners according to their professional background. A tool to fine-tune the experience was reported with covering the limb during therapy. Full consensus was reached on several treatment modalities.
The results suggest that the different treatment plans suit different patients and practitioners. Matching these could enhance effectiveness and compliance. Knowledge about side effects needs to inform treatment decisions. These findings triggered the development of a MVF gateway to guide patients to the treatment plan for their needs and collect data from the practitioners to enhance neuroscientific understanding and inform practice.
... In addition, this study involved acute patients who were more susceptible to any changes in their medical condition and hence more likely to drop out. Casale, Damiani, and Rosati (2009) in a retrospective study reported that MT had adverse effects in 29 out of 33 patients with phantom limb pain. The main side effects reported were confusion, dizziness, and grief. ...
... This finding was not replicated in the other studies included here. Furthermore, this work (Casale et al., 2009) is limited as the cohort under study was not prescreened nor were the participants profiled psychologically. Another intriguing factor in this study was the application of training in the use of prosthesis simultaneously with MT training. ...
... Another intriguing factor in this study was the application of training in the use of prosthesis simultaneously with MT training. These two methodologies were clearly conflicting insofar MT tricks the brain into thinking that the phantom limb was moving normally (i.e., as it did before amputation), and conventional rehabilitation attempts to reconstruct a new body image using prosthesis (Casale et al., 2009). However, to ensure safe clinical use of the technique, future studies on MT with the stroke population should still check for any potential adverse effects due to the intervention. ...
Objective/Background
This study aims to review the current evidence on effectiveness of mirror therapy (MT) in improving motor function of the hemiplegic upper limb (UL) among the adult stroke population in the last 12 years.
Methods
A systematic review of studies published in English from 1999 to 2011, retrieved from four electronic databases MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Sage Online, and ScienceDirect, was performed. Only articles focusing on the effects of MT to train UL motor function were included. The methodological quality of the studies was appraised based on the design and Physiotherapy Evidence Database Scale.
Results
Of the 1,129 articles, nine (six randomised controlled trials and three case reports) were reviewed. The majority of the studies were heterogeneous in design. The review indicated that the strength of current evidence for the use of MT with the stroke population is moderate and seemed to benefit participants with subacute stroke. Little is known about its long-term sustainability, the right target group of the stroke population, and the optimal time to start intervention.
Conclusion
More research is needed to determine the optimal dose of therapy, optimal time to start this intervention, and the right target group. Accordingly, no firm conclusions can now be drawn on the effectiveness of MT until more evidence is present.
... Data of age, sex, weight, height, days from the pre-operative evaluation to surgery, educational status, Short Form Geriatric Depression Scale (SFGDS) 20 , VAS at rest and during movement, active range of movement of flexion and extension 21 , Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) 22 , graded ambulation distances 23 , 6 minute walk test 24 , and timed-stands test 25 , were collected by another physiatrist, who was blind to the allocation. Scores of all above scales, except SFGDS, and total weekly amounts of intravenous tramadol demands, adverse effects (dizziness, psychiatric distress, boredom, depressive mood, muscles twitching 26,27 , and nausea 28 ) were recorded shortly after completion of each one-week session and 3 weeks after completion of the final intervention by the same physiatrist. ...
... Considering that the same VR showed an error range in ROM assessment of up to 7.2° in flexion and extension and to 16.1° in rotation 62 , the current trial may be the first evidence that the VR improves active ROM. No major or minor adverse event was noticed although simulator sickness in the VR 28,38 and dizziness, emotional discomfort, depressive mood, and muscle twitching in the MT 26,27 were reported. However, objective evaluation, similar to a study by Keshavarz and Hecht 63 , was not performed. ...
To overcome the limitation of short-term efficacy of virtual reality (VR), an enhanced reality (ER) analgesia, (combination of the VR, real-time motion capture, mirror therapy [MT]) involving a high degree of patients' presence or embodiment was explored. Patients, who underwent unilateral total knee arthroplasty (TKA), received ER analgesia. The duration was 5 times a week, for 2 weeks for one group and 5 times a week, for 1 week in the other. Visual Analogue Scale (VAS) at rest and during movement, active knee range of motion (ROM) for flexion and extension were measured repeatedly. After screening 157 patients, 60 were included. Pre-interventional evaluation was performed at 6.7 days and ER was initiated at 12.4 days after surgery. Evaluation was performed at 5, 12, 33 days after the initiation of ER. Analgesia in the 2 week therapy group was effective until the third evaluation (p = 0.000), whereas in the other group, it was effective only until the second evaluation (p = 0.010). Improvement in ROM in the 2 week group was also maintained until the third evaluation (p = 0.037, p = 0.009). It could lay the foundations for the development of safe and long-lasting analgesic tools.
... MT consists of placing a mirror medial to the intact limb and allowing the patient to view a reflection of their anatomical limb in the visual space occupied by the phantom limb. 10 Patients can move or touch their anatomical limb while looking into the mirror and visualizing both limbs doing the same action. MT is thought to provide the link between the visual and motor systems that is missing in PLP. ...
... The literature reporting MT outcomes describes the use of prescribed MT on a scheduled basis, such as sessions of 30 min/day, 5 days/week, for 3 weeks. 10 This is seemingly most effective for reversing the maladaptive cortical reorganization that occurs after an amputation. The use of MT "as needed," rather than on a scheduled basis, may have been less effective in reducing the duration and intensity of the PLP. ...
Background and purpose/objective:
Mirror therapy has not been reported for phantom limb pain (PLP) in pediatric oncology. Our aims are to describe the incidence and duration of PLP post-amputation, the duration of follow-up, pain scores and pain medications, and the differences between a group that received mirror therapy (MT) in addition to the standard treatment and a group that received only the standard treatment (non-MT).
Methods:
A retrospective review of patients' medical records from June 2009 to March 2015 was completed. The demographic characteristics, diagnoses and types of surgery were collected. The incidence and duration of PLP, duration of pain service follow-up, pain medications and pain scores were collected and analyzed using the Wilcoxon rank sum test.
Results:
Of 21 patients who underwent amputations (median age 13 years, range, 8-24 years), most common primary diagnosis osteosarcoma), 18 (85.7%) experienced PLP; 38.9% of them experienced PLP at 1 year post-amputation (11.1% of the MT group and 66.7% of the non-MT group). The MT group and non-MT groups experienced PLP for a mean (± SD) of 246 (± 200) days, and 541 (± 363) days, respectively (p=0.08). The mean (SD) opioid doses (mg/kg/day) in the MT and non-MT groups were 0.81 (± 0.99) and 0.33 (± 0.31), respectively; the mean (SD) gabapentin doses (mg/kg/day) were 40.1 (± 21) for the MT group and 30.5 (± 11.5) for the non-MT group.
Conclusion:
MT in children with cancer-related amputations is associated with lower incidence of PLP at 1 year and shorter duration of PLP.
... Patients with mental disorders (e.g. post traumatic stress disorders) should only perform mirror therapy after prior assessment through a psychologist, as the mirror image of two intact limbs might elicit memories associated with the trauma and thereby could evoke emotional reactions (20,30,31). ...
... The mirror image of two intact limbs can evoke emotional reactions (30)(31)(32). Other reactions like dizziness, nausea or sweating can be triggered in individual patients when observing the mirror reflection. ...
... As still several clinical methods are used in treating stroke and pain patients with MT interventions, future studies have to identify which treatment characteristics are more effective than others, enabling the design for clinical protocols. Remarkably, only two studies have reported on adverse effects of an MT intervention (Chan et al., 2007;Casale et al., 2009), finding them to be clinically significant and not infrequent. In the retrospective study of Casale et al. (2009), 29 out of 33 patients with PLP withdrew from MT treatment because of side effects such as grief, confusion or dizziness. ...
... Remarkably, only two studies have reported on adverse effects of an MT intervention (Chan et al., 2007;Casale et al., 2009), finding them to be clinically significant and not infrequent. In the retrospective study of Casale et al. (2009), 29 out of 33 patients with PLP withdrew from MT treatment because of side effects such as grief, confusion or dizziness. These results show the potential adverse reactions that can be induced by the intervention and are in line with the results as that of Moseley et al. (2008), who showed that motor imagery led to increased pain and swelling in patients with chronic arm pain. ...
The objective of this study was to evaluate the clinical aspects of mirror therapy (MT) interventions after stroke, phantom limb pain and complex regional pain syndrome. A systematic literature search of the Cochrane Database of controlled trials, PubMed/MEDLINE, CINAHL, EMBASE, PsycINFO, PEDro, RehabTrials and Rehadat, was made by two investigators independently (A.S.R. and M.J.). No restrictions were made regarding study design and type or localization of stroke, complex regional pain syndrome and amputation. Only studies that had MT given as a long-term treatment were included. Two authors (A.S.R. and S.M.B.) independently assessed studies for eligibility and risk of bias by using the Amsterdam-Maastricht Consensus List. Ten randomized trials, seven patient series and four single-case studies were included. The studies were heterogeneous regarding design, size, conditions studied and outcome measures. Methodological quality varied; only a few studies were of high quality. Important clinical aspects, such as assessment of possible side effects, were only insufficiently addressed. For stroke there is a moderate quality of evidence that MT as an additional intervention improves recovery of arm function, and a low quality of evidence regarding lower limb function and pain after stroke. The quality of evidence in patients with complex regional pain syndrome and phantom limb pain is also low. Firm conclusions could not be drawn. Little is known about which patients are likely to benefit most from MT, and how MT should preferably be applied. Future studies with clear descriptions of intervention protocols should focus on standardized outcome measures and systematically register adverse effects.
... It should be mentioned that mirror treatment has certain negative effects, such as a hazy feeling of psychological annoyance and confusion. 63 It is challenging to comprehend the system's complete involvement in mirror treatment because the mirror neuron system is little known and was just recently identified. ...
Pain remains a very important issue that needs to be addressed after amputation of the lower limb. There are may pharmacological
agents available and many procedures which can be used to give pain relief to these patients but with varying degree of
acceptability and success.
