Thesis (Ph. D.)--Washington State University. / Includes bibliographical references.

Phantom Limb pain (PLP) affects up to 85% of all patients following an amputation, causing debilitating effects on their quality of life. Mirror Therapy (MT) has been reported to have potential success for the alleviation of PLP. Current understanding of PLP and the efficacy of MT for its alleviation are still unclear, therefore guidelines for treatment protocols are lacking. This literature review assesses the current best evidence for using MT to alleviate PLP of patients with amputation. Method: The authors systematically searched the academic databases Medline, Amed, CINAHL and Google Scholar, using key search terms with inclusion and exclusion criteria to identify relevant articles on the use of MT in populations of patients suffering PLP after unilateral limb amputation. Findings: Seven primary papers were identified and appraised. All the articles reported significant PLP alleviation after using MT with a trend for achieving phantom limb movement (PLM) prior to pain relief. Conclusions: Mirror Therapy is a promising intervention for PLP. Regular MT sessions are required to maintain treatment effect. Causes of PLP and pathways to its alleviation may be multifactorial; therefore further well-conducted RCTs are required to identify best practice.

Introduction: This study investigates a new form of Mirror Therapy (MT), the Mirror Specs. Evidence suggests that MT is a non-invasive, cost effective method of reducing pain and increasing functioning in some chronic pain conditions. There is no clear explanation for the underlying mechanisms of MT, however, a plausible hypothesis suggests that adaptation to the Body Schema is an integral component. Aims and Hypotheses: The current study examined Body Schema adaptation in healthy participants when performing a Finger Tapping Task with both Mirror Specs and a Mirror Box. It was hypothesised that adaptation would be indicated by increases in Reaction Times (RTs) and Error Rates when comparing unimanual phases of a Finger Tapping Task, following a bimanual „adaptation‟ phase. It was hypothesised that there would be no difference between participants‟ ability to adapt to each device. Finally, the study proposed that there would be a relationship between the adaptation observed on the Finger Tapping Task and participants individual imagery abilities. Method: Participants performed 4 phases of a Finger Tapping Task with alternate bimanual and unimanual phases when using both the Mirror Specs and Mirror Box. Imagery abilities were measured using self-report questionnaires and a Motor Imagery computer task. Results and Discussion: Repeated Measures ANOVAs revealed reductions in RTs and Error Rates in Phase 3 compared to Phase 1 on the Finger Tapping Task. There were no differences between RTs and Error Rates when using the Mirror Specs and Mirror Box. These findings suggest that healthy participants were able to use each Mirror Device effectively and this provide impetus for the proposal that Mirror Specs could provide a practical, cost effective addition to rehabilitation services. Finally, there were no clinically significant relationships between use of the Mirror Devices and imagery abilities, thereby indicating imagery abilities did not influence how participants adapted to using the Mirror Devices.

Chronic neuropathic pain affects up to 8% of the United Kingdom population and is a difficult condition to manage. It is established and maintained through many mechanisms, including central sensitisation (CS) in the spinal cord and brainstem. Neuropathic pain manifests as spontaneous pain, sensory loss and evoked hypersensitivity. The development of novel treatments for neuropathic pain is challenging, in part due to inadequate experimental models of clinically relevant pain. The use of functional magnetic resonance imaging (fMRI) techniques for imaging acute and increasingly tonic states enables the assessment of the neural correlates of evoked hypersensitivity and persistent pain, with the goal of developing appropriate biomarkers to test new therapies. This thesis develops novel techniques for the assessment of ongoing pain states and their modulation by therapies. We first identified a suitable human experimental model of CS using topical capsaicin, and an fMRI pipeline for the investigation of supraspinal involvement in pain hypersensitivity. In a placebo-controlled study, we then demonstrated the improved sensitivity of fMRI above subjective reports in detecting the efficacy of a known analgesic as compared to an ineffective active compound in a small cohort. To translate this to the more clinically relevant symptom of spontaneous pain, we developed and validated the use of a multi-inversion time pseudo-continuous arterial spin labelling (ASL) imaging and analysis pipeline for the neural assessment of tonic states and the absolute quantification of cerebral blood flow (CBF). Current evidence from structural and functional studies suggests a direct role for the posterior insula cortex in the encoding of nociception and pain. Using the ASL pipeline, we found that only a CBF change in the posterior insula region was correlated with the changing perception of persistent capsaicin-induced pain, and in a separate experiment showed that suppression of CBF in this region by gabapentin was related to the drug's suppression of subjective pain perception. We also demonstrated in a cohort of phantom limb patients that pain relief resulting from transcranial direct current stimulation of the deprived sensorimotor cortex is neurally represented by a decrease in posterior insula CBF. In a separate study, we showed that baseline CBF in the periaqueductal grey can predict individuals who are most vulnerable to pain and hypersensitivity following the induction of capsaicin-related CS. Taken together, these findings suggest that fMRI can be used as a tool to assess the efficacy of established and novel analgesics, with the midbrain reticular formation and posterior insula cortex being prime candidates as biomarkers of CS mechanisms and persistent pain respectively. Relatedly, ASL-fMRI may also be an effective technique for evaluating individuals' susceptibility to pain following inflammation or injury.

