Application of immersive virtual reality mirror therapy for upper limb rehabilitation after stroke: a scoping review

Mirror therapy is a commonly used rehabilitation intervention in post stroke upper limb rehabilitation. Despite many potential technological developments, mirror therapy is routinely delivered through the use of a static mirror or mirror box. This review aims to synthesise evidence on the application of immersive virtual reality mirror therapy (IVRMT) in poststroke upper limb rehabilitation. A scoping review was performed on relevant English studies published between 2013 to 2023. Literature search was undertaken on APA PsycInfo, CINAHL, Cochrane Library, MEDLINE, PubMed and Web of Science between August 5 and 17, 2023. Additional studies were included from Google Scholar and reference lists of identified articles. A total of 224 records were identified, of which 8 full-text articles were selected for review. All included studies were published between 2019 and 2023, and from high- and upper-middle-income nations. All the studies were experimental (n = 8). The total sample size in the studies was 259, most of whom were stroke patients with upper limb weakness (n = 184). This review identified three major themes and two sub-themes based on the contents of the studies conducted on the application of IVRMT: IVRMT's technical application, feasibility and impact on clinical outcomes (motor recovery and adverse events). IVRMT was concluded to be a safe and feasible approach to post-stroke upper limb rehabilitation, offering enhanced engagement and motor recovery. However, more methodologically robust studies should be conducted to advance this area of practice, and to include a uniform IVRMT intervention protocol, dose, and use of outcome measure.

Integrating Complementary Therapies in Managing Phantom Limb Pain: A Case Review

OBJECTIVES

This paper describes phantom limb pain (PLP), its impact on patients, and the various treatment options, including pharmacologic and complementary therapies. It investigates the efficacy of incorporating complementary and alternative therapies, both invasive and noninvasive, for amputees who have not achieved satisfactory results with pharmacologic treatments and suffer from adverse drug events. Furthermore, with the predicted increase in limb amputations, it is crucial for nurses, as frontline providers, to understand PLP, be prepared to manage persistent pain and associated psychological and functional issues and educate patients and families about alternative treatment options.

APPROACH

The review includes recent studies on pharmacologic interventions for PLP, case reports, and randomized clinical trials on non-pharmacologic complementary therapies, covering both invasive and noninvasive modalities. Studies from 2013 to 2022 were identified using the PubMed search engine with terms such as "Amputation," "phantom limb pain," "invasive therapies," and "non-invasive therapies."

RESULTS AND CONCLUSION

The pathogenesis of PLP remains unclear, complicating the identification of causes and the selection of targeted therapies for each patient. Uncontrolled PLP can severely impact the quality of life, causing psychological distress and loss of productivity. Traditional pharmacologic therapy often requires supplementation with other options due to PLP's refractory nature. A comprehensive, multimodal treatment plan, including non-pharmacologic therapies, can enhance rehabilitation and reduce complications. Incorporating these therapies can decrease reliance on medications, particularly opioids, and mitigate side effects. Although many potential PLP treatments exist, further clinical studies are needed to determine their effectiveness and establish protocols for optimizing patient outcomes.

The Test-Retest Reliability of Pain Outcome Measures in People With Phantom Limb Pain

OBJECTIVES

To quantify the test-retest reliability of 3 patient-reported outcome measures of pain for people living with phantom limb pain (PLP) and assess the impact of test-retest errors on future research and clinical decisions.

METHODS

Thirty-nine participants (30 males), mean (SD) age: 55 (16), mean (SD) years postamputation: 6.8 (8.3), reported their PLP levels on a visual analogue scale (VAS) for pain intensity, the revised short-form McGill Pain Questionnaire (SF-MPQ-2), and a pain diary, on 2 occasions 7 to 14 days apart. Mean systematic change, within-subjects SD, limits of agreement (LOA), coefficient of variation, and the intraclass correlation coefficient (ICC) were quantified alongside their respective 95% confidence intervals (95% CIs).

RESULTS

Systematic learning effects (mean changes) were not clinically relevant across the VAS, SF-MPQ-2, and pain diary. Within-subject SDs (95% CI) were 11.8 (9.6-15.3), 0.9 (0.7-1.2), and 8.6 (6.9-11.5), respectively. LOA (95% CI) were 32.6 (26.5-42.4), 2.5 (2-3.3), and 23.9 (19.2-31.8), respectively. ICCs (95% CI) were 0.8 (0.6-0.9), 0.8 (0.7-0.9), and 0.9 (0.8-0.9), respectively, but may have been inflated by sample heterogeneity. The test-retest errors allowed detection of clinically relevant effect sizes with feasible sample sizes in future studies, but individual errors were large.

DISCUSSION

For people with PLP, a pain intensity VAS, the SF-MPQ-2, and a pain diary show an acceptable level of intersession reliability for use in future clinical trials with feasible sample sizes. Nevertheless, the random error observed for all 3 of the pain outcome measures suggests they should be interpreted with caution in case studies and when monitoring individuals' clinical status and progress.

The effect of rehabilitation therapies on quality of life and function in individuals with phantom limb pain after lower-limb amputation: A systematic review

PURPOSE

To evaluate the existing evidence surrounding the effect of rehabilitation therapies on quality of life (QOL) and function of individuals with a lower-limb amputation and experiencing phantom limb pain (PLP).

METHODS

This review followed Preferred Reporting Items for Systematic reviews and Meta-Analyses methodology. Four databases were searched with key terms that covered 4 broad areas: phantom limb, lower-limb amputation, rehabilitation interventions, and randomized controlled trial (no date limits). Outcomes of either function or QOL in people receiving rehabilitation for PLP were included. The RoB2.0 risk-of-bias tool was used to rate quality.

RESULTS

Five studies were included, reporting on QOL (n = 5) and function (n = 3), using interventions including mirror therapy, phantom exercises, and muscle relaxation. The evidence was mixed in direction and significance, and this was likely attributed to by the heterogeneity of interventions and types of outcomes as well as incomplete reporting. There was very low certainty in the effect of these rehabilitation interventions to affect QOL or function.

CONCLUSION

The overall effect of rehabilitation interventions on QOL and function is inconclusive because of the variable results across the included randomized controlled trials. More research is needed to explore the impact of interventions beyond the outcome of pain and to establish a clearer conclusion. Including measures of QOL and function as well as pain in studies with people with PLP is encouraged.

Virtual and Augmented Reality in Management of Phantom Limb Pain: A Systematic Review

Upper and lower limb amputations are frequently associated with phantom limb pain (PLP). Recently, virtual reality (VR) and augmented reality (AR) have been reported as a potential therapy of PLP. We have conducted a systematic review of literature to evaluate the efficacy of VR and AR in managing PLP. Four databases were searched: PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Web of Science. We utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for our organization. The initial search resulted in 164 results. After title, abstract, and full-text screening, 9 studies were included. One study was of good quality and 8 studies were of fair to poor quality. Seven studies utilized VR and 2 studies utilized AR. The number of treatment sessions ranged from 1 to 28 and the duration ranged from 10 minutes to 2 hours. Several pain scales were used to evaluate PLP pre- and postintervention including Numeric Rating Scale, Pain Rating Index, McGill Pain Questionnaire, and Visual Analog Scale. All the studies reported improvement of PLP on one or more of pain scales after one or more sessions of VR or AR. Despite the promising results reported by literature, we cannot recommend using VR or AR for PLP. Most of the studies are of poor design and have limited sample size with high bias levels. Therefore, no substantial evidence can be derived from them. However, we do believe further research with high-quality randomized controlled trials should take place to increase the knowledge of the potential advantages.

From Augmented to Virtual Reality in Plastic Surgery: Blazing the Trail to a New Frontier

BACKGROUND

 Augmented reality (AR) and virtual reality (VR)-termed mixed reality-have shown promise in the care of operative patients. Currently, AR and VR have well-known applications for craniofacial surgery, specifically in preoperative planning. However, the application of AR/VR technology to other reconstructive challenges has not been widely adopted. Thus, the purpose of this investigation is to outline the current applications of AR and VR in the operative setting.

METHODS

 The literature pertaining to the use of AR/VR technology in the operative setting was examined. Emphasis was placed on the use of mixed reality technology in surgical subspecialities, including plastic surgery, oral and maxillofacial surgery, colorectal surgery, neurosurgery, otolaryngology, neurosurgery, and orthopaedic surgery.