The current review article discusses about the challenges related to the management of pain after amputation of lower limb
and recent trends in this field
... De plus, lorsqu'il est question de patients amputés, la vision du reflet de leur membre sain prenant la place de leur membre manquant peut être particulièrement éprouvante étant donné qu'ils n'ont pas toujours fait le deuil de ce dernier (Chan et al., 2007;Cole et al., 2009;Rothgangel et al., 2011). En effet, une étude de Casale et collaborateurs (2009) a observé qu'un grand nombre de patients (29/33) reportaient la présence de sensations désagréables (irritation, vertiges, confusion) et un nombre non négligeable d'entre eux (4/33) allaient jusqu'à interrompre la thérapie (Casale et al., 2009). En outre, le membre fantôme ressenti ne ressemble pas, en général, à un membre normal et donc le reflet du membre controlatéral ne correspond pas à celui-ci (Desmond et al., 2006;Wright, 1997Wright, , 2010. ...
La kinesthésie est la perception consciente des mouvements des différentes parties de son propre corps dans l’espace. Elle résulte de l’intégration de multiples signaux sensoriels tels que les signaux visuels, proprioceptifs ou tactiles. L’intégration multisensorielle dépendrait de trois types de congruence : les congruences temporelle, spatiale et sémantique. Pour que l’intégration soit optimale, les différents signaux sensoriels devraient survenir en même temps, au même endroit et être associés sémantiquement. L’objectif principal de cette thèse visait à étudier les mécanismes d’intégration sensorielle en jeu dans la kinesthésie en utilisant des signaux artificiels. Pour cela, nous avons étudié la mesure dans laquelle des signaux sensoriels artificiels pouvaient prendre part à la kinesthésie en fonction de leur degré d’incongruence avec les signaux naturels, générant ainsi des situations ne pouvant être obtenues avec des signaux naturels.Nous avons adapté le paradigme miroir à la réalité virtuelle, remplaçant les signaux visuels naturels (i.e., le reflet du bras dans le miroir) par des signaux artificiels (i.e., les bras d’un avatar). Cette implémentation du paradigme miroir en réalité virtuelle nous a permis de manipuler différents degrés d’incongruence sémantique (dissimilarité morphologique entre avatar et corps réel) ou spatiale (perspective dans laquelle est vu l’avatar) entre stimuli visuels provenant de l’avatar et stimuli non visuels (notamment proprioceptifs) provenant du corps du participant. Dans leur ensemble, nos résultats ont fait apparaitre que l’incongruence sémantique ou spatiale n’empêchait pas la contribution (et donc l’intégration) au percept kinesthésique des informations visuelles provenant de l’avatar, même lorsque le niveau d’incongruence était important (e.g., bras de l’avatar représentés par trois points ; perspective à la troisième personne). Cependant, cette contribution se réduisait quand le niveau d’incongruence augmentait, l’information visuelle ayant donc d’autant moins de poids dans le percept kinesthésique (multisensoriel) que l’incongruence augmente (Articles 1-3 ).Dans ce travail nous avons également exploré l’hypothèse selon laquelle seuls des signaux visuels issus du corps même du participant ou de tout objet incarné, pouvaient être pris en compte à des fins kinesthésiques. Cette hypothèse est partiellement validée par une analyse transversale des résultats des cinq expériences des Articles 2, 3 et 4, faisant apparaitre un lien positif entre le niveau d’incarnation de l’avatar et l’intensité des illusions kinesthésiques telle qu’évaluée par des mesures subjectives de vitesse et de durée des illusions. Toutefois, l'étude dédiée (Article 4), visant à manipuler expérimentalement le niveau d’incarnation d’un avatar, n’a pas permis d’apporter la preuve d’un tel lien.Enfin, nous avons aussi testé si un stimulus auditif généré par sonification des mouvements pouvait contribuer à la kinesthésie, en l’absence de vision. Dans cette étude (Article 5), les informations auditives préalablement associées aux mouvements n’ont pas été efficaces pour générer des illusions de mouvement.Dans leur ensemble, les résultats obtenus ont mis en évidence la contribution de stimuli visuels artificiels à la kinesthésie. De plus, ils indiquent que cette contribution varie en fonction du degré de congruence sémantique et spatiale entre les stimuli artificiels et les stimuli naturels.
... [48,49] Reported adverse effects to mirror visual feedback are increased pain, exacerbation of movement disorders, confusion and dizziness. [31,50] Congruence of movements of the healthy and phantom limbs seem to be important for treatment effect. Therefore, treatment may begin with an adaptive phase, where the patient observes the reflection of the healthy limb without moving the limbs. ...
Following amputation, patients may present with phantom limb sensations and some report phantom limb pain. Mirror visual feedback is considered a promising mechanism-based treatment for phantom limb pain. In this review, we apprise research evaluating the clinical efficacy of mirror visual feedback for the treatment of phantom limb pain and the possible mechanisms of action, and we will discuss current and future perspectives on the principles underpinning clinical use. Evidence for the efficacy of mirror visual feedback is mainly inconclusive due to heterogeneity of study sample and protocol. Nevertheless, mirror visual feedback seems to reduce pain in subgroups of patients and when used as a course of treatment. The mechanism of action of mirror visual feedback remains unclear, with cortical reorganization, reintegration of motor and sensory systems and ownership of the mirror reflected limb likely to influence outcome. There are no protocols for the clinical use of mirror visual feedback, but studies suggest that a course of home-based treatment should be used. Finally, embodiment of the reflection of the limb, movement and perception congruence are important and the use of new technologies, such as virtual reality and augmented reality, may improve outcome in the future.
... In their review [Richardson and Kulkarni 2017] state that "various mechanisms have been proposed for the effects of mirror therapy, including reversal of cortical reorganizations, relinking the visual and motor systems, activating mirror neurons in the contralateral brain, modulation of pain pathways, the reawakening of proprioceptive memories and the reversal of a potential neglect syndrome. [Casale et al. 2009;Hanling et al. 2010;Rothgangel et al. 2011;Weeks et al. 2010]" but that future "research needs to be refined to assist elucidation between these potential mechanisms. " ...
Phantom limb pain (PLP) is a phenomenon that affects millions of amputees worldwide. Its causes are poorly understood, and traditional forms of pain relief are largely ineffective. For over a decade virtual reality (VR) has shown tantalising possibilities of treating or managing this debilitating condition. Until recently however, the cost, complexity and fragility of VR hardware made exploring this unorthodox approach at any meaningful scale challenging; patients have had to travel to the location of specialist equipment to participate in studies, and missed appointments, dropouts or broken hardware have hampered data-gathering. Improvements in 'consumer grade' VR headsets now makes larger trials of this visual approach to pain management viable. We describe a trial of a VR system for PLP reduction utilising lightweight, standalone and low-cost VR hardware suitable for independent home use.
... Finally, some adverse events were noticed after the intervention following dizziness, muscle twist, and motion sickness. This is similar to the VR [41,42] and mirror therapy [43,44]. ...
Objective: Our objective was to investigate the effect of the rehabilitation system using augmented reality (AR) on upper extremity motor performance of patients with stroke. Methods: The system using AR applying mirror therapy mechanism provides the intervention protocol for the patient with hemiplegia after stroke. The system consists of a patient positioning tool (a chair), a white surface table, an image acquisition unit, an image processing unit, an image displaying unit, an arm holder, a Velcro-strap, and two blue circle stickers. To assess the feasibility of our system in motor function recovery, a stroke patient was recruited to receive the AR intervention. The treatment was performed two times a day for ten minutes over two weeks (ten days of treating weeks), except for the time of installation, calibration, and three minute breaks. Jebsen Taylor hand function test and Arm Motor Fugl-Meyer assessment were used as primary and secondary outcome measures, respectively, to evaluate the effect of motor function recovery. Additionally, stroke impact scale, Korean version-Modified Barthel Index (K-MBI), active range of motion of wrist joint (ROM), and the grasp force in Newtons were measured. Participants’ feedback and adverse effects were recorded as well. Results: Motor function improvements were exhibited in wrist and hand subtest of Arm Motor Fugl-Meyer (baseline: 19; post-intervention: 23), proximal arm subtest of Fugl-Meyer (baseline: 31; post-intervention: 34), ROM (extending ROM: 10° and 3° for flexion and extension, repeatedly), stroke impact scale (baseline: 46; post-intervention: 54), K-MBI (baseline: 92; post-intervention: 95), nine-hole pegboard (baseline: 30 s; post-intervention: 25 s), and grasp force in Newtons (baseline: 12.7; post-intervention: 17.7). However, the adverse effects were reported after the intervention. Conclusion: The system using AR applying mirror therapy mechanism demonstrated the feasibility in motor function recovery for the stroke patient.
... En las publicaciones no se comunican los efectos adversos de la IMG y sus contraindicaciones. Sólo dos estudios sobre el uso de la terapia con espejo han mencionado casos raros de reacciones emocionales (ansiedad, sudoración, mareos, etc.) y de aumentos transitorios en el dolor [38,39] . ...
La imaginería motora graduada (IMG) se puede definir como un tratamiento no farmacológico de algunas afecciones dolorosas. Inicialmente destinada al tratamiento del síndrome doloroso regional complejo, del dolor del miembro fantasma y de los dolores por avulsión del plexo braquial, su uso comienza a extenderse a otras afecciones dolorosas como, en particular, los dolores crónicos raquídeos. La IMG está constituida por tres etapas de tratamiento realizadas de forma gradual en un orden determinado: primero ejercicios de reconocimiento derecha/izquierda (tarea de lateralidad), luego movimientos imaginados (imaginería motora) y, por último, ejercicios de terapia con espejo. El objetivo de este artículo es presentar el concepto de IMG. Se exponen los principios generales de este protocolo terapéutico (prerrequisitos neurocientíficos, principios de progresión, indicaciones, posología, etc.), así como una descripción del contenido de sus tres etapas acompañado por sus principios de funcionamiento y sus métodos de aplicación clínica. El análisis de las evidencias científicas relacionadas con este protocolo revela pruebas alentadoras y al mismo tiempo varias limitaciones. Por lo tanto, aunque los primeros ensayos controlados aleatorizados muestran resultados favorables en términos de eficacia sobre el dolor, todavía es demasiado pronto para comprender completamente el funcionamiento de la IMG y definir las modalidades terapéuticas óptimas.
... 10 Side effects to mirror therapy are motor extinction, increased pain, exacerbation of movement disorders, confusion and dizziness. 11 Treatment is discontinued and contraindicated if any of these occur during a course of mirror therapy. ...
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.
