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Three Part Question

In [adult amputees] does [graded motor imagery] reduce [phantom limb pain?]

Clinical Scenario

Phantom Limb Pain is the sensation that an amputated or missing limb is still present and attached to the body. Phantom limb pain or phantom sensations are usually painful and can be an extremley troublemsome phenomenon.

Search Strategy

AHMED, CINAHL, EMBASE, MEDLINE, psychINFO, Cochrane.
All via the National Library for Health databases, all dates available.


1. AMED, BNI, EMBASE, HMIC, MEDLINE, PsycINFO, CINAHL, HEALTH BUSINESS ELITE; (graded AND
motor AND imagery).ti,ab; 21 results.
2. AMED,BNI,EMBASE,HMIC,MEDLINE,PsycINFO,CINAHL,HEALTH BUSINESS ELITE; Duplicate filtered:
[(graded AND motor AND imagery).ti,ab]; 21 results.
3. AMED, BNI, EMBASE, HMIC, MEDLINE, PsycINFO, CINAHL, HEALTH BUSINESS ELITE; (mirror AND
therapy OR laterality AND reconstruction OR motor AND imagery).ti,ab; 3344 results.
4. AMED, BNI, EMBASE, HMIC, MEDLINE, PsycINFO, CINAHL, HEALTH BUSINESS ELITE; (phantom AND
limb AND pain).ti,ab; 2199 results.
5. AMED, BNI, EMBASE, HMIC, MEDLINE, PsycINFO, CINAHL, HEALTH BUSINESS ELITE; 1 AND 4; 10
results.
6. AMED, BNI, EMBASE, HMIC, MEDLINE, PsycINFO, CINAHL, HEALTH BUSINESS ELITE; 3 AND 4; 35
results.
7. AMED,BNI,EMBASE,HMIC,MEDLINE,PsycINFO,CINAHL,HEALTH BUSINESS ELITE; Duplicate filtered: [1
AND 4], [3 AND 4]; 45 results.
8. AMED; (graded AND motor AND imagery).ti,ab; 0 results.
9. AMED; (motor AND imagery).ti,ab; 85 results.
10. AMED; exp PAIN/ AND exp PHANTOM LIMB/; 64 results.
11. AMED; 9 AND 10; 1 results.
12. AMED; PSYCHOSOMATIC THERAPIES/; 1467 results.
13. AMED; (phantom AND limb AND pain).ti,ab; 112 results.
14. AMED; 12 AND 13; 1 results.
15. MEDLINE; exp "IMAGERY (PSYCHOTHERAPY)"/; 854 results.
16. MEDLINE; exp PHANTOM LIMB/; 1336 results.
17. MEDLINE; 15 AND 16; 14 results.
18. EMBASE; exp GRADED MOTOR IMAGERY/; 0 results.
19. EMBASE; exp PSYCHOTHERAPY/; 152912 results.
20. EMBASE; exp AGNOSIA/; 3547 results.
21. EMBASE; 19 AND 20; 71 results.
22. EMBASE; *TRAUMATIC AMPUTATION/; 1031 results.
23. EMBASE; 21 [Limit to: English Language]; 49 results.
24. EMBASE; (graded AND motor AND imagery).ti,ab; 7 results.
25. PsycINFO; (graded AND motor AND imagery).ti,ab; 5 results.
26. CINAHL; (graded AND motor AND imagery).ti,ab; 4 results.
27. AMED, BNI, EMBASE, HMIC, MEDLINE, PsycINFO, CINAHL, HEALTH BUSINESS ELITE; "moseley
Gl*".au; 160 results.
28. AMED,BNI,EMBASE,HMIC,MEDLINE,PsycINFO,CINAHL,HEALTH BUSINESS ELITE; Duplicate filtered:
["moseley Gl*".au]; 160 results.
29. AMED; (mirror AND therapy OR laterality AND reconstruction OR motor AND imagery).ti,ab; 85 results.
30. AMED; 10 AND 29; 1 results.
31. MEDLINE; (mirror AND therapy OR laterality AND reconstruction OR motor AND imagery).ti,ab; 964 results.
32. MEDLINE; 16 AND 31; 15 results.
33. EMBASE; (mirror AND therapy OR laterality AND reconstruction OR motor AND imagery).ti,ab; 1095 results.
34. EMBASE; (phantom AND limb).ti,ab; 1160 results.
35. EMBASE; 33 AND 34; 16 results.
36. AMED; (phantom AND limb).ti,ab; 127 results.
37. AMED; 29 AND 36; 1 results.
38. PsycINFO; (mirror AND therapy OR laterality AND reconstruction OR motor AND imagery).ti,ab; 953 results.
39. PsycINFO; (phantom AND limb).ti,ab; 447 results.
40. PsycINFO; 38 AND 39; 13 results.

Search Outcome

45 papers were retrieved and after reading the abstracts, a total of 3 papers were considered relevant to the question. Two investigated the effects of GMI on Chronic Regional Pain Syndrome solely. These were discounted as they did not answer the clinical question. The final paper was a high quality trial, which indicates positive results for a graded motor imagery (GMI) program in the management of phantom limb pain (PLP).

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Moseley, G. L. 2006 UK	n= 69. 46 Chronic Regional Pain Syndrome (CRPS), 9 Brachial Plexus Avulsion Injury (BPAI) 15 Amputees with PLP.	RCT	Pain. The mean decrease in pain between pre and post treatment (100mm visual analogue scale) was 23.4mm for the GMI group and 10.5mm for the control group.	Function. For function NRS there was a main effect for treatment group. The mean increase in average score for each patient, measured using a 0 to 10 NRS was 2.2 points (1.3 – 3.0) for the GMI group and 0.6 points (0.2 -1.0) for the control group. Main statistical effect of treatment group, but not diagnostic group on pain and function. All improvements were maintained at 6 months follow up.	Of the 51 subjects who completed the trial only 9 had PLP following amputation. The current design, may conceal stronger effects in one group than another and the fact that the effect occurred regardless of diagnostic group does not imply that the same mechanisms underpin that effect in each group. The current study was underpowered to systematically evaluate different response profiles between the diagnostic groups

Comment(s)

A GMI programme consists of 3 sequential stages; Limb laterality recognition, imagined movements and mirror visual feedback. Numerous Case studies and anecdotal data exist in support of GMI to relieve phantom limb pain. In addition, a larger body of research exist in support of the separate aspects of GMI (e.g. mirror therapy, imagined movements or virtual mirror therapy) in isolation.. However, at present there is limited high quality research into GMI in the management of PLP.

Clinical Bottom Line

There is promising evidence to support the use of GMI as a new modality in the management of PLP. Further robust clinical trials are required to explore further its effects with Phantom Limb Pain in isolation within different population groups.

References

1. Moseley, G. L. Graded motor imagery for pathologic pain: a randomized controlled trial. Neurology Vol 67: 2129-2134.