RESULTS

 Presently, mixed reality is widely used in the care of patients requiring complex reconstruction of the craniomaxillofacial skeleton for pre- and intraoperative planning. For upper extremity amputees, there is evidence that VR may be efficacious in the treatment of phantom limb pain. Furthermore, VR has untapped potential as a cost-effective tool for microsurgical education and for training residents on techniques in surgical and nonsurgical aesthetic treatment. There is utility for mixed reality in breast reconstruction for preoperative planning, mapping perforators, and decreasing operative time. VR has well- documented applications in the planning of deep inferior epigastric perforator flaps by creating three-dimensional immersive simulations based on a patient's preoperative computed tomography angiogram.

CONCLUSION

 The benefits of AR and VR are numerous for both patients and surgeons. VR has been shown to increase surgical precision and decrease operative time. Furthermore, it is effective for patient-specific rehearsal which uses the patient's exact anatomical data to rehearse the procedure before performing it on the actual patient. Taken together, AR/VR technology can improve patient outcomes, decrease operative times, and lower the burden of care on both patients and health care institutions.

Performance in myoelectric pattern recognition improves with transcranial direct current stimulation

Sensorimotor impairments, resulting from conditions like stroke and amputations, can profoundly impact an individual's functional abilities and overall quality of life. Assistive and rehabilitation devices such as prostheses, exo-skeletons, and serious gaming in virtual environments can help to restore some degree of function and alleviate pain after sensorimotor impairments. Myoelectric pattern recognition (MPR) has gained popularity in the past decades as it provides superior control over said devices, and therefore efforts to facilitate and improve performance in MPR can result in better rehabilitation outcomes. One possibility to enhance MPR is to employ transcranial direct current stimulation (tDCS) to facilitate motor learning. Twelve healthy able-bodied individuals participated in this crossover study to determine the effect of tDCS on MPR performance. Baseline training was followed by two sessions of either sham or anodal tDCS using the dominant and non-dominant arms. Assignments were randomized, and the MPR task consisted of 11 different hand/wrist movements, including rest or no movement. Surface electrodes were used to record EMG and the MPR open-source platform, BioPatRec, was used for decoding motor volition in real-time. The motion test was used to evaluate performance. We hypothesized that using anodal tDCS to increase the excitability of the primary motor cortex associated with non-dominant side in able-bodied individuals, will improve motor learning and thus MPR performance. Overall, we found that tDCS enhanced MPR performance, particularly in the non-dominant side. We were able to reject the null hypothesis and improvements in the motion test's completion rate during tDCS (28% change, p-value: 0.023) indicate its potential as an adjunctive tool to enhance MPR and motor learning. tDCS appears promising as a tool to enhance the learning phase of using assistive devices using MPR, such as myoelectric prostheses.

Feasibility study of a home-based graded motor imagery intervention (GraMI protocol) for amputees with phantom limb pain

INTRODUCTION

Phantom limb pain affects 64% of amputees. Graded Motor Imagery comprises three consecutive application techniques designed to reorganize maladaptive changes that have occurred after the amputation.

OBJECTIVE

To assess the feasibility of a home-based Graded Motor Imagery intervention, the GraMI protocol, for amputee people with phantom limb pain.

METHODS

Twenty individuals over 18 years of age with upper or lower limb amputation, experiencing phantom limb pain, who were pharmacologically stable, and had been discharged from the hospital were recruited. The experimental group followed the GraMI protocol. Primary outcomes included study processes, such as recruitment time and rate, adherence, compliance, and the acceptability of digital technologies as a treatment tool. Secondary outcomes assessed the impact on phantom limb pain, quality of life, functionality, and depressive symptoms.

RESULTS

On average, seven participants were recruited monthly over a three-month period. No losses were recorded throughout the nine weeks of intervention. Treatment adherence averaged 89.32%, and all participants demonstrated familiarity with the usability of digital technologies. No significant differences were observed between groups (p = .054). However, within the experimental group, intragroup analysis revealed a significant (p = .005) and clinically relevant reduction (>2 points) with a large effect size (0.89) in phantom limb pain.

CONCLUSION

Conducting a multicenter study with a home-based intervention using the GraMI protocol is feasible. Future clinical trials are needed to verify its effectiveness in managing phantom limb pain.

[Orthopedics and trauma surgery in the digital age]

BACKGROUND

Digital transformation is shaping the future of orthopedics and trauma surgery. Telemedicine, digital health applications, electronic patient records and artificial intelligence play a central role in this. These technologies have the potential to improve medical care, enable individualized patient treatment plans and reduce the burden on the treatment process. However, there are currently challenges in the areas of infrastructure, regulation, reimbursement and data protection.

REALISING THE TRANSFORMATION

Effective transformation requires a deep understanding of both technology and clinical practice. Orthopedic and trauma surgeons need to take a leadership role by actively engaging with new technologies, designing new treatment processes and enhancing their medical skills with digital and AI competencies. The integration of digital skills into medical education and specialist training will be crucial for actively shaping the digital transformation and exploiting its full potential.

Effects of task-based mirror therapy on upper limb motor function in hemiplegia: study protocol for a randomized controlled clinical trial

BACKGROUND AND PURPOSE

Research to date has lacked definitive evidence to determine whether mirror therapy promotes the recovery of upper extremity function after stroke. Considering that previous studies did not stratify patients based on structural retention, this may be one of the reasons for the negative results obtained in many trials. The goal evaluates the efficacy of TBMT (utilizing an innovatively designed mirror) versus standard occupational therapy for stroke patient's upper limb functionality.

METHODS AND ANALYSIS

This single-center randomized controlled trial will involve 50 patients with stroke. All patients will be randomly assigned to either the task-based mirror therapy or the control group. The interventions will be performed 5 days per week for 4 weeks. The primary outcomes will be the mean change in scores on both the FMA-UE and modified Barthel Index (MBI) from baseline to 4 weeks intervention and at 12 weeks follow-up between the two groups and within groups. The other outcomes will include the Action Research Arm Test (ARAT), the Nine Hole Peg Test (9HPT), the Functional Independence Measure, and MRI.

DISCUSSION

This trial will not only to establish that task-based mirror therapy (TBMT) could improve the recovery of hand function after stroke but also to explore the underlying mechanisms. We expect that this finding will clarify the brain activation and brain network mechanisms underlying the improvement of hand function with task-oriented mirror therapy and lead to new ideas for stroke hand function rehabilitation.

TRIAL REGISTRATION

URL: https://www.chictr.org.cn ; Unique identifier: ChiCTR2300068855. Registered on March 1, 2023.

The effectiveness of graded motor imagery and its components on phantom limb pain in amputated patients: A systematic review

BACKGROUND

Phantom limb pain (PLP) can be defined as pain in a missing part of the limb. It is reported in 50%-80% of people with amputation.

OBJECTIVES

To provide an overview of the effectiveness of graded motor imagery (GMI) and the techniques which form it on PLP in amputees.

STUDY DESIGN

Systematic review.

METHODS

Two authors independently selected relevant studies, screened the articles for methodological validity and risk of bias, and extracted the data. Inclusion criteria used were clinical studies, written in English or Spanish, using GMI, laterality recognition, motor imagery, mirror therapy, or a combination of some of them as an intervention in amputated patients, and one of the outcomes was PLP, and it was assessed using a validated scale. The databases used were PubMed, Scopus, Web of Science, CINAHL, and PEDro.

RESULTS

Fifteen studies were included in the review. After the intervention, all the groups in which the GMI or one of the techniques that comprise it was used showed decrease in PLP.

CONCLUSION

The 3 GMI techniques showed effectiveness in decreasing PLP in amputees, although it should be noted that the application of the GMI showed better results.

A qualitative study of clinicians' and individuals' with lower limb loss perspectives on the development of a novel online self-management program

PURPOSE

To explore the rehabilitation preferences and experiences of clinicians and patients for education after lower limb loss to facilitate the development of an online self-management program.