... Current evidence though is difficult to judge, as there does not appear to be a defined standard for what constitutes mirror therapy and various mechanisms have been proposed for the effects of mirror therapy, including reversal of cortical reorganizations, relinking the visual and motor systems, activating mirror neurons in the contralateral brain, modulation of pain pathways, the reawakening of proprioceptive memories and the reversal of a potential neglect syndrome. [125][126][127][128] Future mirror therapy research needs to be refined to assist elucidation between these potential mechanisms. Currently, comparison between studies is almost impossible; so, forthcoming studies need to control for the individual elements within mirror therapy to assess which are the most important and if they are additive. ...
Background
Phantom limb pain (PLP) occurs in 50% and 80% of amputees. Although it is often classified as a neuropathic pain, few of the large-scale trials of treatments for neuropathic pain included sufficient numbers of PLP sufferers to have confidence that they are effective in this condition. Many therapies have been administered to amputees with PLP over the years; however, as of yet, there appears to be no first-line treatment.
Objectives
To comprehensively review the literature on treatment modalities for PLP and to identify the challenges currently faced by clinicians dealing with this pain.
Method
MEDLINE, EMBASE, CINAHL, British Nursing Index, Cochrane and psycINFO databases were searched using “Phantom limb” initially as a MeSH term to identify treatments that had been tried. Then, a secondary search combining phantom limb with each treatment was performed to find papers specific to each therapy. Each paper was assessed for its research strength using the GRADE system.
Results
Thirty-eight therapies were identified. Overall, the quality of evidence was low. There was one high-quality study which used repetitive transcutaneous magnetic stimulation and found a statistical reduction in pain at day 15 but no difference at day 30. Significant results from single studies of moderate level quality were available for gabapentin, ketamine and morphine; however, there was a risk of bias in these papers. Mirror therapy and associated techniques were assessed through two systematic reviews, which conclude that there is insufficient evidence to support their use.
Conclusion
No decisions can be made for the first-line management of PLP, as the level of evidence is too low. Robust studies on homogeneous populations, an understanding of what amputees consider a meaningful reduction in PLP and agreement of whether pain intensity is the legitimate therapeutic target are urgently required.
... They clarify, however, that the reasons for this large number of adverse effects may be the lack of selection of patients and that mirror therapy was performed simultaneously with conventional rehabilitation for the use of a prosthesis. 36 Dier et al. conducted a study using functional magnetic resonance imaging to investigate the neural correlates of mirror therapy. It involved 14 participants with upper limb amputation, 7 with phantom limb pain, 7 without pain and 9 healthy control subjects. ...
Introduction
The phantom limb pain has been described as a condition in which patients experience a feeling of itching, spasm or pain in a limb or body part that has been previously amputated. Such pain can be induced by a conflict between the representation of the visual and proprioceptive feedback of the previously healthy limb. The phantom limb pain occurs in at least 42–90% of amputees. Regular drug treatment of phantom limb pain is almost never effective.
Methods
A systematic review of the literature was conducted in Medline and Cochrane using the MESH terms “phantom limb pain” and “psychotherapy”, published in the last 10 years, in English and Spanish, finding 49 items. After reviewing the abstracts, 25 articles were excluded for not being related to the objective of the research. Additionally cross references of included articles and literature were reviewed.
Objectives
To describe the psychotherapies used in the management of phantom limb pain, their effectiveness and clinical application reported in the literature.
Aims
The mechanisms underlying phantom limb pain were initially explained, as were the published studies on the usefulness of some psychotherapies such as mirror visual feedback and immersive virtual reality, visual imagery, desensitisation and reprocessing eye movements and hypnosis.
Conclusions
The phantom limb pain is a complex syndrome that requires pharmacological and psychotherapeutic intervention. The psychotherapies that have been used the most as adjuvants in the treatment of phantom limb pain are mirror visual feedback, desensitisation and reprocessing eye movements, imagery and hypnosis. Studies with more representative samples, specifically randomised trials are required.
... Dal gennaio 2007 abbiamo introdotto la Mirror Therapy nel percorso terapeutico del paziente amputato. Il dato più interessante che è emerso dallo studio di questi pazienti è che la cosi detta mirror therapy ha come ogni tecnica dei limiti precisi e alcune controindicazioni (39). In un gruppo non selezionato di 34 pazienti, di età compresa tra i 18 e i 90 anni, ambosessi, amputati a diversi livelli (piede, gamba o coscia), destra o sinistra, in esito a traumi, arteriopatia obliterante, neoplasia e processi infettivi abbiamo applicato accanto alla tradizionale riabilitazione anche sedute giornaliere di mirror therapy ed abbiamo osservato che la gran parte dei pazienti rifiutava la metodica con lo specchio, manifestando sentimenti di confusione, irritazione, insofferenza al trattamento. ...
Phantom limb and phantom limb pain control are pivotal points in the sequence of intervention to bring the amputee to functional autonomy. The alterations of perception and sensation, the pain of the residual limb and the phantom limb are therefore aspects of amputation that should be taken into account in the "prise en charge" of these patients. Within the more advanced physical therapies to control phantom and phantom limb pain there is the use of mirrors (mirror therapy). This article will focus on its useand on the possible side effects induced by the lack of patient selection and a conflict of body schema restoration through mirror therapy with concurrent prosthetic training and trauma acceptance. Advice on the need to select patients before treatment decisions, with regard to their psychological as well as clinical profile (including time since amputation and clinical setting), and the need to be aware of the possible adverse effects matching different and somehow conflicting therapeutic approaches, are put forward. Thus a coordinated sequence of diagnostic, prognostic and therapeutic procedures carried out by an interdisciplinary rehabilitation team that works globally on all patients' problems is fundamental in the management of amputees and phantom limb pain. Further studies and the development of a multidisciplinary network to study this and other applications of mirror therapy are needed.
... Ayna tedavisinin üst ekstremite fonksiyonel durum üzerine etkinliğinin değerlendirildiği çalışmalarda fonksiyonel düzelmeye aktif el bileği eklem hareket açıklığının artışının eşlik ettiği gözlenmiştir (9,10 (24,26). ...
OBJECTIVE: A variety of methods is used in the treatment of upper extremity functional impairment after stroke.In recent years, a new therapeutic approach in the treatment of stroke rehabilitation is the mirror therapy.The purpose of this study is to investigate the efficacy of mirror therapy,which is applied through motor imagination training, combined with conventional stroke rehabilitation program on upper extremity motor and functional recovery in patients with subacute stroke. MATERIAL and METHODS: This is a randomized,prospective,controlled single-blind trial.The study included 20 patients who were diagnosed with stroke.Patients were randomly divided into two groups:first group received conventional rehabilitation program and the second group received conventional rehabilitation program plus mirror therapy on nonparetic upper extremity consisting of wrist extension daily 4 times for 15minutes per session. Both groups received the conventional rehabilitation program for 4 weeks, 5 days a week and daily 1-2h. All patients were evaluated at baseline and at the end of the treatment(week 4).The evaluations were performed by using Brunnstrom Staging, Fugl Meyer Motor Function Scale(FM),Barthel Index(BI) and goniometric measurement of wrist extension. RESULTS: The Brunnstrom stage(p<0.01), total score on FM and BI scores (p<0.01) were improved at week 4 compared to the baseline, whereas wrist subscore on FM and the goniometric measurements of the wrist and wrist extension were significantly improved only in group II.The two treatment groups were not statistically different in terms of posttreatment evaluation parameters. CONCLUSION: In our study,the mirror therapy combined with conventional rehabilitation program was not superior to conventional rehabilitation program alone in terms of upper extremity motor and functional recovery.
... A small retrospective chart review from an acute inpatient rehabilitation facility was done. The majority of the patients reported some side effect to the therapy with over half of the patients reporting confusion and dizziness [21]. However, as this was a retrospective review and the subjects were in the acute rehabilitation phase, no conclusions about true side effects or absolute contraindications can be made. ...
Phantom limb pain (PLP) continues to place a significant emotional and physical burden on amputees and remains a challenge for those treating amputees. Despite advances in psychological, pharmacologic, and interven-tional therapies, treatment modalities and research results show promise, but there is no evidence to highly recommend any particular treatment. This review concludes that the best treatment approach is a measured and diligent trial of multiple modes of treatment. As researchers forge forward toward definitively establishing etiologies, focused treatment options may become available. Until then, PLP is an area that calls for intense research and which will continue to challenge the clinician caring for the amputee population.
... Une étude rétrospective [32] a analysé l'incidence des effets secondaires chez des patients souffrant de douleurs post-amputation. Quoique la littérature mentionne rarement l'existence d'effets secondaires, dans cette étude 19 patients sur 33 rapportent confusion et sensations ébrieuses, 6 décrivent une sensation mal définie d'irritation, 4 ont refusé de continuer et seuls 4 patients n'avaient aucune plainte. ...
La thérapie par miroirs est de plus en plus fréquemment proposée dans le traitement de certains syndromes douloureux neuropathiques, en complément de l’approche réadaptative. Son mode d’action est mal élucidé et plusieurs hypothèses non exclusives ont été suggérées : amélioration de la congruence sensori-motrice, modulation de la douleur par la vision, activation de neurones miroirs, réduction de la kinésiophobie, effets attentionnels, modification d’excitabilité corticale… Si les rapports de cas ont montré des résultats encourageants, les rares études contrôlées sont plus mitigées. D’autres études sont nécessaires pour mieux tester ce traitement, préciser ses modes d’action et évaluer l’hypothèse selon laquelle certains sous-groupes de patients seraient plus susceptibles d’en bénéficier que d’autres. Malgré ces inconnues, il est possible de faire un certain nombre de recommandations pratiques.
... 15 Hypnosis uses images to modify the patient's representation of pain or uses suggestions to make the patient move the phantom limb and control the pain 16 ; this technique is thought to cause changes in multiple areas of the brain involved in pain processing. 17 Mirror therapy [18][19][20][21][22][23][24] and mental imagery are mind-body therapies that essentially attempt to fool the brain into thinking that the missing limb is still there and to reinstate a coherent representation of the missing limb within the somatosensory and motor cortices. ...
Objective:
To evaluate the reduction in phantom pain and sensation with combined training of progressive muscle relaxation, mental imagery, and phantom exercises.
Design:
Randomized controlled prospective trial with 2 parallel groups.
Setting:
Amputee unit of a rehabilitation hospital.
Participants:
Subjects with unilateral lower limb amputation (N=51) with phantom limb pain (PLP) and/or phantom limb sensation (PLS).
