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Three Part Question

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

Clinical Scenario

The aim of the bet was to establish whether Graded Motor Imagery was a useful tool in managing Phantom Limb Pain in amputees. In addition, to established and moderately successful modalities such as medication, hypnosis and accupuncture.

Search Strategy

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

1) Amput*
2) lower limb loss
3) Graded Motor Imagery
4) Mirror Therapy
5) amputat* pain
6) phantom pain
7) phantom sensation

8) 1 OR 2
9) 3 OR 4
10) 5 OR 6 OR 7
11) 8 AND 9 AND 10



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

One high quality trial indicates positive results for a graded motor imagery (GMI) program in the management of phantom limb pain (PLP).


1. Graded motor imagery for pathologic pain: a randomized controlled trial. Moseley, G. L. 2006.

Fifty one patients with either CRPS or PLP were randomly allocated to a graded motor imagery group consisting of 2 weeks each of laterality recognition, imagined movements and mirror movements or to a control group of physical therapy and ongoing medical care. The results demonstrated a main statistical effect of treatment group, but not diagnostic group on pain and function. The mean decrease in pain was 23.4mm for the GMI group versus 10.5mm for the control group, which achieved a statistically significant difference. Improvement in function was similar with improvements maintained at 6 months follow up. In conclusion, GMI reduced pain and disability in patients with PLP, CRPS or Brachial Plexus Avulsion Injury.

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. Furthermore, there is also a growing body of evidence into the positive effects of GMI in the management of Chronic Regional Pain Syndrome.

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. 1. Graded motor imagery for pathologic pain: a randomized controlled trial. Moseley, G. L. 2006. Neurology 2006 Dec 26; 67(12):2129-34.