Phantom Exercise for Lower Limb Amputees
Condition: Lower Limb Amputation
Study type: Interventional

Summary: 
      In this research, the aim is to find out the effects of phantom exercises in terms of pain,
      mobility and quality of life among lower-limb amputees having phantom limb pain. This is a
      randomized control trial in which amputees having phantom limb pain will be randomly divided
      into two groups i.e. Experimental group (Routine physical therapy, mirror therapy and phantom
      exercises) and control group (Routine physical therapy and mirror therapy). Non-probability
      purposive sampling technique will be employed. Patients of age between 18 to 50 years and
      having phantom limb pain after lower limb amputation will be recruited by evaluating with
      limb deficiency and phantom limb questionnaire. Other tools will be Visual analogue scale
      (pain), Amputee mobility predictor (Ambulatory status) and 36-Item Short-Form Health Survey
      questionnaire (Health-related quality of life). The study will be conducted in 6 months and
      data obtained will be analyzed through Statistical Package for Social Sciences (SPSS) 20.
    

Detailed description: 
      An amputation is a distressing event that will result in physical, psychological, and social
      consequences. The loss of limb means a huge impact, not only for the patient's body and the
      way he notices it, as well as the perception of the environment around him. Most of the
      patients with lower extremity amputations experienced phantom limb pain. It is defined by
      painful sensation in the missing limb. According to a recent study, the prevalence of phantom
      limb pain ranges from 45% to 85%. Regardless of the reason for amputation, phantom limb pain
      diminishes over time in most cases. However, in about 5-10% of amputees' severe pain persists
      for several years. It affects the patient's capacity for self-care and personal independence
      as it is mentally and physically debilitating. Incidence of PLP in recent studies is reported
      to be approximately 42.2-78.8% of amputees. It should be noted that phantom limb pain (PLP)
      differs from pain in the stump called residual limb pain (RLP), which is due to skin
      complications, vascular compromise, inappropriate healing, painful neuromas, excess soft
      tissue and bone irregularities.

      However, the exact mechanism of phantom limb pain is unknown, but advancement in pain
      physiology indicates that multiple mechanisms are involved including peripheral, spinal and
      supraspinal mechanisms. The first changes may take place in the periphery where the nerve
      endings are sensitized by pre-amputation pain and nerve transection. But the complexity of
      phantom phenomena and the association between catastrophizing and phantom limb pain indicate
      that supraspinal changes play a significant role in phantom pain. It is likely that the
      relative contributions of these mechanisms vary from one amputee to another and that they may
      change over time in the individual patient.

      It has been seen that phantom limb pain is typically experienced in regions with large
      cortical representation, such as the hands/fingers and feet/toes. The pain is often described
      with words such as knifelike, sticking, pricking, shooting, and burning. Both PLP and RLP
      have a high incidence among amputees. These pains are a continual reminder of circumstances
      and can affect important factors of Quality of life such as sleep, fatigue mood and
      relationships compromising the acquisition of skills and quality of life. Thus, interfering
      with the physical and psychosocial rehabilitation of the amputee. This should be considered
      clinically during therapeutic encounters, and amputees should be given appropriate
      information on these potential associations, though often neglected by the medical team.
      Although QOL in amputees seems primarily determined by mobility impairment, pain, emotional
      perturbation, it is seen that physician-controlled factors such as the timing of amputation,
      informed decision making, and postamputation support may also play an important role. This
      data can be efficiently collected through limb deficiency and phantom limb questionnaire.
      During the rehabilitation process, multiple tools are available that help physicians to
      determine both motor ability and mobility in amputees as well as other determinants of
      quality of life and pain status of amputees. These include tests that determine motor ability
      as Single-limb standing balance test (Balance test), the Lower-Extremity Motor Coordination
      Test (LEMOCOT) and the Amputee Mobility Predictor without a prosthesis (AMPnoPRO). The AMP is
      a highly reliable instrument and it is relatively easy to administer in 15 minutes or less.
      Patients characteristics can be easily evaluated using "Limb Deficiency and Phantom Limb
      Questionnaire (Questionnaire 2008, Version 2)" and visual analogue scale (VAS) for the
      presence and extent of PLP. Health-related quality of life (HRQL) will be measured by the
      SF-36 questionnaire.

      Despite a growing body of evidence, phantom limb pain remains a challenging condition to
      treat. There remains a large potential for innovation in improving the treatment strategies
      for these patients. More than 25 treatments for PLP are currently available yet not one is
      widely accepted or superior to others. Common self-treatment strategies can include wearing
      an elastic stump sock to minimise volume changes in the residual limb, stump massage, mental
      imagery of the phantom limb and taking physical exercise.