Interventions:
The experimental group performed combined training of progressive muscle relaxation, mental imagery, and phantom exercises 2 times/wk for 4 weeks, whereas the control group had the same amount of physical therapy dedicated to the residual limb. No pharmacological intervention was initiated during the trial period.
Main outcome measures:
The Prosthesis Evaluation Questionnaire and the Brief Pain Inventory were used to evaluate changes over time in different aspects (intensity, rate, duration, and bother) of PLS and PLP. Blind evaluations were performed before and after treatment and after 1-month follow-up.
Results:
The experimental group showed a significant decrease over time in all the Prosthesis Evaluation Questionnaire domains (in terms of both PLS and PLP; P<.04 for both) and the Brief Pain Inventory (P<.03). No statistically significant changes were observed in the control group. Between-group analyses showed a significant reduction in intensity (average and worst pain) and bother of PLP and rate and bother of PLS at follow-up evaluation, 1 month after the end of the treatment.
Conclusions:
Combined training of progressive muscle relaxation, mental imagery, and modified phantom exercises should be taken into account as a valuable technique to reduce phantom limb pain and sensation.
... The importance of social support is mentioned five times, body image four times and other factors such as pain, phantom pain, coping and sense of self-esteem only rarely. [31][32][33][34][35][36] In addition to mood and anxiety problems in patients who have undergone an amputation, frequent problems due to self-esteem and body image occur not only immediately following the amputation but also persist for a long period afterwards (Level 3). ...
Background:
A structured, multidisciplinary approach in the rehabilitation process after amputation is needed that includes a greater focus on the involvement of both (para)medics and prosthetists. There is considerable variation in prosthetic prescription concerning the moment of initial prosthesis fitting and the use of replacement parts.
Objectives:
To produce an evidence-based guideline for the amputation and prosthetics of the lower extremities. This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice. Part 2 focuses on rehabilitation process and prosthetics.
Study design:
Systematic literature design.
Methods:
Literature search in five databases and quality assessment on the basis of evidence-based guideline development.
Results:
An evidence-based multidisciplinary guideline on amputation and prosthetics of the lower extremity.
Conclusion:
The best care (in general) for patients undergoing amputation of a lower extremity is presented and discussed. This part of the guideline provides recommendations for treatment and reintegration of patients undergoing amputation of a lower extremity and can be used to provide patient information.
Clinical relevance:
This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice.
Purpose of review:
Chronic postamputation pain (cPAP) remains a clinical challenge, and current understanding places a high emphasis on prevention strategies. Unfortunately, there is still no evidence-based regimen to reliably prevent chronic pain after amputation.
Recent findings:
Risk factors for the development of phantom limb pain have been proposed. Analgesic preventive interventions are numerous and no silver bullet has been found. Novel techniques such as neuromodulation and cryoablation have been proposed. Surgical techniques focusing on reimplantation of the injured nerve might reduce the incidence of phantom limb pain after surgery.
Summary:
Phantom limb pain is a multifactorial process involving profound functional and structural changes in the peripheral and central nervous system. These changes interact with individual medical, psychosocial and genetic patient risk factors. The patient collective of amputees is very heterogeneous. Available evidence suggests that efforts should focus on prevention of phantom limb pain, since treatment is notoriously difficult. Questions as yet unanswered include the evidence-base of specific analgesic interventions, their optimal "window of opportunity" where they may be most effective, and whether patient stratification according to biopsychosocial risk factors can help guide preventive therapy.
Phantom limb is a disabling neuropsychiatric condition among amputees resulting in pain and disturbance that impact their functions, quality of life, and autonomy. While pharmacological approaches appeared to be ineffective, the emergence and integration of X-reality, including virtual reality, augmented reality, and mixed reality, might elevate the effectiveness of mirror therapy in managing phantom limb. The objective of this study is to review X-reality for managing phantom pain. A systematic search was conducted on PubMed, Scopus, Web of Science, PsycINFO, Embase, and CINAHL. Sixteen (n = 16) studies containing 66 lower-limb and 53 upper-limb amputees were included for the review over the thematic framework of amputee characteristics and intervention designs, while thirteen (n = 13) studies were further proceeded for the meta-analysis. We found eleven studies on virtual reality (n = 11), four studies on marker-based augmented reality (n = 4) and one study on mixed reality (n = 1) with a total of 40 game/task themes involving, motor skills, motor control, and stimulus-sensing. Regardless, all these interventions adopted the movement representation strategies with different techniques. Overall, the X-reality interventions reduced the pain level of the amputees (mean difference: -2.30, 95% CI, -3.38 to -1.22), especially the virtual reality subgroup (mean difference: -2.83, 95% CI, -4.43 to -1.22). However, there were substantial heterogeneity and partially explained by the subgroup analysis on publication year. The strength of evidence was limited by case reports and case series in this review.
Ağrının birincil önemi vücudu yaralanmalardan korumaktır. Ancak, hayatta kalmak için acıyı algılamamanın daha önemli olduğu bazı durumlar da söz konusudur. Ağrının kendiliğinden bastırılması veya nosisepsiyonun zayıflamasına, endojen antinosiseptif (analjezik) sistem aracılık eder. Anatomik oluşumu, orta beyindeki periakueduktal gri maddeden, beyin sapının noradrenerjik ve serotonerjik çekirdeklerinden, nosiseptörlerden "ağrı" bilgisi alan spinal nöronlara kadar uzanır. Bu sistemin faaliyeti, duygusal ve bilişsel devrelerin kontrolü altındadır. Ağrı, olumlu duyguların uyarılmasıyla hafifletilebilirken, olumsuz duygular hissedilen acıyı artırmaktadır. İlginç şekilde, bir ağrı başka bir acıyı bastırabilme özelliğine de sahiptir. Analjezi; stres, fiziksel egzersiz, orosensöryel uyarılma (tatlı gıda tüketimi), müzik dinleme ve plasebo sonrası, yani ağrıdan kurtulma beklendiğinde duyusal uyarımla indüklenebilir. Ağrının; duyusal, duyuşsal ve bilişsel bileşenleri olduğundan, bu tüm sistemlerin aktivasyonunun belirli şekillerde ağrının bastırılmasına katkıda bulunabileceği ortaya konmuştur.
Objective
To evaluate the effectiveness of mirror therapy (MT) for phantom limb pain (PLP).
Data Sources
PubMed, EMBASE, Ovid MEDLINE, Scopus, Cochrane Library, Physiotherapy Evidence Database, CNKI, and WanFang Data were used to search for studies published up to March 31, 2021.
Study Selection
Randomized controlled trials (RCTs) comparing the pain intensity of MT for PLP were performed. A total of 2094 articles were found. Among them, 10 were eligible for the final analysis.
Data Extraction
The quality of the RCTs was assessed using the PEDro scale by two independent reviewers. Outcome data were pooled according to follow-up intervals (1, 3, 6, and 12 months). Duration times were used as a basis for distinguishing subgroups. The primary evaluation was by visual analog scale (VAS). The PEDro scale was used to assess the methodological quality of studies.
Data Synthesis
Meta-analysis revealed a statistically significant decrease in pain in the MT group versus the control group within 1 month (I² = 0%, SMD = -0.46, 95% CI: -0.79–-0.13, p = 0.007). The patients with pain for longer than one year benefited more from MT (I² = 0%, SMD = -0.46, 95% CI: -0.85–-0.07, p = 0.02).
Conclusions
MT has beneficial effects for patients suffering from PLP in the short-term, as evidenced by their improved pain scores. There was no evidence that MT had a long-term effect, but that may be a product of limited data. For patients with long-term PLP, MT may be an effective treatment.
The standard means of controlling an upper-limb prosthesis is by wearing a harness around the shoulders and flexing the shoulders to open (or close) the terminal device, which is usually a hook. This method was developed and patented in 1912. Possibly better control is offered by using signals from muscular action of muscles in the residuum as commands to the prosthesis. There are many new methods being tried to improve UL prosthetic function.
Dieser Praxisleitfaden für die Anwendung der Spiegeltherapie bei Patienten mit Phantomschmerzen nach Amputationen wurde im Rahmen des PACT (PAtient Centered Telerehabilitation)-Projekts entwickelt. In diesem Projekt wird ein eHealth-Applikation entwickelt, die Patienten darin unterstützen soll, selbstständig Ihre Phantomschmerzen zu reduzieren. Ein Bestandteil dieses Selbstmanagements ist ein Übungsprogramm für die Spiegeltherapie. Da die Spiegeltherapie bislang noch nicht einheitlich im klinischen Alltag eingesetzt wird, wurde dieser Praxisleitfaden entwickelt, um auch den betreuenden Therapeuten einen strukturierten Leitfaden für die Behandlung zu bieten. Er soll als Hilfsmittel dienen die Behandlung zu strukturieren und die Implementierung der Therapie in die Routineversorgung zu unterstützen.
Hierbei wurde dasselbe auf evidenzbasierter Praxis basierende Grundgerüst verwendet, welches auch schon für den Praxisleitfaden Schlaganfall verwendet wurde: Die aktuell beste verfügbare Evidenz wurde mit den klinischen Erfahrungen von Therapeuten sowie den Wünschen und Präferenzen von Patienten kombiniert. In zahlreichen Interviews wurden wichtige klinische Aspekte zur Spiegeltherapie (z.B. genaue Übungsinhalte), die in wissenschaftlichen Studien nur selten ausreichend beschrieben werden, zusammengetragen.
Wie bei vielen anderen Therapiemethoden auch sind die Effektstärken der Spiegeltherapie noch relativ klein, so dass neue wissenschaftliche Studien die bestehende Evidenz leicht verändern können. Daher sollte die Spiegeltherapie als ein möglicher Bestandteil innerhalb eines komplexen Rehabilitationsprogramms gesehen werden, die in Kombination mit anderen Therapieverfahren angewendet werden sollte. Für manche Patienten können selbst andere Behandlungsmethoden geeigneter sein und/oder Priorität haben.
Der aktuelle Praxisleitfaden sollte mehr als flexibles Grundgerüst als ein starres Kochbuch gesehen werden. Darin werden grundlegende Behandlungsrichtlinien und Übungsvorschläge vorgestellt, jedoch lässt er dem Therapeuten ausreichend Spielraum, um die Behandlung individuell an die Fähigkeiten und Wünsche seines Patienten anzupassen. Hierdurch werden die klinischen Erfahrungen und Präferenzen des Therapeuten innerhalb des Leitfadens zusätzlich berücksichtigt, was die Anwendbarkeit in der täglichen Arbeit erleichtern sollte.