METHODS

A qualitative descriptive approach was used. Thirty-one clinicians (physiotherapists, occupational therapists, and prosthetists), and 26 patients with lower limb loss (transtibial and transfemoral amputation; mean age (SD) of 63.3 (9.1), years) were recruited. We used semi-structured focus groups and one-on-one interviews, and audio recorded the interviews. Data were analyzed using conventional content analysis.

RESULTS

Three themes were identified: (1) Needing education in rehabilitation described the education in current practice as one-on-one discussion and booklets and highlighted the limitations of education such as its length, static nature, and inaccessible for patients living in remote areas. (2) Getting back to activities prior to amputation emphasized how goal setting and social support could assist patients and facilitate self-management. (3) Augmenting learning highlighted the need for an accessible complementary source for education and potential solutions to overcome the barriers of online delivery.

CONCLUSIONS

Our findings underscore the importance of education in the rehabilitation of patients to help them get back to their activities. An online accessible tool may improve education by providing information and peer support.

Graded motor imagery and its phases for individuals with phantom limb pain following amputation: A scoping review

OBJECTIVE

Three-phase graded motor imagery (limb laterality, explicit motor imagery, and mirror therapy) has been successful in chronic pain populations. However, when applied to phantom limb pain, an amputation-related pain, investigations often use mirror therapy alone. We aimed to explore evidence for graded motor imagery and its phases to treat phantom limb pain.

DATA SOURCES

A scoping review was conducted following the JBI Manual of Synthesis and Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews. Thirteen databases, registers, and websites were searched.

REVIEW METHODS

Published works on any date prior to the search (August 2023) were included that involved one or more graded motor imagery phases for participants ages 18+ with amputation and phantom limb pain. Extracted data included study characteristics, participant demographics, treatment characteristics, and outcomes.

RESULTS

Sixty-one works were included representing 19 countries. Most were uncontrolled studies (31%). Many participants were male (75%) and had unilateral amputations (90%) of varying levels, causes, and duration. Most works examined one treatment phase (92%), most often mirror therapy (84%). Few works (3%) reported three-phase intervention. Dosing was inconsistent across studies. The most measured outcome was pain intensity (95%).

CONCLUSION

Despite the success of three-phase graded motor imagery in other pain populations, phantom limb pain research focuses on mirror therapy, largely ignoring other phases. Participant demographics varied, making comparisons difficult. Future work should evaluate graded motor imagery effects and indicators of patient success. The represented countries indicate that graded motor imagery phases are implemented internationally, so future work could have a widespread impact.

Effect of augmented reality-based rehabilitation of hand burns on hand function in children: A randomized controlled trial

BACKGROUND

Despite the use of traditional rehabilitation methods, hand function may still remain impaired in children suffering from burn injuries.

PURPOSE

This study aimed to assess the impact of implementing an augmented reality (AR) rehabilitation booklet designed for pediatric hand burn on their hand functionality.

STUDY DESIGN

This was a randomized controlled trial.

METHODS

Seventy-two children, aged 8-14 years with a hand burn, were randomly allocated into intervention (n = 36) and control (n = 36) groups. Children in the control group received routine rehabilitation program, while in the intervention group, children performed exercises using a printed booklet with related AR application. The Jebsen-Taylor Hand Function Test was completed before the intervention at the time of the patients' discharge and 1 month later.

RESULTS

The results of analysis of covariance based on baseline- and fully-adjusted models showed significant intervention effect after discharge as well as after intervention for hand function (mean difference [95% confidence interval] for discharge: -8.2 [-15.0 to -1.4] and for after intervention: -74.0 [-88.8 to -59.1]) and the items (all p < 0.05), except for writing and lifting large light objects for both after discharge and after intervention measures (all p-value > 0.05).

CONCLUSIONS

A significant decrease in the total time taking to complete the Jebsen-Taylor hand function test was observed in the intervention group compared to the control group 1 month after discharge. Rehabilitation of children with hand burns, using printed educational booklet with related AR application, improves their hand function.

Efficacy of Mirror Therapy in Patients with Phantom Pain after Amputation of a Lower Limb: A Systematic Literature Review

Up to 80% of patients after amputation are affected by phantom limb pain. This may be due to various mechanisms of cortical reorganisation. Non-surgical treatment of the neuropathic phantom limb pain involves mirror therapy. Thereby, the use of a mirror should induce the illusion that the extremity has been preserved. This illusion should initiate processes to restore the original organisation of the somatosensory and motor cortex and thus to reduce pain. Evidence of mirror therapy to treat lower extremity phantom limb pain is rare. Therefore, the aim of this systematic review is to qualitatively analyse the efficacy of mirror therapy for treatment of phantom limb pain in adult patients after unilateral amputations of the lower extremity.The databases Medline (PubMed), Physiotherapy Evidence Database (PEDro), Cochrane Library (Central), and OPENGREY were systematically searched until 26th November 2020, followed by continued searches in these databases to provide a review of updated literature. Study selection, data extraction, and risk of bias evaluation (Risk of Bias Tool [RoB]) of included studies were conducted by two reviewers independently. The primary outcome was pain intensity, and secondary outcomes were pain frequency, pain duration, activities of daily life (ADL), and quality of life. The methodology of this review follows the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and the Cochrane Handbook for Systematic Reviews of Interventions.The search revealed 234 articles. Four articles were included in the analysis. A reduction in pain intensity due to mirror therapy was reported in all studies, however, in only 2 studies there were significant differences between mirror therapy and the comparison after 4 weeks of treatment (p < 0.001; p < 0.05). This significant difference was maintained after 3 and 6 months follow-up in one of those studies (p < 0.001). The outcomes pain frequency, pain duration, and ADL were decreased after 4 and 10 weeks of mirror therapy compared to comparison, but with no statistical significance (p > 0.05). After 6 months, there was a significant improvement in the duration of pain and in ADL after mirror therapy compared with the control group (p < 0.05). Differences in the results quality of life between the intervention group and comparison were observed in 2 studies.Mirror therapy of high frequency and duration is an effective intervention to reduce phantom limb pain in patients after unilateral lower extremity amputation. The superiority of mirror therapy to other interventions cannot be concluded, as the evidence was of low quality.

Could Vulnerability to Motion Sickness and Chronic Pain Coexist within a Sensorimotor Phenotype? Insights from over 500 Pre-Pain Motion Sickness Reports

BACKGROUND

The sensorimotor incongruence theory proposes that certain instances of pain result from conflicts in the brain's sensorimotor networks. Indeed, injuries may cause abnormalities in afferent and cortical signaling resulting in such conflicts. Motion sickness also occurs in instances of incongruent sensorimotor data. It is possible that a sensory processing phenotype exists that predisposes people to both conditions.

AIM

The aim of this study was to investigate whether participants with chronic pain recall greater susceptibility to motion sickness before chronic pain onset.

METHOD

Data were collected via an online LimeSurvey. A self-report tendency toward motion sickness was measured using the Motion Sickness Susceptibility Questionnaire. Group differences were analysed using analysis of covariance methods.

RESULTS

530 patients (low back pain, n = 198; neck pain, n = 59; whiplash-associated disorder, n = 72; fibromyalgia syndrome, n = 114; Migraine, n = 41) and 165 pain-free controls were surveyed. ANCOVA analysis, using sex and anxiety as covariates, suggested that childhood motion sickness susceptibility scores differed by group (F = 2.55 (6, 615), p = 0.019, (ηp2) = 0.024). Planned comparisons, with corrected p-values, suggested that childhood motion sickness was not statistically greater for low back pain, rheumatoid arthritis, migraine, neck pain or whiplash-associated disorder (ps > 0.05), although scores were on average 27%, 42%, 47%, 48% and 58% higher, respectively. Childhood susceptibility was statistically higher in people with FMS (p = 0.018), with scores on average 83% higher than controls. ANCOVA analysis, using sex and anxiety as covariates, suggested that adult motion sickness susceptibility scores did not differ by group (F = 1.86 (6, 613), p = 0.086), although average scores were, on average, at least 33% higher in persistent pain groups.

CONCLUSIONS

According to retrospective reporting, greater susceptibility to motion sickness appears to pre-date persistent pain in some conditions. This supports the possibility that motion sickness and chronic pain may, in some cases, have overlapping mechanisms related to the handling of incongruent sensorimotor data.