      A rehabilitation technique that proved promising in recent years is mirror therapy, which
      involves a mirror being placed in a position that allows the patient to view a reflection of
      a body part. whilst the nonpainful limb is placed in front of the mirror so that it creates a
      reflection that can be seen by the patient, the stump is kept behind the mirror. In amputees,
      this creates the illusion of having two intact limbs and then the patient is asked to move an
      intact limb in certain patterns. This gives the illusion that the painful limb can move
      normally too. The mechanism of action of mirror therapy remains uncertain, with the
      reintegration of motor and sensory systems, restored body image and control over
      fear-avoidance likely to influence the outcome. Nevertheless, mirror therapy is inexpensive,
      safe and easy for the patient to self-administer but the level of evidence is insufficient. A
      limitation of the mirror box technique is the poor verisimilitude of the sensory feedback
      provided from the missing limb. The participant may have the visual illusion that the phantom
      extremity is moving, but the apparatus is crude and the illusion often not compelling.
      Patients cannot independently control the mirrored extremity, so only symmetric actions can
      be modelled.

      Moreover, a relatively less researched method of reduction of phantom limb pain is Phantom
      exercises (PE). This involved imagining moving the phantom limb and then attempting to
      perform a few movements. The neurophysiological network activated during phantom limb
      movements is similar to that of executed movements of intact limbs and differs from the
      phantom limb imagination network. The dual ability of amputees to execute and imagine
      movements of their phantom limb and the fact that these two tasks activate distinct cortical
      networks are important factors to consider when designing rehabilitation programmes for the
      treatment of phantom limb pain. Few studies indicate that phantom exercises can be used
      safely to alleviate phantom limb pain in lower and upper limb amputees.

      The evidence for clinical efficacy of mirror therapy is encouraging, but not yet definitive.
      Virtual reality could be a substitute for mirror therapy especially in the case if person
      suffers from bilateral amputation but even though the use of an immersive virtual reality
      (VR) environment may have a short-term effect on PLP for the majority of amputees who
      experience PLP, it's cost remain a problem in developing country like Pakistan, Moreover,
      because of high prevalence and high pain intensity of phantom limb pain, there is need to
      find an effective, easily administered home-based treatment for amputees, thus comparing
      effects of mirror therapy with and without phantom exercises in reducing pain and improving
      QOL and psychological status of amputees is a useful guide for future studies as these
      protocols are cost-effective and efficient.

      In a pilot, study authors investigated the effects of phantom limb exercises on phantom limb
      pain. A total of 20 traumatic amputees participated in the study. Ten received phantom
      exercises and prosthetic training, and 10 were treated with routine prosthetic training and a
      general exercise programme. They found that pain intensity decreased in all subjects after 4
      weeks of treatment in both groups. according to the visual analogue scale scores at the end
      of 4 weeks, the phantom exercises group differed significantly from the general exercise
      group. Thus, the study indicated that phantom exercises can be used safely to alleviate
      phantom limb pain in lower and upper limb amputees.

      This study combines the effect of mirror therapy with phantom exercises in the experimental
      group. Similarly, another randomized controlled trial (RCT) was done to evaluate the
      reduction in phantom pain and sensation with combined training of progressive muscle
      relaxation, mental imagery and phantom exercises. This randomized controlled prospective
      trial with two parallel groups included Fifty-one subjects with unilateral lower limb
      amputation with Phantom Limb Pain. The experimental group performed combined training of
      progressive muscle relaxation, mental imagery and phantom exercises 2 times a week for 4
      weeks, while the control group had the same amount of physical therapy dedicated to the
      residual limb. The results showed a significant decrement over time in all the Patient
      evaluation questionnaire domains (both in terms of phantom limb sensation (PLS) and phantom
      limb pain (PLP) and Brief pain intensity in experimental groups. The conclusion of this
      suggested that 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. As Mirror therapy (MT) has been proposed as an effective
      rehabilitative strategy to alleviate pain symptoms in amputees with phantom limb pain (PLP)
      so in this study mirror therapy is used as conventional treatment along with the general
      exercise programme for amputees.
    

Intervention name(s): phantom limb exercise; conventional treatment
Intervention type(s): Other; Other
Intervention description(s): phantom limb exercises (that is, active imaginal efforts to move the phantom), under the assumption that the neural pathways involved in performing actual movements are activated when using one's imagination to move the phantom extremity; Mirror therapy uses a flat mirror placed parasagittally in front of the patient's body with the reflective surface toward the sound limb so that the amputee sees the reflection of the sound limb in the mirror [Figure 1]. This reflection mimics the amputated limb, and with the movement of the intact limb, the mirror provides an optical illusion that the phantom limb is moving simultaneously.
Equipment:
Therapy mirror: A standing mirror (130 cm × 46 cm) with wooden frame and base (62 cm × 65 cm) Routine physiotherapy The general exercise programme consisted of strengthening, stretching, dynamic, and isometric exercises based on the level of amputation and their assessment results. Participants allocated to the control group were advised to continue rehabilitation at their respective physiotherapy out-patient departments as frequently as possible. Participants were given a diary and advised to record their activities, specifying the nature, frequency and duration of each activity
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Phantom exercises involved imagining moving the phantom limb and then attempting to perform these movements
The phantom exercises will be administered as follows:
(i) subjects will be asked in which position they felt the phantom limb; (ii) they will be asked to place the intact limb in the same position as they felt their phantom limb; (iii) they will be asked to move both limbs in the opposite direction; (iv) they will be then asked to return to the starting position again.
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: Phantom; Amputation; Prosthesis