Wir hoffen dass dieser Praxisleitfaden eine auf den individuellen Patienten mit Phantomschmerzen maßgeschneiderte Behandlung fördert.
Resumen
Introducción
El dolor de miembro fantasma ha sido descrito como una condición en la que los pacientes experimentan una sensación de prurito, espasmo o dolor en un miembro o parte del cuerpo previamente amputado. Dicho dolor puede ser inducido por un conflicto entre la representación de la retroalimentación visual y propioceptiva del miembro previamente sano. El dolor de miembro fantasma ocurre en al menos 42 al 90% de los amputados. El tratamiento farmacológico regular del dolor del miembro fantasma casi nunca es efectivo.
Método
Se realizó una revisión sistemática en las bases de datos Medline y Cochrane usando palabras MESH “phantom limb pain” y “psychotherapy”, publicados en los últimos 10 años, en español e inglés, encontrando 49 artículos. Al revisar los resúmenes, se excluyeron 25 artículos por no ser afines con el objetivo de la investigación. Adicionalmente se revisaron referencias cruzadas de los artículos incluidos y literatura médica.
Objetivos
Describir las psicoterapias usadas en el manejo del dolor de miembro fantasma, su efectividad y aplicación clínica reportada en la literatura.
Desarrollo
Se explican inicialmente los mecanismos subyacentes al dolor de miembro fantasma y se describen los estudios publicados sobre la utilidad del uso de algunas psicoterapias como la retroalimentación visual con espejo y con realidad virtual inmersiva, imaginería visual, reprocesamiento y desensibilización por movimientos oculares e hipnoterapia.
Conclusiones
El dolor de miembro fantasma es un síndrome complejo que requiere intervención farmacológica y psicoterapéutica. Las psicoterapias que más se han usado como coadyuvantes en el tratamiento del dolor de miembro fantasma son la retroalimentación visual con espejo, la desensibilización y reprocesamiento por movimientos oculares, la imaginería y la hipnosis. Se requieren estudios con muestras más significativas, específicamente estudios clínicos aleatorizados.
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.
Objective: Mirror therapy is a new neurophysiological treatment, that has shown clinical relevance in several diseases like phantom limb pain, stroke and complex regional pain syndrome. This study wants to demonstrate the effectiveness of mirror therapy in rehabilitation of upper limb functioning in patients suffering from chronic stroke. Methods: This pilot study was carried out in the form of a single blind randomised clinical trial. The experimental group received five weeks of mirror therapy according to a standardized treatment protocol. The control group followed the same protocol but without the mirror (bilateral arm training). The primary outcome variable consisted of upper limb functioning measured with the Action Research Arm test (ARAT) and the Patient Specific Function Scale (PSK). Results: Totally 16 chronic stroke patients fulfilled the stated in- and exclusion criteria. The statistical evaluation of the results showed that upper limb functioning improved in both groups, experimental as well as control group; the experimental group more than the control group. Conclusions: Mirror therapy showed positive effects on rehabilitation of upper limb functioning in this population. Because of the small sample size no firm conclusions are possible, yet. It is advised to carry out further research with a larger and more homogeneous group of patients.
The amputation of a limb can result in a range of physical and psychological challenges, as individuals must learn to adjust to changes in their physical capabilities in addition to an altered appearance. While intervention strategies such as prosthetics and counselling may be of benefit, further research is required to better understand the psychological needs of these patients. Laura Armstrong-James explores this issue
Objective: To test the feasibility and preliminary efficacy of self-delivered home-based mirror therapy for phantom pain. Design: Uncontrolled prospective treatment outcome pilot study. Participants: Forty community-dwelling adults with unilateral amputation and phantom pain > 3 on a 0–10 numeric rating scale enrolled either during a one-time study visit (n = 30) or remotely (n = 10). Methods: Participants received an explanation of mirror therapy and were asked to self-treat for 25 min daily. Participants completed and posted back sets of outcomes questionnaires at months 1 and 2 post-treatment. Main outcome was mean phantom pain intensity at post-treatment. Results: A significant reduction in mean phantom pain intensity was found at month 1 (n = 31, p = 0.0002) and at month 2 (n = 26, p = 0.002). The overall median percentage reduction at month 2 was 15.4%. Subjects with high education (> 16 years) compared with low education (< 16 years) (37.5% vs 4.1%) had greater reduction in pain intensity (p = 0.01). Conclusion: These findings support the feasibility and efficacy of home-based self-delivered mirror therapy; this low-cost treatment may defray medical costs, therapy visits, and the patient travel burden for people with motivation and a high level of education. More research is needed to determine methods of cost-effective support for people with lower levels of education.
To describe the development and content of a clinical framework for mirror therapy (MT) in patients with phantom limb pain (PLP) following amputation.
Based on an a priori formulated theoretical model, 3 sources of data collection were used to develop the clinical framework. First, a review of the literature took place on important clinical aspects and the evidence on the effectiveness of MT in patients with phantom limb pain. In addition, questionnaires and semi-structured interviews were used to analyze clinical experiences and preferences of physical and occupational therapists and patients suffering from PLP regarding the application of MT. All data were finally clustered into main and subcategories and were used to complement and refine the theoretical model.
For every main category of the a priori formulated theoretical model, several subcategories emerged from the literature search, patient, and therapist interviews. Based on these categories, we developed a clinical flowchart that incorporates the main and subcategories in a logical way according to the phases in methodical intervention defined by the Royal Dutch Society for Physical Therapy. In addition, we developed a comprehensive booklet that illustrates the individual steps of the clinical flowchart.
In this study, a structured clinical framework for the application of MT in patients with PLP was developed. This framework is currently being tested for its effectiveness in a multicenter randomized controlled trial.
© 2015 World Institute of Pain.
Phantom Limb Pain (PLP) is a form of chronic neuropathic pain that responds poorly to treatment interventions derived from the neuroanatomic understanding of pain and analgesia. Several new psychological and behavioral treatments that have proven more effective have been explained by invoking neural plasticity as their mechanism of action. Other novel treatments that are based on an “energy medicine” model also appear to be quite effective, especially when addressing the psychological trauma of the amputation itself, a factor whichis generally overlooked in the standard surgical approach to limb amputation. A speculative trauma/energy model for the etiology of PLP is proposed. This model is developed in some detail, and its utility in explaining several anomalous aspects of PLP, as well as the clinical efficacy of energy therapies, is outlined. This model is proposed as a step in the development of simple and effective energy/trauma treatment protocols for this widespread and largely treatment-resistant disorder.
Preface The main reason to develop a practice-based protocol was because mirror therapy is still inconsistently used in clinical situations and many physical and occupational therapists expressed a strong need for some form of guidance to structure therapy and support imple-mentation of mirror therapy in routine care. As in most protocols, evidence based practice was the starting point: Evidence from literatu-re, clinical experience from therapists and patient preferences* were taken into account to determine the content and select the examples. As in almost all specific rehabilitation interventions, effect sizes for mirror therapy are still relatively small and new evidence might overturn existing evidence. Mirror therapy should therefore be considered as one of several therapy interventions within a rehabilitation programme where other interventions can be offered as well, or sometimes may even be preferred. The present protocol should be seen as a framework, not a predefined recipe for all patients. Within the protocol the basic principles and many examples of how to apply mirror therapy are given. The framework however leaves enough room for the therapist to adjust the protocol and tailor it to the abilities and preferences of his / her patient. This way the clinical experience and the preferences of therapists are incorporated in the protocol as well, making it easier to use the protocol in everyday practice. A critical mind is of course still requi-red. The first version of this protocol for mirror therapy was developed by Andreas Rothgangel and Susy Braun together with students of Zuyd University of Applied Sciences (Heerlen, The Netherlands) as part of their physiotherapy bachelor thesis in 2011. The protocol was published in the German Journal of Physical Therapy in 2012. Since then the protocol has been updated, expanded, restructured and trans-lated into English. New evidence and experiences have been incorporated into this second version. Also, the content has been restructu-red with two overview figures being added. The protocol is now presented in the order a professional would need to start providing mir-ror therapy in everyday practice. We hope that this protocol facilitates the tailored treatment of patients after stroke with mirror therapy in everyday care. Andreas Rothgangel & Susy Braun July 2013 * A group of twelve german occupational and physical therapists and three stroke patients was interviewed.
Casale R, Negrini S, Franceschini M, Michail X: Chronic disabling pain: A scotoma in the eye of both pain medicine and rehabilitation in Europe. Am J Phys Med Rehabil 2012; 91: 1097-1100.
To test the feasibility and preliminary efficacy of self-delivered home-based mirror therapy for phantom pain.
Uncontrolled prospective treatment outcome pilot study.
Forty community-dwelling adults with unilateral amputation and phantom pain > 3 on a 0-10 numeric rating scale enrolled either during a one-time study visit (n = 30) or remotely (n = 10).
Participants received an explanation of mirror therapy and were asked to self-treat for 25 min daily. Participants completed and posted back sets of outcomes questionnaires at months 1 and 2 post-treatment. Main outcome was average phantom pain intensity at post-treatment. Results: A significant reduction in average phantom pain intensity was found at month 1 (n = 31, p = 0.0002) and at month 2 (n = 26, p = 0.002). The overall median percentage reduction at month 2 was 15.4%. Subjects with high education (> 16 years) compared with low education (< 16 years) (37.5% vs 4.1%) had greater reduction in pain intensity (p = 0.01).
These findings support the feasibility and efficacy of home-based self-delivered mirror therapy; this low-cost treatment may defray medical costs, therapy visits, and the patient travel burden for people with motivation and a high level of education. More research is needed to determine methods of cost-effective support for people with lower levels of education.
Phantom sensations, that is, sensations perceived in a body part that has been lost, are a common consequence of accidental or clinical extremity amputations. Most amputation patients report a continuing presence of the limb, with some describing additional sensations such as numbness, tickling, or cramping of the phantom limb. The type, frequency, and stability of these phantom sensations can vary immensely. The phenomenon of painful phantom sensations, that is, phantom limb pain, presents a challenge for practitioners and researchers and is often detrimental to the patient's quality of life. In addition to the use of conventional therapies for chronic pain disorders, recent years have seen the development of novel treatments for phantom limb pain, based on an increasing body of research on neurophysiological changes after amputation. This article describes the current state of research in regard to the demographics, causal factors, and treatments of phantom limb pain.