Mirror Therapy in Patients with Somatoform Pain Disorders-A Pilot Study

Patients with chronic pain report reduced quality of life and high symptom burden while often responding insufficiently to treatment options. Mirror therapy has been proven to be effective in treating phantom limb pain and other conditions such as CRPS. This study was designed to investigate the efficacy of mirror therapy in patients with somatoform pain disorders on symptom severity and associated physiological parameters. Fifteen patients with persistent somatoform pain disorder (F45.40) or chronic pain disorder with somatic and psychological factors (F45.41) participated and received four weeks of tablet-based mirror therapy. Symptom severity was measured with established questionnaires, and their thermal detection, pain thresholds, and heart rate variability (HRV) were also assessed. After mirror therapy, pain intensity was reduced (z = -2.878, p = 0.004), and pain thresholds for cold stimuli were also diminished, i.e., the subjects became more sensitive to cold stimuli (z = -2.040, p = 0.041). In addition, a reduction of absolute power in the low-frequency band of HRV (t(13) = 2.536, p = 0.025) was detected. These findings indicate that this intervention may reduce pain intensity and modulate associated physiological parameters. As these results are limited by several factors, e.g., a small sample size and no control group, they should be validated in further studies investigating this novel intervention in these patients.

The Efficacy of Graded Motor Imagery and Its Components on Phantom Limb Pain and Disability: A Systematic Review and Meta-Analysis

Introduction

Graded Motor Imagery (GMI) is a non-invasive and inexpensive therapy used to treat Phantom Limb Pain (PLP) by sequentially activating motor networks in such a way that movement and pain are unpaired. The objective of this systematic review was to critically appraise relevant data on the efficacy of GMI and its components for reducing PLP and disability in amputees.

Methods

We searched 11 electronic databases for controlled trials investigating GMI and its components in amputees with PLP from inception until February 2023. Two reviewers independently screened studies and extracted relevant data. Study-level data were entered using the inverse variance function of the Review Manager 5 and pooled with the random effects model.

Results

Eleven studies with varying risk of bias were eligible. No eligible study considered left/right judgement tasks in isolation. Studies showed no effect for imagined movements, but positive effects were seen for GMI [weighted mean difference: -21.29 (95%CI: -31.55, -11.02), I2= 0%] and mirror therapy [weighted mean difference: -8.55 (95%CI: -14.74, -2.35, I2= 61%]. A comparison of mirror therapy versus sham showed no difference [weighted mean difference: -4.43 (95%CI: -16.03, 7.16), I2= 51%].

Conclusion

Our findings suggest that GMI and mirror therapy may be effective for reducing PLP. However, this conclusion was drawn from a limited body of evidence, and the certainty of the evidence was very low. Therefore, rigorous, high-quality trials are needed to address the gap in the literature and inform practice.

When proprioceptive feedback enhances visual perception of self-body movement: rehabilitation perspectives

Introduction

Rehabilitation approaches take advantage of vision's important role in kinesthesia, using the mirror paradigm as a means to reduce phantom limb pain or to promote recovery from hemiparesis. Notably, it is currently applied to provide a visual reafferentation of the missing limb to relieve amputees' pain. However, the efficiency of this method is still debated, possibly due to the absence of concomitant coherent proprioceptive feedback. We know that combining congruent visuo-proprioceptive signals at the hand level enhances movement perception in healthy people. However, much less is known about lower limbs, for which actions are far less visually controlled in everyday life than upper limbs. Therefore, the present study aimed to explore, with the mirror paradigm, the benefit of combined visuo-proprioceptive feedback from the lower limbs of healthy participants.

Methods

We compared the movement illusions driven by visual or proprioceptive afferents and tested the extent to which adding proprioceptive input to the visual reflection of the leg improved the resulting movement illusion. To this end, 23 healthy adults were exposed to mirror or proprioceptive stimulation and concomitant visuo-proprioceptive stimulation. In the visual conditions, participants were asked to voluntarily move their left leg in extension and look at its reflection in the mirror. In the proprioceptive conditions, a mechanical vibration was applied to the hamstring muscle of the leg hidden behind the mirror to simulate an extension of the leg, either exclusively or concomitantly, to the visual reflection of the leg in the mirror.

Results

(i) Visual stimulation evoked leg movement illusions but with a lower velocity than the actual movement reflection on the mirror; (ii) proprioceptive stimulation alone provided more salient illusions than the mirror illusion; and (iii) adding a congruent proprioceptive stimulation improved the saliency, amplitude, and velocity of the illusion.

Conclusion

The present findings confirm that visuo-proprioceptive integration occurs efficiently when the mirror paradigm is coupled with mechanical vibration at the lower limbs, thus providing promising new perspectives for rehabilitation.

Evolving techniques for reducing phantom limb pain

At least two million people in the United States of America live with lost limbs, and the number is expected to double by 2050, although the incidence of amputations is significantly greater in other parts of the world. Within days to weeks of the amputation, up to 90% of these individuals develop neuropathic pain, presenting as phantom limb pain (PLP). The pain level increases significantly within one year and remains chronic and severe for about 10%. Amputation-induced changes are considered to underlie the causation of PLP. Techniques applied to the central nervous system (CNS) and peripheral nervous system (PNS) are designed to reverse amputation-induced changes, thereby reducing/eliminating PLP. The primary treatment for PLP is the administration of pharmacological agents, some of which are considered but provide no more than short-term pain relief. Alternative techniques are also discussed, which provide only short-term pain relief. Changes induced by various cells and the factors they release are required to change neurons and their environment to reduce/eliminate PLP. It is concluded that novel techniques that utilize autologous platelet-rich plasma (PRP) may provide long-term PLP reduction/elimination.

Comparative Effects of Interventions on Phantom Limb Pain: A Network Meta-Analysis

BACKGROUND

Phantom limb pain (PLP) is a common type of chronic pain that occurs after limb amputation. Many treatment approaches are available; however, the treatment of PLP is still a challenge. This study aimed to quantify and rank the efficacy of interventions for phantom limb pain.

METHODS

A comprehensive literature search was performed using the databases of PubMed, MEDLINE, Embase, Web of Science, and Cochrane. A network meta-analysis was applied to formulate direct and indirect comparisons among interventions for PLP.

RESULTS

Twenty-two studies comprising 662 patients and 13 different interventions were included in this study. The mirror therapy (MT) (-1.00; 95% confidence interval, -1.94 to -0.07) and MT + phantom exercise (PE) (-6.05; 95% confidence interval, -8.29 to -3.81) group presented significantly lower pain intensity compared with placebo. In SUCRA (surface under the cumulative ranking curve) analysis, the MT+PE and neuromodulation techniques groups had the highest SUCRA value (81.2).

CONCLUSIONS

Our results suggest that MT is the most optimal treatment for PLP, and a combination of therapies would enhance the therapeutic effect.

Amputation and prosthetics of the lower extremity: The 2020 Dutch evidence-based multidisciplinary guideline

BACKGROUND

Lower-limb amputations are rare but debilitating events in the lives of affected persons. Treatment of persons with amputation inherently involves many different health care professions at different stages leading to and after an amputation. There are prevailing clinical questions within the work field related to different facets of care including peri/postoperative aspects, prosthetic components, rehabilitation treatment, and health care processes.

OBJECTIVES

To provide an up-to-date multidisciplinary evidence-based guideline for health care professionals involved in the treatment of persons with lower-limb amputation in the Netherlands.

METHODS

Identification of key questions in a focus group, systematic review of the evidence (up to March 2019, using Embase and MEDLINE databases), and weighing considerations, culminating in clinical recommendations.

RESULTS

Twelve key questions were formulated. Recommendations of two key questions were upheld in line with the previous 2012 guideline. Ten systematic literature searches were performed, leading to the inclusion of 59 studies.

CONCLUSION

A summary of evidence-based conclusions, considerations, and recommendations of the 2020 guideline is presented.

Effect of mirror therapy in the treatment of phantom limb pain in amputees: A systematic review of randomized placebo-controlled trials does not find any evidence of efficacy

BACKGROUND AND OBJECTIVE

Phantom limb pain (PLP) concerns >50% of amputees and has a negative impact on their rehabilitation, mental health and quality of life. Mirror therapy (MT) is a promising strategy, but its effectiveness remains controversial. We performed a systematic review to: (i) evaluate the effectiveness of MT versus placebo in reducing PLP, and (ii) determine MT effect on disability and quality of life.