Fantomsmärta är ett komplext fenomen som drabbar många patienter efter amputation av extremitet. Syftet var att utforska hur fantomsmärtor efter amputation av extremitet kan upplevas och lindras. Litteraturstudiens resultat utgörs av 15 vetenskapliga artiklar som presenteras i tre huvudteman vilka är fantomsmärtans komplexitet, lindring genom transkutan elektrisk nervstimulering och lindring genom rörelseterapi. Det har visat sig att upplevelsen av fantomsmärta medför en negativ påverkan för patienter efter amputation av extremitet. Olika behandlingsmetoder till exempel transkutan elektrisk nervstimulering och rörelseterapi har beprövats med varierande resultat. Vidare forskning är nödvändig för att klarlägga den bakomliggande patofysiologin gällande fantomfenomenet för att generera bättre anpassade lindringsmetoder. Vidare forskning är även angelägen för att få en ökad förståelse för patienters upplevelser kring smärtproblematiken. Utformande av PM gällande vård av patienter som lider av fantomsmärtor efter amputation av extremitet vore betydelsefulla. / Phantom limb pain is a complex phenomenon that affects numerous patients following amputation of the extremities. The aim of this study was to explore how phantom limb pain following amputation of extremities can be experienced and alleviated. The study was conducted as a literature review where 15 scientific articles were the basis for the results. Three major themes are presented in the result: the complexity of phantom limb pain, alleviation through transcutaneous electrical nerve stimulation and alleviation through movement therapy. It has been shown that the experiences of phantom limb have a negative impact on patients following amputation of extremities. Different options regarding treatment, for example transcutaneous electrical nerve stimulation and movement theory, has been proven with variation in the results. Further research is required to elucidate the underlyingpathophysiology regarding the phantom phenomenon for better understanding and suitable alleviation options. Specific guidelines regarding nursing for patients who suffer from phantom limb pain would be of importance.

Bakgrund: Fantomsmärta upplevs av cirka 50-85% av alla som genomgår amputation. Antalet amputationsingrepp ökar i världen likväl som i Sverige, detta på grund av en generellt åldrande befolkning samt ökad sjukdomsprevalens. Trots ett så pass vanligt förekommande fenomen är patienters erfarenheter sparsamt beskrivet och då även i svensk vårdkontext. Syfte: Syftet med detta arbete är att beskriva patienters erfarenheter av att leva med fantomsmärta efter amputation.  Metod: Åtta kvalitativa studier identifierades till denna studie. Relevanta data söktes fram i CINAHL och PubMed. Innehållsanalys utfördes med inspiration av Fribergs modell, innehållande fem steg. Resultat: Patienters erfarenheter av fantomsmärta presenteras i fyra kategorier och nio subkategorier: Olika dimensioner av smärta, Självbild i förändring, Nya utmaningar i vardagslivet och Behöver stöd från omgivningen. Konklusion: Att leva med fantomsmärta är komplext. Amputation medför en förändringsprocess med både påfrestningar och begränsningar men också anpassning till en förändrad livssituation. Livskvalitet trots dessa utmaningar är möjligt och som sjuksköterska är det således essentiellt att identifiera varje enskild patients hinder för och möjligheter till anpassning. Detta för att gemensamt uppnå hälsa i största möjliga mån. / Background: Phantom limb pain occurs in circa 50-85% of all the cases of amputation. Amputations are increasing worldwide as well as in Sweden because of an ageing population and an increase of disease-prevalence. Although phantom limb pain is common, there is a lack of knowledge and information when it comes to patients’ experiences. Aim: The aim of this study is to describe patients’ experiences of living with phantom limb pain after amputation. Methods: Eight qualitative studies were identified for this review. Relevant data was collected from CINAHL and PubMed. Qualitative content analyses were conducted, inspired by Friberg’s five step model for analysis.  Results: Patients’ experiences of phantom limb pain were presented in four categories and nine subcategories: Different dimensions of pain, Self-image in change, New challenges in everyday-life and The need of support from the surroundings.  Conclusion: Living with phantom limb pain is complex. Amputation induces a process of change, presenting limitations, stresses and a need to adapt. However, good quality of life is possible and as a nurse it is essential to identify patients’ possibilities and obstacles to strive for the best possible health care.