Working with patients with different chronic pain syndromes can be challenging. Pharmacological therapies are often associated with variety of side effects. Mind-body modalities are thought to play a role; however, the lack of clear consensus and large body of clinical experience makes it hard to provide good evidence-based recommendation to most of our chronic pain patients. In recent years the Phantom Limb Pain (PLP) and to some degree Complex Regional Pain Syndrome (CRPS) may prove to be an exception. In this review we summarize the current evidence supporting use of Mirror Box Therapy and its successor, Immersive Virtual Reality.
Phantom pain is a frequent consequence of amputation or deafferentation. There are many possible contributing mechanisms, including stump-related pathology, spinal and cortical changes. Phantom limb pain is notoriously difficult to treat. Continued consideration of the factors associated with phantom pain and its treatment is of utmost importance, not only to advance the scientific knowledge about the experience of the body and neuropathic pain, but also fundamentally to promote efficacious pain management.
This review first discusses the mechanisms associated with phantom pain and summarizes the current treatments. The mechanisms underlying phantom pain primarily relate to peripheral/spinal dysfunction, and supraspinal and central plasticity in sensorimotor body representations. The most promising methods for managing phantom pain address the maladaptive changes at multiple levels of the neuraxis, for example, complementing pharmacological administration with physical, psychological or behavioural intervention. These supplementary techniques are even efficacious in isolation, perhaps by replacing the absent afferent signals from the amputated limb, thereby restoring disrupted bodily representations.
Ultimately, for optimal patient outcomes, treatments should be both symptom and mechanism targeted.
To determine if simple, robust spectacle mounted devices are feasible for the replacement of the mirror boxes currently used in the rehabilitation of patients suffering from phantom limb pain, complex regional pain syndrome and stroke.
Four devices, using three different optical systems were produced: plane mirror, astronomical telescope using cylindrical lenses and two reflecting prism systems.
The illusory effect of the devices was similar to that of the mirror box.
Any of the systems would be suitable to replace the mirror box, but the reflecting prism system is the easiest to set up.
Home-based patient-delivered mirror therapy is a promising approach in the treatment of phantom limb pain. Previous studies and case reports of mirror therapy have used a therapist-guided, structured protocol of exercises. No case report has described treatment for either upper or lower limb phantom pain by using home-based patient-delivered mirror therapy. The success of this case demonstrates that home-based patient-delivered mirror therapy may be an efficacious, low-cost treatment option that would eliminate many traditional barriers to care.
To ascertain the existence of contralateral painful muscle areas mirroring phantom pain and to evaluate the short-term effects of anaesthetic vs saline, injected contra notlaterally to control phantom and phantom limb pain.
Double-blinded cross-over study.
Inpatients; rehabilitation institute.
Eight lower limb amputees with phantom limb pain in the past 6 months.
Either 1 ml of 0.25% bupivacaine or 0.9% saline injected alternately in each point with a 28-gauge needle, with 72 h between injections. Main outcome measurePhantom sensation modification and the intensity of phantom limb pain (visual analogue scale) before and after injections.
Although present, painful muscle areas in the healthy limb do not mirror the topographical distribution of phantom limb pain. Sixty minutes after the injection, a statistically significant greater relief of phantom limb pain was observed after using local anaesthetic than when using saline injection (p = 0.003). Bupivacaine consistently reduced/abolished the phantom sensation in 6 out of 8 patients. These effects on phantom sensation were not observed after saline injections.
Contralateral injections of 1 ml 0.25% bupivacaine in myofascial hyperalgesic areas attenuated phantom limb pain and affected phantom limb sensation. The clinical importance of this treatment method requires further investigation.
Home-based patient-delivered mirror therapy is a promising approach in the treatment of phantom limb pain. Previous studies and case reports of mirror therapy have used a therapist-guided, structured protocol of exercises. No case report has described treatment for either upper or lower limb phantom pain by using home-based patient-delivered mirror therapy. The success of this case demonstrates that home-based patient-delivered mirror therapy may be an efficacious, low-cost treatment option that would eliminate many traditional barriers to care.
The phantom phenomenon is a well-known example of the difference between body awareness and body schema. The present study is aimed at showing how body changes and prosthesis use are reflected in body schema and body awareness-the latter relating to the image that various amputees have of their bodies.
(i) Examining the configuration of body schema: A trial examining the spatial location of the phantom limb (50 people with lower or upper limb loss); (ii) examining the functional aspect of body schema: The distribution of weight power between intact and prosthetic limbs (34 people with tibial amputation); (iii) examining body awareness: Body Focus Questionnaire by Fisher (44 people with lower limb amputation, 33 intact people); and (iv) Questionnaire on anamnesis- and prosthesis-wearing habits (people participating in research methods [i] and [iii] mentioned above).
We found that when the amputees wore their prostheses, the configuration of body schema did not change, however, the people who had not used their prosthesis for a long period of time (in our study, at least for six years), the phantom limb shortened, a phenomenon known as telescoping. The functional adaptation of the prosthesis to the body schema starts in a short time (within two weeks) after wearing it, and it becomes close to normal in carrying body weight after a longer period of time (two years). In the beginning phase of rehabilitation, the awareness of legs is similar to that of the control group, while later on it this awareness decreases. Over time, however, the lost limb, regardless of having a prosthesis or not, loses its importance. People with a more serious or vascular amputation of the upper limbs have a clearer image of them. Limb parts having a greater cortical representation appear more intensively in phantom sensations, while the strength of the cortical representation in body schema has no significance.
From both configuration and functional aspects, wearing a prosthesis helps maintain a body schema in which the phantom limb remains similar to the intact one, which can be explained by the connectional schema model. This is needed for movements to be carried out properly. Although the amputee can see the prosthesis and senses the phantom limb, they do not consider it their own since they are aware of the loss. Therefore, the fact that a prosthesis is worn will not be represented in body awareness as the highest level of mental structure.
Multiple sensory stimuli contribute to the conscious awareness of the body. It is well known that limb amputation can result in abnormal body awareness, but the manner in which the CNS constructs and updates a body schema after injury is largely unknown. The purpose of the present study was to systematically evaluate the effects of sensory inputs on phantom limb awareness (PLA) shortly after unilateral upper extremity amputation. The location, quality and intensity of spontaneous and tactile-evoked phantom sensations and awareness were assessed in 13 amputees who were referred sequentially for their initial post-operative rehabilitation. Subjects were tested in three visual conditions: (i) with their eyes open; (ii) with their eyes closed; and (iii) while they viewed their intact hand in a mirror, which created an illusion of their amputated hand (i.e. mirror visual illusion). The mirror illusion was also used to test the effect of combined visual and movement-related stimuli during active voluntary movement. Spontaneous PLA was reported by 12 of the 13 amputees and was not affected by normal visual inputs. Tactile stimulation of the residual limb or face evoked dual percepts in six amputees; i.e. these amputees perceived these touch stimuli as if they were being applied both to the stimulus site and also to a location on the missing limb. This mislocalization phenomenon was most prevalent in the eyes-closed condition. Thus, normal vision can strongly override the phantom component of touch-evoked dual percepts. In eight cases, the visual illusion of the missing limb transiently enhanced the spontaneous conscious awareness of the phantom limb. However, the visual illusion did not change the capacity of a tactile stimulus to induce dual percepts. These findings demonstrate that (i) phantom awareness of an amputated body part is common within the 14 months after traumatic upper extremity amputation, (ii) evoked dual percepts are less common than spontaneous PLA, (iii) visual, tactile and sensorimotor systems contribute to PLA, (iv) subtle changes in congruence of sensory information affects both evoked dual percepts and spontaneous PLA, however, (v) sensorimotor information pertaining to the state of the motor system can strongly influence spontaneous PLA, whereas the visual system can predominantly influence evoked PLA.
Phantom limb pain (PLP) can be an enduring and distressing experience for people with amputations. Previous research has shown that 'mirror treatment' can reduce PLP for some people who have an upper limb amputation, and that it can increase a sense of motor control over the phantom in people with lower limb amputations who are not reporting PLP. There has been no previous report of therapeutic 'mirror treatment' for lower-limb phantom pain.
We present the first case study of the use of 'mirror treatment' in a person with a lower limb amputation who was reporting PLP at the time of treatment.
During the intervention there was a significant reduction in his PLP, an increase in sense of motor control over the phantom and a change in aspects of the phantom limb that was experienced.
This case study, conducted in a conventional clinical setting, supports the potential of 'mirror treatment' for PLP in people with a lower limb amputation.
Experiments on patients with phantom limbs suggest that neural connections in the adult human brain are much more malleable than previously assumed. Three weeks after amputation of an arm, sensations from the ipsilateral face are referred to the phantom; this effect is caused by the sensory input from the face skin 'invading' and activating deafferented hand zones in the cortex and thalamus. Many phantom arms are 'paralysed' in a painful position. If a mirror is propped vertically in the sagittal plane and the patient looks at the reflection of his/her normal hand, this reflection appears superimposed on the 'felt' position of the phantom. Remarkably, if the real arm is moved, the phantom is felt to move as well and this sometimes relieves the painful cramps in the phantom. Mirror visual feedback (MVF) has shown promising results with chronic regional pain syndrome and hemiparesis following stroke. These results suggest two reasons for a paradigm shift in neurorehabilitation. First, there appears to be tremendous latent plasticity even in the adult brain. Second, the brain should be thought of, not as a hierarchy of organised autonomous modules, each of which delivers its output to the next level, but as a set of complex interacting networks that are in a state of dynamic equilibrium with the brain's environment. Both principles can be potentially exploited in a clinical context to facilitate recovery of function.
This paper describes the design and implementation of a case-study based investigation using immersive virtual reality as a treatment for phantom limb pain. The authors' work builds upon prior research which has found the use of a mirror box (where the amputee sees a mirror image of their remaining anatomical limb in the phenomenal space of their amputated limb) can reduce phantom limb pain and voluntary movement to paralyzed phantom limbs for some amputees. The present project involves the transposition of movements made by amputees' anatomical limb into movements of a virtual limb which is presented in the phenomenal space of their phantom limb. The three case studies presented here provide qualitative data which provide tentative support for the use of this system for phantom pain relief. The authors suggest the need for further research using control trials.
