Effectiveness of mirror therapy in phantom limb pain: A literature review

INTRODUCTION

Phantom limb pain (PLP) is a type of neuropathic pain that affects the territory of an amputated limb or other surgically removed body parts. Between 60% and 90% of amputees suffer from PLP during follow-up. There are a range of therapeutic options for PLP, both pharmacological (gabapentin, amitriptyline, tricyclic antidepressants, etc) and non-pharmacological (transcutaneous electrical nerve stimulation, hypnosis, acupuncture, etc). A widely accepted hypothesis considers PLP to be the consequence of postamputation cortical reorganisation. New treatment approaches, such as mirror therapy (MT), have been developed as a result of Ramachandran's groundbreaking research in the 1990s. This review analyses the current evidence on the efficacy of MT for treating PLP.

DEVELOPMENT

We performed a literature review of publications registered from 2012 to 2017 on the CINAHL, Cochrane, Scopus, and PubMed (including Medline) databases Using the descriptors "phantom limb‿ and "mirror therapy.‿ We identified 115 publications addressing MT in PLP. Of these, 17 (15%) contributed useful information for pooled analysis.

CONCLUSIONS

MT seems to be effective in relieving PLP, reducing the intensity and duration of daily pain episodes. It is a valid, simple, and inexpensive treatment for PLP. The methodological quality of most publications in this field is very limited, highlighting the need for additional, high-quality studies to develop clinical protocols that could maximise the benefits of MT for patients with PLP.

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.

Treatment Recommendations for Phantom Limb Pain in People with Amputations: An Expert Consensus Delphi Study

Background

Phantom limb pain (PLP) is common and often accompanied by serious suffering. Current systematic‐review evidence suggests that recommended treatments are no more effective than placebo for reducing PLP. Given the difficulty in conducting a meta‐analysis for nonpharmacological treatments and the weak evidence for pharmacological treatments for PLP, consensus on the first‐line management of PLP needs to be reached using alternative methods.

Objective

To reach expert consensus and make recommendations on the effective management of PLP.

Design

A three‐round Delphi design was used.

Setting

The study was conducted using e‐mail and Google survey tool as the main methods of communication and providing feedback.

Participants

The study included 27 clinicians and researchers from various health disciplines who are experts in PLP management.

Method

Data were collected using three sequential rounds of anonymous online questionnaires where experts proposed and ranked the treatments for PLP. A consensus was reached on the treatments that were endorsed by 50% or more of the experts.

Results

Thirty‐seven treatments were proposed for the management of PLP at the beginning of the study. Consensus was reached on seven treatments that were considered effective for managing PLP and on two treatments that were considered ineffective. Graded motor imagery, mirror therapy, amitriptyline, sensory discrimination training, and use of a functional prosthesis were endorsed by most experts because of the available backing scientific evidence and their reported efficacy in clinical practice. Cognitive behavioral therapy and virtual reality training were endorsed by most experts because of their reported efficacy in clinical practice despite indicating a dearth of scientific evidence to support their ranking. Citalopram and dorsal root ganglion pulsed radiofrequency were rejected owing to a lack of relevant scientific evidence.

Conclusion

The results of this study suggest that the nonpharmacological treatments endorsed in this study may have an important role in the management of PLP.

Targeted muscle reinnervation in oncologic amputees: Early experience of a novel institutional protocol

BACKGROUND

We describe a multidisciplinary approach for comprehensive care of amputees with concurrent targeted muscle reinnervation (TMR) at the time of amputation.

METHODS

Our TMR cohort was compared to a cross-sectional sample of unselected oncologic amputees not treated at our institution (N = 58). Patient-Reported Outcomes Measurement Information System (NRS, PROMIS) were used to assess postamputation pain.

RESULTS

Thirty-one patients underwent amputation with concurrent TMR during the study; 27 patients completed pain surveys; 15 had greater than 1 year follow-up (mean follow-up 14.7 months). Neuroma symptoms occurred significantly less frequently and with less intensity among the TMR cohort. Mean differences for PROMIS pain intensity, behavior, and interference for phantom limb pain (PLP) were 5.855 (95%CI 1.159-10.55; P = .015), 5.896 (95%CI 0.492-11.30; P = .033), and 7.435 (95%CI 1.797-13.07; P = .011) respectively, with lower scores for TMR cohort. For residual limb pain, PROMIS pain intensity, behavior, and interference mean differences were 5.477 (95%CI 0.528-10.42; P = .031), 6.195 (95%CI 0.705-11.69; P = .028), and 6.816 (95%CI 1.438-12.2; P = .014), respectively. Fifty-six percent took opioids before amputation compared to 22% at 1 year postoperatively.

CONCLUSIONS

Multidisciplinary care of amputees including concurrent amputation and TMR, multimodal postoperative pain management, amputee-centered rehabilitation, and peer support demonstrates reduced incidence and severity of neuroma and PLP.

Presentation and management of chronic pain

Chronic pain is an important clinical problem affecting significant numbers of children and their families. The severity and impact of chronic pain on everyday function is shaped by the complex interaction of biological, psychological and social factors that determine the experience of pain for each individual, rather than a straightforward reflection of the severity of disease or extent of tissue damage. In this article we present the research findings that strongly support a biopsychosocial concept of chronic pain, describe the current best evidence for management strategies and suggest a common general pathway for all types of chronic pain. The principles of management of some of the most important or frequently encountered chronic pain problems in paediatric practice; neuropathic pain, complex regional pain syndrome (CRPS), musculoskeletal pain, abdominal pain and headache are also described.