DATABASES AND DATA TREATMENT

We selected randomized-controlled trials in five databases (Medline, Cochrane Library, CINAHL, PEDro and Embase) that included patients with unilateral lower or upper limb amputation and PLP and that compared the effects on PLP of MT versus a placebo technique. The primary outcome was PLP intensity changes and the secondary outcomes were PLP duration, frequency, patients' disability and quality of life.

RESULTS

Among the five studies included, only one reported a significant difference between the MT group and control group, with a positive MT effect at week 4. Only one study assessed MT effect on disability and found a significant improvement in the MT group at week 10 and month 6.

CONCLUSIONS

Our systematic review did not allow concluding that MT reduces PLP and disability in amputees. This lack of strong evidence is probably due to (i) the low methodological quality of the included studies, and (ii) the lack of statistical power. Future trials should include a higher number of patients, increase the number and frequency of MT sessions, have a long-term follow-up and improve the methodological quality.

SIGNIFICANCE

Recent meta-analyses concluded that MT is effective for reducing phantom limb pain. Conversely, the present systematic review that included only studies with the best level of evidence did not find any evidence about its effectiveness for this condition. We identified many ways to improve future randomized-controlled trials on this topic: increasing the number of participants, reducing the intra-group heterogeneity, using a suitable placebo and intensifying the MT sessions and frequency.

Identification of phantom movements with an ensemble learning approach

Phantom limb pain after amputation is a debilitating condition that negatively affects activities of daily life and the quality of life of amputees. Most amputees are able to control the movement of the missing limb, which is called the phantom limb movement. Recognition of these movements is crucial for both technology-based amputee rehabilitation and prosthetic control. The aim of the current study is to classify and recognize the phantom movements in four different amputation levels of the upper and lower extremities. In the current study, we utilized ensemble learning algorithms for the recognition and classification of phantom movements of the different amputation levels of the upper and lower extremity. In this context, sEMG signals obtained from 38 amputees and 25 healthy individuals were collected and the dataset was created. Studies of processing sEMG signals in amputees are rather limited, and studies are generally on the classification of upper extremity and hand movements. Our study demonstrated that the ensemble learning-based models resulted in higher accuracy in the detection of phantom movements. The ensemble learning-based approaches outperformed the SVM, Decision tree, and kNN methods. The accuracy of the movement pattern recognition in healthy people was up to 96.33%, this was at most 79.16% in amputees.

Use and efficacy of virtual, augmented, or mixed reality technology for chronic pain: a systematic review

Aim: Characterize use and efficacy/effectiveness of virtual, augmented, or mixed reality (VR/AR/MR) technology as non-pharmacological therapy for chronic pain. Methods: Systematic search of 12 databases to identify empirical studies, of individuals who experience chronic pain or illness involving chronic pain, published between 1990 and 2021. JBI Critical Appraisal Checklists assessed study bias and a narrative synthesis was provided. Results: 46 studies, investigating a total of 1456 participants and including 19 randomized controlled trials (RCT), were reviewed. VR/AR/MR was associated with improved pain-related outcomes in 78% of the RCTs. Conclusion: While most studies showed effects immediately or up to one month post treatment, RCTs are needed to further evaluate VR/AR/MR, establish long-term benefits, and assess accessibility, especially among individuals who experience pain management disparities.

Telehealth interventions for mobility after lower limb loss: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Mobility is a crucial component for healthy aging after lower limb loss (LLL). Telehealth technologies, for example, smart devices, are novel approaches for health programs delivery regardless of geographical boundaries.

OBJECTIVES

To assess the effect of telehealth interventions on mobility, quality of life, and antecedents of health behavior compared with a control condition (usual care or simpler telehealth interventions with fewer number of behavior change techniques [BCTs]) for community-dwelling adults (>50 years) with an LLL and the effect of mode of delivery and BCTs used in telehealth interventions on health outcomes.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

We systematically searched MEDLINE, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane, PsycINFO, and SPORTDiscus on January 28, 2021, to identify relevant randomized controlled trials. Two authors independently screened records and assessed risk of bias. We conducted a narrative synthesis of evidence and, when appropriate, used the standardized mean difference (SMD) and mean difference for meta-analyses and the Grading Recommendations Assessment, Development, and Evaluation approach for practice recommendations.

RESULTS

We identified six randomized controlled trials. Telephone was the most common delivery mode (n = 3), and "instructions for performing behaviors" was the most common BCT (n = 5). Very low certainty evidence showed no changes in mobility (six studies: SMD = 0.33 [95% confidence interval [CI] = -0.08, 0.75]), quality of life (two studies: mean difference = -0.08 [95% CI = -0.30, 0.15]), and antecedents of behavior (five studies: SMD = 0.04 [95% CI = -0.28, 0.36]).

CONCLUSIONS

Our review highlights a knowledge gap for the effect of telehealth interventions for people with LLL. Although no promising effect was shown for telehealth interventions, very low certainty evidence precludes making a definitive clinical recommendation.

Efficacy of mirror therapy and virtual reality therapy in alleviating phantom limb pain: a meta-analysis and systematic review

INTRODUCTION

Amputations result from trauma, war, conflict, vascular diseases and cancer. Phantom limb pain (PLP) is a potentially debilitating form of chronic pain affecting around 100 million amputees across the world. Mirror therapy and virtual reality (VR) are two commonly used treatments, and we evaluated their respective success rates.

METHODS

A meta-analysis and systematic review was undertaken to investigate mirror therapy and VR in their ability to reduce pain levels. A mean difference (MD) model to compare group pain levels pretreatment and post-treatment via aggregating these results from numerous similar studies was employed. Meta-analysis was conducted using RevMan (V.5.4) and expressed in MD for visual analogue scale (VAS) score.

RESULTS

A total of 15 studies met our search criteria; they consisted of eight mirror therapy with 214 participants and seven VR including 86 participants, totalling 300 participants. Mean age ranged from 36 to 63 years, 77% male, of which 61% were lower body amputees. Both led to a VAS reduction (mirror therapy mean reduction VAS score was 2.54, 95% CI 1.42 to 3.66; p<0.001; VR 2.24, 95% CI 1.28 to 3.20; p<0.001). There was no statistically significant difference in pain alleviation between mirror therapy and VR (p=0.69).

CONCLUSIONS

Mirror therapy and VR are both equally efficacious in alleviating PLP, but neither is more effective than the other. However, due to small sample size and limited number of studies, factors such as gender, cause of amputation, site of limb loss or length of time from amputation, which may influence treatment success, could not be explored.

Using Virtual Reality Exposure Therapy in Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

This study aimed to assess the effectiveness of virtual reality (VR) in managing different types of pain in different age groups and to provide evidence for the clinical application of new alternative strategy for pain management.

METHODS

Electronic databases, including the Cochrane Library, PubMed, EMBASE, and the Web of Science, were searched for studies published up to October 2020. Randomized controlled trials that reported on VR for pain management were included.

RESULTS

A total of 31 randomized controlled trials were included. As for the pain intensity, the increase of visual analog scale score in the VR group was 1.62 scores less than that in the control group. In juvenile patients, the VR group had 1.79 scores lower than that in control group. For adult patients, the VR group had 1.34 scores lower than that in control group. As for other pain-related indicators, the VR group had lower levels of anxiety, lower pain unpleasantness, lower pulse rate, and shorter duration of dressing change and spent less time thinking about pain. Nevertheless, there was no statistical difference in pain tolerance. VR can effectively alleviate acute pain. In terms of chronic low back pain and cancer-related pain, there was no statistical difference between VR therapy and standard therapy.

CONCLUSIONS

VR is a feasible alternative therapy for both juveniles and adults in pain management, and it has a greater potential for juveniles. VR can effectively alleviate acute pain. Nevertheless, VR showed little effectiveness in increasing pain tolerance, which may explain in part the ineffectiveness of VR therapy in pain management for chronic pain.

Augmented Reality in Physical Therapy: Systematic Review and Meta-analysis

Background

Augmented reality (AR) is a rapidly expanding technology; it comprises the generation of new images from digital information in the real physical environment of a person, which simulates an environment where the artificial and real are mixed. The use of AR in physiotherapy has shown benefits in certain areas of patient health. However, these benefits have not been studied as a whole.