This paper describes a study protocol to investigate the use of immersive virtual reality as a treatment for amputees' phantom limb pain. This work builds upon prior research using mirror box therapy to induce vivid sensations of movement originating from the muscles and joints of amputees' phantom limbs. The present project transposes movements of amputees' anatomical limbs into movements of a virtual limb presented in the phenomenal space of their phantom limb. It is anticipated that the protocol described here will help reduce phantom limb pain.
Phantom limbs provide valuable insight into the mechanisms underlying bodily awareness and ownership. This paper reviews the complexity of phantom limb phenomena (proprioception, form, position, posture and telescoping), and the various contributions of internal constructs of the body, or body schema, and neuromatrix theory in explaining these phenomena. Specific systems and processes that have received little attention in phantom limb research are also reviewed and highlighted as important future directions, These include prosthesis embodiment and extended physiological proprioception (i.e., the extension of the body's "area of influence" that thereby extends one's innate sense of proprioception, mirror neurons and cross-referencing of the phantom limb with the intact limb (and the related phenomena of perceiving referred sensations and mirrored movements in the phantom form the intact limb). The likely involvements of the body schema and the body-self neuromatrix, mirror neurons, and cross-callosal and ipsilateral mechanisms in phantom limb phenomena all suggest that the perception of a "normal" phantom limb (that is, a non-painful phantom that has the sensory qualities of an intact limb) is more than likely an epiphenomenon of normal functioning, action understanding and empathy, and potentially may even be evolutionarily adaptive and perhaps necessary. Phantom pain, however, may be a maladaptive failure of the neuromatrix to maintain global bodily constructs.
Following long-term deafferentation of one upper limb in adult primates, the cortical areas corresponding to that limb become responsive to stimuli applied to the face. To explore this phenomenon, we studied some patients after upper limb amputation. In patient VQ, stimuli applied to the lower face or 7 cm above the stump evoked precisely localized referred sensations in individual digits which were often modality specific. Similarly, in another patient, WK several complete somatotopic representations of the phantom limb were found, on the face, chest and axilla, indicating the emergence of such maps in regions remote from the stump. These effects may be a direct perceptual correlate of the physiological observations of Merzenick et al (1984), Wall (1977) and Pons et al (1991).
The phenomenon of a phantom limb is a common experience after a limb has been amputated or its sensory roots have been destroyed. A complete break of the spinal cord also often leads to a phantom body below the level of the break. Furthermore, a phantom of the breast, the penis, or of other innervated body parts is reported after surgical removal of the structure. A substantial number of children who are born without a limb feel a phantom of the missing part, suggesting that the neural network, or 'neuromatrix', that subserves body sensation has a genetically determined substrate that is modified by sensory experience.
The primary somatosensory cortex of small rodents is an isomorphic representation of the body surface. Similar representations are characteristic of the subcortical pathways, leading from the periphery to the cortex, and these representations develop in a sequence that begins at the periphery, and that ends in the cortex. Furthermore, central representations at all levels of the neural axis are altered by perinatal perturbations of the peripheral surface. This has led to the hypothesis that the periphery plays an instructional role in the formation of central neuronal structures. The morphology of this discrete organization has been examined thoroughly during the development of the thalamocortical projections. The mechanism(s) that underlies the formation of these representations remains unclear although some recent evidence suggests the involvement of activity-dependent processes that are modulated by 5-HT.
Although there is a vast clinical literature on phantom limbs, there have been no experimental studies on the effects of visual input on phantom sensations. We introduce an inexpensive new device--a 'virtual reality box'--to resurrect the phantom visually to study inter-sensory effects. A mirror is placed vertically on the table so that the mirror reflection of the patient's intact had is 'superimposed' on the felt position of the phantom. We used this procedure on ten patients and found the following results. 1. In six patients, when the normal hand was moved, so that the phantom was perceived to move in the mirror, it was also felt to move; i.e. kinesthetic sensations emerged in the phantom. In D.S. this effect occurred even though he had never experienced any movements in the phantom for ten years before we tested him. He found the return of sensations very enjoyable. 2. Repeated practice led to a permanent 'disappearance' of the phantom arm in patient D.S. and the hand became telescoped into the stump near the shoulder. 3. Using an optical trick, impossible postures--e.g. extreme hyperextension of the fingers--could be induced visually in the phantom. In one case this was felt as a transient 'painful tug' in the phantom. 4. Five patients experienced involuntary painful 'clenching spasms' in the phantom hand and in four of them the spasms were relieved when the mirror was used to facilitate 'opening' of the phantom hand; opening was not possible without the mirror. 5. In three patients, touching the normal hand evoked precisely localized touch sensations in the phantom. Interestingly, the referral was especially pronounced when the patients actually 'saw' their phantom being touched in the mirror. Indeed, in a fourth patient (R.L.) the referral occurred only if he saw his phantom being touched: a curious form of synaesthesia. These experiments lend themselves readily to imaging studies using PET and fMRI. Taken collectively, they suggest that there is a considerable amount of latent plasticity even in the adult human brain. For example, precisely organized new pathways, bridging the two cerebral hemispheres, can emerge in less than three weeks. Furthermore, there must be a great deal of back and forth interaction between vision and touch, so that the strictly modular, hierarchical model of the brain that is currently in vogue needs to be replaced with a more dynamic, interactive model, in which 're-entrant' signalling plays the main role.
The experience of phantom limb pain, non-painful phantom limb sensation and telescoping was ascertained by questionnaire in a group of upper extremity amputees wearing a functionally effective Sauerbruch prosthesis which permits extensive use of the affected limb and in a group of patients wearing a cosmetic prosthesis that did little to increase the utilization of the amputation stump. The Sauerbruch prosthesis group exhibited a significant and large decrease in amount of phantom limb pain while the cosmetic prosthesis group showed no change. Neither group experienced a decrease in non-painful phantom limb sensation or telescoping. The amount of phantom limb pain has been found to be highly correlated with the amount of injury-related, afferent-decrease cortical reorganization. It is possible that the increased use of the amputation stump induced by wearing a Sauerbruch prosthesis produced a countervailing use-dependent, afferent-increase type of cortical reorganization that reversed the phantom limb pain. These preliminary results require replication. Their therapeutic implications are discussed.
Contrary to the classical view of a pre-determined wiring pattern, there is considerable evidence that cortical representation of body parts is continuously modulated in response to activity, behavior and skill acquisition. Both animal and human studies showed that following injury of the peripheral nervous system such as nerve injury or amputation, the somatosensory cortex that responded to the deafferented body parts become responsive to neighboring body parts. Similarly, there is expansion of the motor representation of the stump area following amputation. Reorganization of the sensory and motor systems following peripheral injury occurs in multiple levels including the spinal cord, brainstem, thalamus and cortex. In early-blind subjects, the occipital cortex plays an important role in Braille reading, suggesting that there is cross-modal plasticity. Functional recovery frequently occurs following a CNS injury such as stroke. Motor recovery from stroke may be associated with the adjacent cortical areas taking over the function of the damaged areas or utilization of alternative motor pathways. The ipsilateral motor pathway may mediate motor recovery in patients who undergo hemispherectomy early in life and in children with hemiplegic cerebral palsy, but it remains to be determined if it plays a significant role in the recovery of adult stroke. One of the challenges in stroke recovery is to identify which of the many neuroimaging and neurophysiological changes demonstrated are important in mediating recovery. The mechanism of plasticity probably differs depending on the time frame. Rapid changes in motor representations within minutes are likely due to unmasking of latent synapses involving modulation of GABAergic inhibition. Changes over a longer time likely involve other additional mechanisms such as long-term potentiation, axonal regeneration and sprouting. While cross-modal plasticity appears to be useful in enhancing the perceptions of compensatory sensory modalities, the functional significance of motor reorganization following peripheral injury remains unclear and some forms of sensory reorganization may even be associated with deleterious consequences like phantom pain. An understanding of the mechanism of plasticity will help to develop treatment programs to improve functional outcome.
Injuries of peripheral inputs from the body cause sensory dysfunctions that are thought to be attributable to functional changes in cerebral cortical maps of the body. Prevalent theories propose that these cortical changes are explained by mechanisms that preeminently operate within cortex. This paper reviews findings from humans and other primates that point to a very different explanation, i.e. that injury triggers an immediately initiated, and subsequently continuing, progression of mechanisms that alter substrates at multiple subcortical as well as cortical locations. As part of this progression, peripheral injuries cause surprisingly rapid neurochemical/molecular, functional, and structural changes in peripheral, spinal, and brainstem substrates. Moreover, recent comparisons of extents of subcortical and cortical map changes indicate that initial subcortical changes can be more extensive than cortical changes, and that over time cortical and subcortical extents of change reach new balances. Mechanisms for these changes are ubiquitous in subcortical and cortical substrates and include neurochemical/molecular changes that cause functional alterations of normal excitation and inhibition, atrophy and degeneration of normal substrates, and sprouting of new connections. The result is that injuries that begin in the body become rapidly further embodied in reorganizational make-overs of the entire core of the somatosensory brain, from peripheral sensory neurons to cortex. We suggest that sensory dysfunctions after nerve, root, dorsal column (spinal), and amputation injuries can be viewed as diseases of reorganization in this core.
Recent neuroscientific evidence has revealed that the adult brain is capable of substantial plastic change in such areas as the primary somatosensory cortex that were formerly thought to be modifiable only during early experience. These findings have implications for our understanding of chronic pain. Functional reorganisation in both the somatosensory and the motor system was observed in neuropathic and musculoskeletal pain. In patients with chronic low back pain and fibromyalgia the amount of reorganisational change increases with chronicity; in phantom limb pain and other neuropathic pain syndromes cortical reorganisation is correlated with the amount of pain. These central alterations may be viewed as pain memories that influence the processing of both painful and nonpainful input to the somatosensory system as well as its effects on the motor system. Cortical plasticity related to chronic pain can be modified by behavioural interventions that provide feedback to the brain areas that were altered by somatosensory pain memories or by pharmacological agents that prevent or reverse maladaptive memory formation.
