Efficacy of progressive muscle relaxation, mental imagery, and phantom exercise training on phantom limb: a randomized controlled trial.

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.

[1]  H. Flor,et al.  Phantom Limb Pain After Lower Limb Trauma , 2011, The international journal of lower extremity wounds.

[2]  P. Halligan,et al.  Hypnotic imagery as a treatment for phantom limb pain: two case reports and a review , 2002, Clinical rehabilitation.

[3]  David R. Spiegel,et al.  A presumed case of phantom limb pain treated successfully with duloxetine and pregabalin. , 2010, General hospital psychiatry.

[4]  B. Darnall,et al.  Home-based self-delivered mirror therapy for phantom pain: a pilot study. , 2012, Journal of rehabilitation medicine.

[5]  M. Massimino,et al.  Mirror Therapy for Phantom Limb Pain in An Adolescent Cancer Survivor , 2012, Tumori.

[6]  Stephen T Wegener,et al.  Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. , 2005, Archives of physical medicine and rehabilitation.

[7]  R. Davidson,et al.  Becoming conscious: the science of mindfulness , 2013, Annals of the New York Academy of Sciences.

[8]  S. Gaylord,et al.  Mind-Body Interventions for Treatment of Phantom Limb Pain in Persons with Amputation , 2012, American journal of physical medicine & rehabilitation.

[9]  Christopher L. Wu,et al.  Morphine versus Mexiletine for Treatment of Postamputation Pain: A Randomized, Placebo-controlled, Crossover Trial , 2008, Anesthesiology.

[10]  T. Jensen,et al.  A Randomized Study of the Effects of Gabapentin on Postamputation Pain , 2006, Anesthesiology.

[11]  E. Pfeiffer.  A Short Portable Mental Status Questionnaire for the Assessment of Organic Brain Deficit in Elderly Patients † , 1975, Journal of the American Geriatrics Society.

[12]  M. Jensen,et al.  Hypnotic approaches for chronic pain management: clinical implications of recent research findings. , 2014, The American psychologist.

[13]  Kenneth M Heilman,et al.  Mirror therapy for phantom limb pain. , 2007, The New England journal of medicine.

[14]  K. Reilly,et al.  Disentangling motor execution from motor imagery with the phantom limb. , 2012, Brain : a journal of neurology.

[15]  K. J. Hollenbeck,et al.  Preamputation mirror therapy may prevent development of phantom limb pain: a case series. , 2010, Anesthesia and analgesia.

[16]  T. Elbert,et al.  Phantom-limb pain as a perceptual correlate of cortical reorganization following arm amputation , 1995, Nature.

[17]  A. J. Harris,et al.  Cortical origin of pathological pain , 1999, The Lancet.

[18]  H Ring,et al.  Phantom limb related phenomena and their rehabilitation after lower limb amputation. , 2009, European journal of physical and rehabilitation medicine.

[19]  I. Robertson,et al.  Individual differences in response to phantom limb movement therapy , 2011, Disability and rehabilitation.

[20]  Charles Spence,et al.  Is mirror therapy all it is cracked up to be? Current evidence and future directions , 2008, PAIN.

[21]  Semra Topuz,et al.  Effectiveness of phantom exercises for phantom limb pain: a pilot study. , 2009, Journal of rehabilitation medicine.

[22]  Ivanei E. Bramati,et al.  Functional Expansion of Sensorimotor Representation and Structural Reorganization of Callosal Connections in Lower Limb Amputees , 2012, The Journal of Neuroscience.

[23]  U Kern,et al.  [Prevalence and risk factors of phantom limb pain and phantom limb sensations in Germany. A nationwide field survey]. , 2009, Schmerz.

[24]  Mohamed A. Ahmed,et al.  Long-term antalgic effects of repetitive transcranial magnetic stimulation of motor cortex and serum beta-endorphin in patients with phantom pain , 2011, Neurological research.

[25]  M. Rockland,et al.  Prävalenz und Risikofaktoren von Phantomschmerzen und Phantomwahrnehmungen in Deutschland , 2009, Der Schmerz.

[26]  R W Davis,et al.  Phantom sensation, phantom pain, and stump pain. , 1993, Archives of physical medicine and rehabilitation.