Objective

This study aims to ascertain the current scientific evidence on AR therapy as a complement to physiotherapy and to determine the areas in which it has been used the most and which variables and methods have been most effective.

Methods

A systematic review registered in PROSPERO (International Prospective Register of Systematic Reviews) was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) recommendations. The search was conducted from July to August 2021 in the PubMed, PEDro, Web of Science, Scopus, and Cochrane Library scientific databases using the keywords augmented reality, physiotherapy, physical therapy, exercise therapy, rehabilitation, physical medicine, fitness, and occupational therapy. The methodological quality was evaluated using the PEDro scale and the Scottish Intercollegiate Guidelines Network scale to determine the degree of recommendation. The Cochrane Collaboration tool was used to evaluate the risk of bias.

Results

In total, 11 articles were included in the systematic review. Of the 11 articles, 4 (36%) contributed information to the meta-analysis. Overall, 64% (7/11) obtained a good level of evidence, and most had a B degree of recommendation of evidence. A total of 308 participants were analyzed. Favorable results were found for the Berg Balance Scale (standardized mean change 0.473, 95% CI −0.0877 to 1.0338; z=1.65; P=.10) and the Timed Up and Go test (standardized mean change −1.211, 95% CI −3.2005 to 0.7768; z=−1.194; P=.23).

Conclusions

AR, in combination with conventional therapy, has been used for the treatment of balance and fall prevention in geriatrics, lower and upper limb functionality in stroke, pain in phantom pain syndrome, and turning in place in patients with Parkinson disease with freezing of gait. AR is effective for the improvement of balance; however, given the small size of the samples and the high heterogeneity of the studies, the results were not conclusive. Future studies using larger sample sizes and with greater homogeneity in terms of the devices used and the frequency and intensity of the interventions are needed.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020180766; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=180766

Development and Validation of a Graded Motor Imagery Intervention for Phantom Limb Pain in Patients with Amputations (GraMI Protocol): A Delphi Study

BACKGROUND

Phantom limb pain can be defined as discomfort or pain in a missing part of the limb. The aims of this study were to develop and validate, through a Delphi methodology, a graded motor imagery protocol in order to reduce phantom limb pain.

METHOD

Physiotherapists and/or occupational therapists with experience in research and a minimum clinical experience of five years in the field of neurorehabilitation and/or pain were recruited by part of a group of experts to assess the intervention. The study was conducted through an online questionnaire, where experts assessed each aspect of the intervention through a Likert scale. As many rounds as necessary were carried out until consensus was reached among experts.

RESULTS

A total of two rounds were required to fully validate the intervention. During the second round, the relative interquartile range of all aspects to be assessed was less than 15%, thus showing a consensus among experts and with good concordance (Kappa index of 0.76).

CONCLUSION

Experts validated a graded motor imagery intervention of phantom limb pain in patients with amputations (GraMi protocol). This intervention can help to homogenize the use of graded motor imagery in future studies and in clinical practice.

Virtual Reality Treatment Displaying the Missing Leg Improves Phantom Limb Pain: A Small Clinical Trial

BACKGROUND

Phantom limb pain (PLP) is a common and in some cases debilitating consequence of upper- or lower-limb amputation for which current treatments are inadequate.

OBJECTIVE

This small clinical trial tested whether game-like interactions with immersive VR activities can reduce PLP in subjects with transtibial lower-limb amputation.

METHODS

Seven participants attended 5-7 sessions in which they engaged in a visually immersive virtual reality experience that did not require leg movements (Cool! ^TM), followed by 10-12 sessions of targeted lower-limb VR treatment consisting of custom games requiring leg movement. In the latter condition, they controlled an avatar with 2 intact legs viewed in a head-mounted display (HTC Vive ^TM). A motion-tracking system mounted on the intact and residual limbs controlled the movements of both virtual extremities independently.

RESULTS

All participants except one experienced a reduction of pain immediately after VR sessions, and their pre session pain levels also decreased over the course of the study. At a group level, PLP decreased by 28% after the treatment that did not include leg movements and 39.6% after the games requiring leg motions. Both treatments were successful in reducing PLP.

CONCLUSIONS

This VR intervention appears to be an efficacious treatment for PLP in subjects with lower-limb amputation.

Effectiveness of Mirror Therapy for Phantom Limb Pain: A Systematic Review and Meta-analysis

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 Physiotherapy Evidence Database (PEDro) scale by 2 independent reviewers. Outcome data were pooled according to follow-up intervals (1, 3, 6, and 12mo). Duration times were used as a basis for distinguishing subgroups. The primary evaluation was by visual analog scale. 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 vs the control group within 1 month (I²=0%; standardized mean difference [SMD]=-0.46, 95% confidence interval [CI], -0.79 to -0.13; P = .007). The patients with pain for longer than 1 year benefited more from MT (I²=0%; SMD=-0.46; 95% CI, -0.85 to -0.07; P = .02).

CONCLUSIONS

MT has beneficial effects for patients with 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.

Effects of Combined and Alone Transcranial Motor Cortex Stimulation and Mirror Therapy in Phantom Limb Pain: A Randomized Factorial Trial

Phantom limb pain (PLP) is a frequent complication in amputees, which is often refractory to treatments. We aim to assess in a factorial trial the effects of transcranial direct current stimulation (tDCS) and mirror therapy (MT) in patients with traumatic lower limb amputation; and whether the motor cortex plasticity changes drive these results. In this large randomized, blinded, 2-site, sham-controlled, 2 × 2 factorial trial, 112 participants with traumatic lower limb amputation were randomized into treatment groups. The interventions were active or covered MT for 4 weeks (20 sessions, 15 minutes each) combined with 2 weeks of either active or sham tDCS (10 sessions, 20 minutes each) applied to the contralateral primary motor cortex. The primary outcome was PLP changes on the visual analogue scale at the end of interventions (4 weeks). Motor cortex excitability and cortical mapping were assessed by transcranial magnetic stimulation (TMS). We found no interaction between tDCS and MT groups (F = 1.90, P = .13). In the adjusted models, there was a main effect of active tDCS compared to sham tDCS (beta coefficient = -0.99, P = .04) on phantom pain. The overall effect size was 1.19 (95% confidence interval: 0.90, 1.47). No changes in depression and anxiety were found. TDCS intervention was associated with increased intracortical inhibition (coefficient = 0.96, P = .02) and facilitation (coefficient = 2.03, P = .03) as well as a posterolateral shift of the center of gravity in the affected hemisphere. MT induced no motor cortex plasticity changes assessed by TMS. These findings indicate that transcranial motor cortex stimulation might be an affordable and beneficial PLP treatment modality.

Effects of mirror therapy on phantom limb sensation and phantom limb pain in amputees: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the effects of mirror therapy on phantom limb sensation and phantom limb pain in amputees.

DATA SOURCES

Nine electronic databases (PubMed, EMBASE, MEDLINE, Web of Science, the Cochrane Library, CINAHL, PsycInfo, PreQuest, PEDro) were searched from their inception to May 10th, 2021.

METHODS

Two authors independently selected relevant studies and extracted the data. The effect sizes were calculated under a random-effects model meta-analysis, and heterogeneity was assessed using the I² test. The risk of bias was evaluated by the Cochrane risk of bias tool, and the methodological quality was appraised by the PEDro scale. The GRADE approach was applied to assess the confidence of the effect.

RESULTS

A total of 11 RCTs involving 491 participants were included in this review and nine RCTs involving 372 participants were included in meta-analysis. The quality of these studies was from poor to good with scores ranging from 2 to 8 points according to PEDro scale. The pooled SMD showed that mirror therapy reduced the pain with a large effect size (-0.81; 95% CI = -1.36 to -0.25; P = 0.005; I² = 82%; n = 372) compared with other methods (four covered mirror, one phantom exercise, three mental visualization, one sensorimotor exercise, one transcutaneous electrical nerve stimulation, one tactile stimuli). The quality of evidence for the outcome pain intensity was determined to be fair according to GRADE approach.

CONCLUSION

There is fair-quality evidence that MT is beneficial for reducing phantom limb pain.