Bakgrund: Fantomsmärtan är vanlig hos patienter som amputerat en kroppsdel. Att behandla smärtan är en utmaning för sjuksköterskan där en kunskap om fenomenets manifestation och de komplementärmedicinska alternativ som finns att tillgå är viktiga redskap för att stötta patienten genom hela vårdförloppet. Syfte: Syftet var att belysa sjuksköterskans roll i omvårdnaden av patienter med fantomsmärta som behandlas med komplementärmedicinska behandlingar. Metod: Studien var en litteraturstudie med induktiv ansats baserad på kvalitativ och kvantitativ forskning med olika design. Resultat: Litteraturstudiens resultat presenteras i två kategorier: Sjuksköterskans roll före amputationen och Sjuksköterskans roll efter amputationen. Sjuksköterskan har en viktig roll i behandlingen av fantomsmärta där den personcentrerade vården är i fokus. Kunskap om fantomsmärtans manifestation samt komplementärmedicinska alternativ, till exempel spegelterapi och VR med AG, är nödvändig för att bygga förtroende och finna rätt behandlingsalternativ till den unika patienten. Konklusion: Sjuksköterskans förståelse för patienter med fantomsmärta samt patientens hälsolitteracitet har en central roll i omvårdnaden. Tidigt implementerande av en vårdplan, utbildning om fantomsmärtans karaktär samt information om komplementärmedicinska behandlingsalternativ skapar förtroende mellan sjuksköterska och patient. Ytterligare forskning kring fantomsmärtan och de komplementärmedicinska metoderna är nödvändig för att arbeta fram tydligare riktlinjer och en bredare förståelse för fantomsmärtan. / Background: Phantom limb pain is common in patients who have amputated a body part. Treating the pain is a challenge for the nurse where a knowledge of the phenomenon's manifestation and the complementary medicine alternatives that are available are important tools for supporting the patient throughout the care process. Aim: The aim was to illustrate the nurse’s role in the care of patients with phantom limb pain who are treated with complementary medicine methods. Method: The study was a literature study with an inductive approach based on qualitative and quantitative research with different designs. Results: The results of the literature study are presented in two categories: Nurse’s role before the amputation and Nurse’s role after the amputation. The nurse has an important role in the treatment of phantom limb pain where the person-centered care is in focus. Knowledge of the manifestation of phantom limb pain as well as complementary medicine alternatives, such as mirror therapy and VR with AG, is necessary to build trust and find the right treatment alternative for the unique patient. Conclusion: The nurse's understanding of patients with phantom limb pain and the patient's health literacy has a central role in nursing. Early implementation of a care plan, education about the nature of phantom limb pain and information about complementary medicine treatment options creates trust between nurse and patient. Further research on phantom limb pain and the complementary medicine methods is necessary to work out clearer guidelines and a wider understanding of phantom limb pain.

Successful treatment alternatives for chronic pain conditions are limited. One type of chronic pain that can occur is the condition of phantom limb pain, which can occur after the loss of a limb. Many studies have researched the correlation between chronic pain, tactile acuity, and cortical reorganization. Sensory discrimination training has been shown to improve tactile acuity and be beneficial when trying to reduce the intensity and duration of the pain in chronic pain conditions. A device has been developed by the Center for Bionics and Pain Research, and it is intended to train sensory discrimination. How efficiently this device can train sensory discrimination and how much improvements in the tactile acuity in able-bodied participants can be achieved after using the device have been investigated in this study. 16 able-bodied subjects participated in the study. The subjects received five 40 minutes training sessions on five consecutive days. The assessment of the subjects’ tactile acuity was performed before the first training session and after the last training session. The tactile acuity was also assessed after one to two weeks to determine the long-term effect of the training. There were two psychophysical analyses to determine the participants’ tactile acuity, the two-point discrimination test and the monofilament test. The results showed a significant improvement in the two-point discrimination threshold after the five training sessions, thus showing evidence of the improvement in the tactile acuity after using the sensory discrimination training device. There was no significant improvement in the monofilament test.