[27]  Francine Malouin,et al.  Decreasing phantom limb pain through observation of action and imagery: a case series. , 2011, Pain medicine.

[28]  G. Moseley,et al.  Graded motor imagery for pathologic pain , 2006, Neurology.

[29]  Jan H B Geertzen,et al.  Phantom pain and risk factors: a multivariate analysis. , 2002, Journal of pain and symptom management.

[30]  M. Jeannerod.  Mental imagery in the motor context , 1995, Neuropsychologia.

[31]  S. Kim,et al.  Mirror Therapy for Phantom Limb Pain , 2012, The Korean journal of pain.

[32]  N. Bolognini,et al.  Motor and parietal cortex stimulation for phantom limb pain and sensations , 2013, PAIN®.

[33]  C. Bonezzi,et al.  [Validazione della versione italiana del Brief Pain Inventory nei pazienti con dolore cronico]. , 2002, Minerva anestesiologica.

[34]  A. Lundervold,et al.  Different Brain Areas Activated during Imagery of Painful and Non-painful ‘Finger Movements’ in a Subject with an Amputated Arm , 2001, Neurocase.

[35]  R. Sherman,et al.  Treatment of phantom limb pain with muscular relaxation training to disrupt the pain-anxiety-tension cycle , 1979, PAIN.

[36]  Mariela Rance,et al.  An augmented reality home-training system based on the mirror training and imagery approach , 2014, Behavior research methods.

[37]  T. Nurmikko,et al.  Phantom limb pain, cortical reorganization and the therapeutic effect of mental imagery , 2008, Brain : a journal of neurology.

[38]  A. Beck,et al.  Comparison of Beck Depression Inventories -IA and -II in psychiatric outpatients. , 1996, Journal of personality assessment.

[39]  J. Czerniecki,et al.  Efficacy of gabapentin in treating chronic phantom limb and residual limb pain. , 2005, Journal of rehabilitation research and development.

[40]  F. Zitman,et al.  Treatment of chronic phantom limb pain using a trauma-focused psychological approach. , 2010, Pain research & management.

[41]  Malcolm MacLachlan,et al.  Mirror treatment of lower limb phantom pain: A case study , 2004, Disability and rehabilitation.

[42]  Christopher L. Wu,et al.  Analgesic Effects of Intravenous Lidocaine and Morphine on Postamputation Pain: A Randomized Double-blind, Active placebo-controlled, Crossover Trial , 2002, Anesthesiology.

[43]  C. Cleeland.  The Brief Pain Inventory User Guide , 2009 .

[44]  N Birbaumer,et al.  Reorganization of Motor and Somatosensory Cortex in Upper Extremity Amputees with Phantom Limb Pain , 2001, The Journal of Neuroscience.

[45]  Herta Flor,et al.  Mirrored, imagined and executed movements differentially activate sensorimotor cortex in amputees with and without phantom limb pain , 2010, PAIN®.

[46]  M. Jeannerod.  The representing brain: Neural correlates of motor intention and imagery , 1994, Behavioral and Brain Sciences.

[47]  R. Casale,et al.  Mirror Therapy in the Rehabilitation of Lower-Limb Amputation: Are There Any Contraindications? , 2009, American journal of physical medicine & rehabilitation.

[48]  Martha S. McCallie,et al.  Progressive Muscle Relaxation , 2006 .

[49]  F. Franchignoni,et al.  Measuring long-term outcome in people with lower limb amputation: cross-validation of the Italian versions of the Prosthetic Profile of the Amputee and Prosthesis Evaluation Questionnaire. , 2005, Europa medicophysica.

[50]  J. Czerniecki,et al.  Chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after lower limb amputation. , 2000, Archives of physical medicine and rehabilitation.

[51]  M. Maclachlan,et al.  Phantom limb pain and residual limb pain following lower limb amputation: a descriptive analysis. , 2001, Disability and rehabilitation.

[52]  R. Sherman,et al.  A survey of current phantom limb pain treatment in the United States , 1980, PAIN.

[53]  C. Niven,et al.  Variation in phantom limb pain: results of a diary study. , 2001, Journal of pain and symptom management.

[54]  Lama Chahine,et al.  Phantom limb syndrome: a review. , 2007, Middle East journal of anaesthesiology.