A scoping review of current non-pharmacological treatment modalities for phantom limb pain in limb amputees

PURPOSE

Phantom limb pain (PLP) is a chronic neuropathic pain condition of a missing limb following amputation. Pain management is multi-modal, including various non-pharmacological therapies. The purpose of this scoping review was to investigate the evidence surrounding current non-pharmacological treatment modalities for PLP and provide insight into their clinical feasibility.

METHOD

A systematic search was conducted using four databases (Medline, Embase, PsychInfo, and CINAHL) following the PRISMA-ScR method. Results from papers meeting the inclusion criteria were charted to summarize findings, demographics, and use of neuroimaging.

RESULTS

A total of 3387 papers were identified, and full texts of 142 eligible papers were assessed. Eleven treatment modalities for PLP were identified with varying levels of evidence. Overall, there were 25 RCTs, 58 case reports, and 59 a combination of pilot, quasi-experimental, observational, and other study designs.

CONCLUSIONS

Currently, the evidence surrounding most treatment modalities is limited and only a fraction of studies are supported by strong evidence. The findings of this review demonstrated a clear need to conduct more rigorous research with diverse study designs to better understand which modalities provide the most benefit and to incorporate neuroimaging to better determine the neural correlates of PLP and mechanisms of various treatments.Implications for RehabilitationPhantom limb pain (PLP) is a prevalent and debilitating condition following amputation and health care professionals should incorporate an evidence-based pain management protocol into their rehabilitation program.There exist a number of different non-pharmacological therapies to address PLP, however the scientific rigor and levels of evidence vary across modalities.Prescription of interventions for PLP should consider individual patient differences, accessibility to the patient, and quite possibly, a multi-modal approach, particularly for those who also experience residual limb pain.Imagery-based therapies provide the highest level of current evidence based on robust and large randomized control trials, are readily accessible, and are thus most recommended for relief of PLP.

[Occupational therapy for complex regional pain syndrome]

Occupational therapy, as a rehabilitative treatment is an essential part of multimodal therapy for complex regional pain syndrome (CRPS). The goals of the treatment and the methods vary greatly for this condition, because they are subject to the changing symptomatology. In some cases there are overlapping and synergistic treatment strategies with physiotherapy. For a positive treatment result it is important to implement occupational therapy early on and continuously during the course of the disease. This allows treatment methods, such as mental exercises or sensory exercises to improve the processing of pain-triggering perceptual stimuli at an early stage. Alongside the classical movement exercises and advice on aids, special treatment methods, such as mirror therapy, neurocognitive rehabilitation according to Perfetti or the graded exposure concept can also be beneficial for CRPS patients.

COVID-19: A catalyst for change in virtual health care utilization for persons with limb loss

The dramatic uptake of virtual care, or telehealth, utilization because of COVID‐19 restrictions for persons with limb loss has led to a much greater understanding of this health care delivery method for this complex patient population. However, much is still unknown. Therefore, the authors provide a comprehensive literature review of existing evidence for virtual care delivery across the phases of amputation rehabilitation, as well as anecdotal evidence, to provide a platform for further discussion and development of research and innovative opportunities. Evidence reveals that virtual care serves as a complement to in‐person health care for individuals with limb loss because it allows for increased accessibility to these services. The authors conclude that continued use of telehealth beyond the COVID‐19 restrictions to optimize outcomes across the continuum of care for persons with limb loss is warranted.

Augmented reality in anesthesia, pain medicine and critical care: a narrative review

Augmented reality (AR) is the integration of computer-generated information with the user's environment in real time. AR is used in many industries, including healthcare, where it has gained significant popularity. Recent strides in hardware and software engineering have reduced the cost of AR, while significantly improving the experience for users and developers. One of the first applications of AR technology in perioperative medicine has been in the identification of anatomical structures for regional blocks and peripheral or central vascular access. AR has also been implemented in pediatric care to reduce periprocedural anxiety. In this narrative review, we summarize the current role of AR in anesthesiology, pain medicine, and critical care.

Telerehabilitation for Amputee Care

Patients with amputation have unique characteristics and needs that must be considered when services are being provided through a virtual platform. The types of amputation rehabilitation services that can be provided virtually are numerous and vary from a full clinical team evaluation to individual therapy services. Whether services are being provided in person or through a virtual platform, rehabilitation of the person with amputation ideally involves a collaborative interdisciplinary team. The potential benefits of providing amputation rehabilitation care through a virtual platform include enhanced access to specialized services, reduced travel burden, and improved continuity of care.

Design of Mirror Therapy System Base on Multi-Channel Surface-Electromyography Signal Pattern Recognition and Mobile Augmented Reality

Numerous studies have proven that the mirror therapy can make rehabilitation more effective on hemiparesis following a stroke. Using surface electromyography (SEMG) to predict gesture presents one of the important subjects in related research areas, including rehabilitation medicine, sports medicine, prosthetic control, and so on. However, current signal analysis methods still fail to achieve accurate recognition of multimode motion in a very reliable way due to the weak physiological signal and low noise-ratio. In this paper, a mirror therapy system based on multi-channel SEMG signal pattern recognition and mobile augmented reality is studied. Besides, wavelet transform method is designed to mitigate the noise. The spectrogram obtained by analyzing electromyography signals is proposed to be used as an image. Two approaches, including Convolutional Neural Network (CNN) and grid-optimized Support Vector Machine (SVM), are designed to classify the SEMG of different gestures. The mobile augmented reality provides a virtual hand movement in the real environment to perform mirror therapy process. The experimental results show that the overall accuracy of SVM is 93.07%, and that of CNN is up to 97.8%.

"I Dreamed of My Hands and Arms Moving Again": A Case Series Investigating the Effect of Immersive Virtual Reality on Phantom Limb Pain Alleviation

Phantom limb pain (PLP) is a type of chronic pain that follows limb amputation, brachial plexus avulsion injury, or spinal cord injury. Treating PLP is a well-known challenge. Currently, virtual reality (VR) interventions are attracting increasing attention because they show promising analgesic effects. However, most previous studies of VR interventions were conducted with a limited number of patients in a single trial. Few studies explored questions such as how multiple VR sessions might affect pain over time, or if a patient's ability to move their phantom limb may affect their PLP. Here we recruited five PLP patients to practice two motor tasks for multiple VR sessions over 6 weeks. In VR, patients “inhabit” a virtual body or avatar, and the movements of their intact limbs are mirrored in the avatar, providing them with the illusion that their limbs respond as if they were both intact and functional. We found that repetitive exposure to our VR intervention led to reduced pain and improvements in anxiety, depression, and a sense of embodiment of the virtual body. Importantly, we also found that their ability to move their phantom limbs improved as quantified by shortened motor imagery time with the impaired limb. Although the limited sample size prevents us from performing a correlational analysis, our findings suggest that providing PLP patients with sensorimotor experience for the impaired limb in VR appears to offer long-term benefits for patients and that these benefits may be related to changes in their control of the phantom limbs' movement.

Methods and strategies of tDCS for the treatment of pain: current status and future directions

INTRODUCTION

Transcranial direct current stimulation (tDCS) is a noninvasive neuromodulation technique that has been widely studied for the treatment of chronic pain. It is considered a promising and safe alternative pain therapy. Different targets have been tested, each having their own particular mechanisms for modulating pain perception.

AREAS COVERED

We discuss the current state of the art of tDCS to manage pain and future strategies to optimize tDCS' effects. Current strategies include primary motor cortex tDCS, prefrontal tDCS and tDCS combined with behavioral interventions while future strategies, on the other hand, include high-intensity tDCS, transcutaneous spinal direct current stimulation, cerebellar tDCS, home-based tDCS, and tDCS with extended number of sessions.

EXPERT COMMENTARY

It has been shown that the stimulation of the prefrontal and primary motor cortex is efficient for pain reduction while a few other new strategies, such as high-intensity tDCS and network-based tDCS, are believed to induce strong neuroplastic effects, although the underlying neural mechanisms still need to be fully uncovered. Hence, conventional tDCS approaches demonstrated promising effects to manage pain and new strategies are under development to enhance tDCS effects and make this approach more easily available by using, for instance, home-based devices.