The phenomenon of phantom limb pain has been well documented for centuries, but little clinical work has been done to alleviate it. Physician and neuroscientist Vilayanur S. Ramachandran began researching this condition nearly two decades ago, and has discovered a promising alternative treatment: mirror-box therapy. This therapy is not yet widely accepted by the scientific and medical communities because there is insufficient data explaining how and why it works. This study analyzes Ramachandran's rhetoric promoting the therapy. Scott Stroud's melioristic method is applied to Ramachandran's scientific and popular publications. The purpose is to determine whether or not his rhetoric is melioristic in that it promotes positive, and thus, pragmatic changes. This thesis indicates the important insights pragmatism can yield when utilized in acts of rhetorical criticism. / Graduation date: 2012

Bakgrund: Majoriteten av de personer som genomgått ett amputationsingrepp drabbas av fantomsmärta. Trots att fantomsmärta är ett vanligt fenomen inom denna patientgrupp så är det ofta missförstått och det föreligger problem förknippade med hanteringen av fantomsmärtor. Tidigare forskning har visat inkonsekventa resultat som varierar från en forskare till en annan och komplexiteten med fantomsmärta har lett till behandlingsresultat med varierande effekt. I första hand har farmakologisk behandling använts, men många patienters smärta förblir refraktär mot farmakologiska medel och kräver därför andra alternativ. En alternativ behandling som först föreslogs i början på 1990-talet i vårdandet av fantomsmärta är spegelterapi. Spegelterapi kan användas som en omvårdnadsåtgärd för att smärtlindra fantomsmärtor och ska minska den amputerade kroppsdelens smärta.Syfte: Syftet med föreliggande litteraturstudie är att belysa effekten av spegelterapi som en omvårdnadsåtgärd för smärtlindring av fantomsmärtor.Metod: Metoden som använts är systematisk databassökning i databaserna PubMed och Cinahl. Litteraturstudien baseras på 10 vetenskapliga studier med kvantitativ studiedesign.Resultat: Litteraturstudiens syfte blev besvarat och kunde fastställa att spegelterapi har en smärtlindrande effekt för fantomsmärtor. Ett bifynd var att interventionen även bidrar till enförbättrad livskvalitet. Således delades resultatet in i två huvudteman: Spegelterapins smärtlindrande effekt utifrån olika smärtskattningsskalor samt påverkan på livskvaliteten. De frågor som ställts är om spegelterapi är en omvårdnadsåtgärd som kan användas i praktiken.Konklusion: Spegelterapi har en smärtlindrande effekt och minskar fantomsmärtor. Ett bifynd var att interventionen även bidrar till en förbättrad livskvalitet samt ökar välmåendet hos amputerade personer som lider av fantomsmärtor. Spegelterapi hade kunnat användas i praktiken efter att ha blivit optimerad och där en standardmetod för spegelterapi tagits fram. Däremot krävs det vidare forskning om spegelterapi. / Background: The majority of amputees suffer from phantom pain. Although phantom pain isa common phenomenon, it is often misunderstood and there are often problems with themanagement of phantom pain. Previous research has shown inconsistent results that varyfrom one researcher to another. The complexity with phantom limb pain has led to treatmentresults with varying effects. Primarily pharmaceuticals have been the main treatment. But many patients' discomfort still remains and the need for alternative treatment options isimperative. One alternative treatment is mirror therapy which was first suggested in thebeginning of the 1990’s century. Mirror therapy is supposed to reduce the phantom limb pain.Aim: The aim of this literature review is to highlight the effect of mirror therapy as a nursing treatment for reducing phantom limb pain.Method: The method that is used is a systematic database search in PubMed and Cinahl. The literature study is based on 10 scientific articles with a quantitative study design.Result: The literature study proved that mirror therapy is effective for reducing phantom limb pain. A secondary finding was the improvement of quality of life. Therefore the result was divided into two main themes: Change in phantom pain based on different pain assessment scales and the impact on the quality of life. Questions that were asked are whether mirror therapy is an intervention that can be used in the treatment of the phenomenon.Conclusion: Mirror therapy does reduce phantom pain in amputees. A secondary finding was that the intervention also contributes to a better quality of life and increases the well-being for the amputee. Mirror therapy could be practically applied after a standard method has been produced. However, further research is needed on mirror therapy.