There has been a recent and dramatic growth of interest in the psychological and neural mechanisms of multisensory integration between different sensory modalities. Much of this recent research has focused specifically on how multisensory representations of body parts and of the 'peripersonal' space immediately around them, are constructed. Research has also focused on how this may lead to multisensorially determined perceptions of body parts, to action execution, and even to attributions of agency and self-ownership for the body parts in question. Converging evidence from animal and human studies suggests that the primate brain constructs various body-part-centred representations of space, based on the integration of visual, tactile and proprioceptive information. These representations can plastically change following active tool-use that extends reachable space and also modifies the representation of peripersonal space. These new results indicate that a modern cognitive neuroscience approach to the classical concept of the 'body schema' may now be within reach.
Neuroimaging data, particularly functional magnetic resonance imaging (fMRI) findings, have not been reported in users of the myoelectric or electromyographic (EMG) prosthetic hand. We developed a virtual EMG prosthetic hand system to eliminate mutual signal noise interference between fMRI imaging and the EMG prosthesis. We used fMRI to localize activation in the human brain during manipulation of the virtual EMG prosthetic hand. Fourteen right-handed normal subjects were instructed to perform repetitive grasping with the right hand with eyes closed (CEG); repetitive grasping with the right hand with eyes open to obtain visual feedback of their own hand movement (OEG); and repetitive grasping with the virtual EMG prosthetic hand with the eyes open to obtain visual feedback of the prosthetic hand movement (VRG). The specific site activated during manipulation of the EMG prosthetic hand was the right ventral premotor cortex. Both paradigms with visual feedback also (OEG and VRG) demonstrated activation in the right posterior parietal cortex. The center of activation of the right posterior parietal cortex shifted laterally for visual feedback with the virtual EMG prosthetic hand compared to a subject's own hand. The results suggest that the EMG prosthetic hand might be recognized in the brain as a high-performance alternative to a real hand, being controlled through a "mirror system" in the brain.
Although previous research reported that the visual feedback of a 'virtual arm' increased the control of a phantom arm, it did not consider that the repeated attempt to move the phantom may have contributed to the effect. Twenty-one lower limb amputees reported the response of their phantom leg during repeated attempts to move both legs in one of two conditions, a control condition in which the amputee only viewed the movements of their intact leg and an experimental condition in which the amputee additionally viewed the movements of a 'virtual' leg. It was found that viewing a virtual leg resulted in amputees reporting a significantly greater number of movements of their phantom leg than with attempted movement alone. The implications were discussed in terms of visuo-motor adaptation and theories of motor control.
Sensory maps in neocortex are adaptively altered to reflect recent experience and learning. In somatosensory cortex, distinct patterns of sensory use or disuse elicit multiple, functionally distinct forms of map plasticity. Diverse approaches-genetics, synaptic and in vivo physiology, optical imaging, and ultrastructural analysis-suggest a distributed model in which plasticity occurs at multiple sites in the cortical circuit with multiple cellular/synaptic mechanisms and multiple likely learning rules for plasticity. This view contrasts with the classical model in which the map plasticity reflects a single Hebbian process acting at a small set of cortical synapses.
When humans use a tool, it becomes an extension of the hand physically and perceptually. Common introspection might occur in monkeys trained in tool-use, which should depend on brain operations that constantly update and automatically integrate information about the current intrinsic (somatosensory) and the extrinsic (visual) status of the body parts and the tools. The parietal cortex plays an important role in using tools. Intraparietal neurones of naïve monkeys mostly respond unimodally to somatosensory stimuli; however, after training these neurones become bimodally active and respond to visual stimuli. The response properties of these neurones change to code the body images modified by assimilation of the tool to the hand holding it. In this study, we compared the projection patterns between visually related areas and the intraparietal cortex in trained and naïve monkeys using tracer techniques. Light microscopy analyses revealed the emergence of novel projections from the higher visual centres in the vicinity of the temporo-parietal junction and the ventrolateral prefrontal areas to the intraparietal area in monkeys trained in tool-use, but not in naïve monkeys. Functionally active synapses of intracortical afferents arising from higher visual centres to the intraparietal cortex of the trained monkeys were confirmed by electron microscopy. These results provide the first concrete evidence for the induction of novel neural connections in the adult monkey cerebral cortex, which accompanies a process of demanding behaviour in these animals.
The extent to which viewing a 'virtual' limb, the mirror image of an intact limb, modifies the experience of a phantom limb, was investigated in 80 lower limb amputees before, during and after repeated attempts to simultaneously move both intact and phantom legs. Subjects were randomly assigned to one of two conditions, a control condition in which they only viewed the movements of their intact limb and a mirror condition in which they additionally viewed the movements of a 'virtual' limb. Although the mirror condition elicited a significantly greater number of phantom limb movements than the control condition, it did not attenuate phantom limb pain and sensations any more than the control condition. The potential of a 'virtual' limb as a treatment for phantom limb pain was discussed in terms of its ability to halt and/or reverse the cortical re-organisation of motor and somatosensory cortex following acquired limb loss.
Phantom limb and complex regional pain syndrome type 1 (CRPS1) are characterized by changes in cortical processing and organization, perceptual disturbances, and poor response to conventional treatments. Graded motor imagery is effective for a small subset of patients with CRPS1.
To investigate whether graded motor imagery would reduce pain and disability for a more general CRPS1 population and for people with phantom limb pain.
Fifty-one patients with phantom limb pain or CRPS1 were randomly allocated to motor imagery, consisting of 2 weeks each of limb laterality recognition, imagined movements, and mirror movements, or to physical therapy and ongoing medical care.
There was a main statistical effect of treatment group, but not diagnostic group, on pain and function. The mean (95% CI) decrease in pain between pre- and post-treatment (100 mm visual analogue scale) was 23.4 mm (16.2 to 30.4 mm) for the motor imagery group and 10.5 mm (1.9 to 19.2 mm) for the control group. Improvement in function was similar and gains were maintained at 6-month follow-up.
Motor imagery reduced pain and disability in these patients with complex regional pain syndrome type I or phantom limb pain, but the mechanism, or mechanisms, of the effect are not clear.
The aim of this study was to examine the psychometric properties of the Amputee Body Image Scale (ABIS) through Rasch analysis, investigating the quality of its rating categories and its reliability and validity.
The ABIS (20 items; ratings of 1-5) and Trinity Amputation Prosthesis Experience Scales (TAPES) were administered by post and completed by 145 people with a lower-limb amputation and currently wearing a prosthesis.
According to Rasch analysis and expert review, some response categories were collapsed and six items were deleted. The remaining 14 items created a revised ABIS (ABIS-R) rated with a three-level rating scale. ABIS-R fitted the unidimensional construct that the scale was intended to measure and demonstrated good reliability (Cronbach's alpha and person separation reliability = 0.87), targeting, and internal construct validity. Moreover, the correlations with the nine TAPES subscales (in particular, r = -0.54 with the general adjustment, r = -0.43 with the social activity restriction, and r = -0.40 with social adjustment) supported the convergent validity of ABIS-R.
The 14-item ABIS-R demonstrates good psychometric characteristics for measuring body image disturbances in people with lower-limb amputation. These preliminary results suggest the general adequacy of the new instrument and provide a good foundation on which further validation and psychometric studies of the ABIS-R can be conducted.
In primates, ventral premotor and rostral inferior parietal neurons fire during the execution of hand and mouth actions. Some cells (called mirror neurons) also fire when hand and mouth actions are just observed. Mirror neurons provide a simple neural mechanism for understanding the actions of others. In humans, posterior inferior frontal and rostral inferior parietal areas have mirror properties. These human areas are relevant to imitative learning and social behavior. Indeed, the socially isolating condition of autism is associated with a deficit in mirror neuron areas. Strategies inspired by mirror neuron research recently have been used in the treatment of autism and in motor rehabilitation after stroke.
This paper describes the design and implementation of a case study based investigation using immersive virtual reality as a treatment for phantom limb pain.
Three participants who experienced phantom limb pain (two with an upper-limb amputation, and one with a lower-limb amputation) took part in between 2 and 5 immersive virtual reality (IVR) sessions over a 3-week period. The movements of participants' anatomical limbs were transposed into the movements of a virtual limb, presented in the phenomenal space of their phantom limb.
Preliminary qualitative findings are reported here to assess proof of principle for this IVR equipment. All participants reported the transferal of sensations into the muscles and joints of the phantom limb, and all participants reported a decrease in phantom pain during at least one of the sessions.
The authors suggest the need for further research using control trials.
Antidepressants and anticonvulsants are currently considered to be the drug treatment of choice for neuropathic pain. Opioids are effective in relieving neuropathic pain, including phantom pain in the early postoperative course. The present study of 42 cancer patients with limb amputation was conducted to determine the incidence of phantom limb pain and phantom sensation and to test the utility of the World Health Organization 3-step analgesic ladder in phantom limb pain management. Patients were monitored monthly for the first 2 months postoperatively and every 2 months thereafter for 2 years. The World Health Organization analgesic ladder was followed for pain management. The patients complaining of phantom sensation, phantom pain, and stump pain decreased from 69%, 60%, and 31%, respectively, at 1 month to 32%, 32%, and 5%, at the end of 2 years with the addition of opioids. The World Health Organization analgesic ladder played significant role in phantom limb pain management.
The authors conducted a trial of mirror therapy versus imagery therapy in patients with phantom limb pain after the amputation of a leg or foot. Pain intensity decreased with mirror treatment, as did the number and duration of pain episodes.
To develop a model for prediction of upper limb prosthesis use or rejection.
A questionnaire exploring factors in prosthesis acceptance was distributed internationally to individuals with upper limb absence through community-based support groups and rehabilitation hospitals.
A total of 191 participants (59 prosthesis rejecters and 132 prosthesis wearers) were included in this study.
A logistic regression model, a C5.0 decision tree, and a radial basis function neural network were developed and compared in terms of sensitivity (prediction of prosthesis rejecters), specificity (prediction of prosthesis wearers), and overall cross-validation accuracy.
The logistic regression and neural network provided comparable overall accuracies of approximately 84 +/- 3%, specificity of 93%, and sensitivity of 61%. Fitting time-frame emerged as the predominant predictor. Individuals fitted within two years of birth (congenital) or six months of amputation (acquired) were 16 times more likely to continue prosthesis use.
To increase rates of prosthesis acceptance, clinical directives should focus on timely, client-centred fitting strategies and the development of improved prostheses and healthcare for individuals with high-level or bilateral limb absence. Multivariate analyses are useful in determining the relative importance of the many factors involved in prosthesis acceptance and rejection.