Mirror therapy simultaneously combined with electrical stimulation for upper limb motor function recovery after stroke: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the current evidence on the effectiveness of simultaneous combination of mirror therapy and electrical stimulation in the recovery of upper limb motor function after stroke, compared with conventional therapy, mirror therapy or electrical stimulation isolated.

DATA SOURCES

Articles published in PubMed, Web of Science, Scopus, Physiotherapy Evidence Database (PEDro), Cochrane Central register of controlled trials and ScienceDirect up to July 2020.

REVIEW METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Methodological quality was assessed using the PEDro tool. The RevMan 5.4 statistical software was used to obtain the meta-analysis, through the standardized mean difference and 95% confidence intervals (CI), and to evaluate the risk of bias. The GRADE approach was employed to assess the certainty of evidence.

RESULTS

Eight articles were included in this systematic review, seven were included in the meta-analysis. A total of 314 participants were analyzed. The overall quality of the articles included in this review was good. There was no overall significant mean difference on upper limb motor function after stroke using the Upper-Extremity Fugl-Meyer Assessment by 1.56 (95% CI = -2.08, 5.20; P = 0.40; moderate-certainty evidence) and the Box and Block Test results by 1.39 (95% CI = -2.14, 4.92; P = 0.44; high-certainty evidence). There was overall significant difference in the Action Research Arm Test by 3.54 (95% CI = 0.18, 6.90; P = 0.04; high-certainty evidence).

CONCLUSION

Direct scientific evidence about the effectiveness of the combined therapy of mirror therapy and electrical stimulation simultaneously for the improvement of the upper limb motor function after stroke is lacking. Further high-quality and well-designed research is needed.

Recent advances in understanding and managing phantom limb pain

Post-amputation phantom limb pain (PLP) is highly prevalent and very difficult to treat. The high-prevalence, high-pain intensity levels, and decreased quality of life associated with PLP compel us to explore novel avenues to prevent, manage, and reverse this chronic pain condition. This narrative review focuses on recent advances in the treatment of PLP and reviews evidence of mechanism-based treatments from randomized controlled trials published over the past 5 years. We review recent evidence for the efficacy of targeted muscle reinnervation, repetitive transcranial magnetic stimulation, imaginal phantom limb exercises, mirror therapy, virtual and augmented reality, and eye movement desensitization and reprocessing therapy. The results indicate that not one of the above treatments is consistently better than a control condition. The challenge remains that there is little level 1 evidence of efficacy for PLP treatments and most treatment trials are underpowered (small sample sizes). The lack of efficacy likely speaks to the multiple mechanisms that contribute to PLP both between and within individuals who have sustained an amputation. Research approaches are called for to classify patients according to shared factors and evaluate treatment efficacy within classes. Subgroup analyses examining sex effects are recommended given the clear differences between males and females in pain mechanisms and outcomes. Use of novel data analytical approaches such as growth mixture modeling for multivariate latent classes may help to identify sub-clusters of patients with common outcome trajectories over time.

Feasibility of a traditional and teletreatment approach to mirror therapy in patients with phantom limb pain: a process evaluation performed alongside a randomized controlled trial

OBJECTIVE

To evaluate the delivery, acceptance and experiences regarding a traditional and teletreatment approach to mirror therapy as delivered in a randomized controlled trial.

DESIGN

Mixed methods, prospective study.

SETTING

Rehabilitation centres, hospital and private practices.

SUBJECTS

Adult patients with phantom pain following lower limb amputation and their treating physical and occupational therapists.

INTERVENTIONS

All patients received 4 weeks of traditional mirror therapy (n = 51), followed by 6 weeks of teletreatment (n = 26) or 6 weeks of self-delivered mirror therapy (n = 25).

MAIN MEASURES

Patient files, therapist logs, log files teletreatment, acceptance questionnaire and interviews with patients and their therapists.

RESULTS

In all, 51 patients and 10 therapists participated in the process evaluation. Only 16 patients (31%) received traditional mirror therapy according to the clinical framework during the first 4 weeks. Between weeks 5 and 10, the teletreatment was used by 14 patients (56%) with sufficient dose. Teletreatment usage decreased from a median number of 31 (weeks 5-10) to 19 sessions (weeks 11-24). Satisfactory teletreatment user acceptance rates were found with patients demonstrating higher scores (e.g. regarding the usefulness to control pain) than therapists. Potential barriers for implementation of the teletreatment perceived by patients and therapists were related to insufficient training and support as well as the frequency of technical problems.

CONCLUSION

Traditional mirror therapy and the teletreatment were not delivered as intended in the majority of patients. Implementation of the teletreatment in daily routines was challenging, and more research is needed to evaluate user characteristics that influence adherence and how technology features can be optimized to develop tailored implementation strategies.

Mirror therapy versus augmented/virtual reality applications: towards a tailored mechanism-based treatment for phantom limb pain

Phantom limb pain (PLP) is a clinically relevant consequence of limb amputation and its treatment is still challenging. Mirror therapy, in other words, observing and engaging in the intact limb's mirrored movements, offers a promising, mechanism-based treatment for PLP. However, intervention and patient characteristics, such as the realism of mirrored exercises and perceptions related to the phantom limb, might influence treatment effectiveness. Novel approaches using augmented and virtual reality setups represent an alternative to traditional mirror therapy. In this paper, based on recent studies in the field, we compare both approaches and discuss their unique advantages and disadvantages. We argue for the necessity of a tailored treatment for PLP that is personalized to the patients’ characteristics, preferences and psychological needs.

Paradoxes in rehabilitation

Paradoxical enhancement and paradoxical recovery of function after brain injury harmonize well with the concept of "ultrabilitation" and its focus on novel forms of flourishing in rehabilitation settings. I consider three sets of paradoxes which may impact on brain injury rehabilitation. Firstly, I consider post-traumatic growth after brain injury and its key determinants. Secondly, I review the role of illusions in rehabilitation and the paradox that some clinical conditions may be improved by invoking perceptual distortions. Thirdly, I consider paradoxical recovery profiles after brain injury, since knowledge of such paradoxical profiles may help inform attempts at rehabilitation of some patients. Finally, I consider how some of these paradoxes relate to components of ultrabilitation, and in addition to the nascent field of positive neuropsychology and the concept of resilience after brain injury.Implications for rehabilitationIllusions can sometimes be harnessed as a therapeutic tool in rehabilitation.There may be spontaneous, positive outcomes of an injury or illness, in the form of "post-traumatic growth", and these should be considered as part of a holistic therapeutic approach in rehabilitation.Some patients make an exceptional recovery from a severe brain insult, and lessons could be learned from such cases, such as disciplined use of compensatory strategies, which could have broader implications for neurorehabilitation.

The Stochastic Entanglement and Phantom Motor Execution Hypotheses: A Theoretical Framework for the Origin and Treatment of Phantom Limb Pain

Phantom limb pain (PLP) is a debilitating condition common after amputation that can considerably hinder patients' quality of life. Several treatments have reported promising results in alleviating PLP. However, clinical evaluations are usually performed in small cohorts and rigorous clinical trials are scarce. In addition, the underlying mechanisms by which novel interventions alleviate PLP are often unclear, potentially because the condition itself is poorly understood. This article presents a theoretical framework of PLP that can be used as groundwork for hypotheses of novel treatments. Current hypotheses on the origins of PLP are discussed in relation to available clinical findings. Stochastic entanglement of the pain neurosignature, or connectome, with impaired sensorimotor circuitry is proposed as an alternative hypothesis for the genesis of PLP, and the implications and predictions this hypothesis entails are examined. In addition, I present a hypothesis for the working mechanism of Phantom Motor Execution (PME) as a treatment of PLP, along with its relation to the aforementioned stochastic entanglement hypothesis, which deals with PLP's incipience. PME aims to reactivate the original central and peripheral circuitry involved in motor control of the missing limb, along with increasing dexterity of stump muscles. The PME hypothesis entails that training of phantom movements induces gradual neural changes similar to those of perfecting a motor skill, and these purposefully induced neural changes disentangle pain processing circuitry by competitive plasticity. This is a testable hypothesis that can be examined by brain imaging and behavioral studies on subjects undergoing PME treatment. The proposed stochastic entanglement hypothesis of PLP can be generalized to neuropathic pain due to sensorimotor impairment, and can be used to design suitable therapeutic treatments.