Clinical Trial of the Virtual Integration Environment to Treat Phantom Limb Pain With Upper Extremity Amputation

Background: Phantom limb pain (PLP) is commonly seen following upper extremity (UE) amputation. Use of both mirror therapy, which utilizes limb reflection in a mirror, and virtual reality therapy, which utilizes computer limb simulation, has been used to relieve PLP. We explored whether the Virtual Integration Environment (VIE), a virtual reality UE simulator, could be used as a therapy device to effectively treat PLP in individuals with UE amputation.Methods: Participants with UE amputation and PLP were recruited at Walter Reed National Military Medical Center (WRNMMC) and instructed to follow the limb movements of a virtual avatar within the VIE system across a series of study sessions. At the end of each session, participants drove virtual avatar limb movements during a period of “free-play” utilizing surface electromyography recordings collected from their residual limbs. PLP and phantom limb sensations were assessed at baseline and following each session using the Visual Analog Scale (VAS) and Short Form McGill Pain Questionnaire (SF-MPQ), respectively. In addition, both measures were used to assess residual limb pain (RLP) at baseline and at each study session. In total, 14 male, active duty military personnel were recruited for the study.Results: Of the 14 individuals recruited to the study, nine reported PLP at the time of screening. Eight of these individuals completed the study, while one withdrew after three sessions and thus is not included in the final analysis. Five of these eight individuals noted RLP at baseline. Participants completed an average of 18, 30-min sessions with the VIE leading to a significant reduction in PLP in seven of the eight (88%) affected limbs and a reduction in RLP in four of the five (80%) affected limbs. The same user reported an increase in PLP and RLP across sessions. All participants who denied RLP at baseline (n = 3) continued to deny RLP at each study session.Conclusions: Success with the VIE system confirms its application as a non-invasive and low-cost therapy option for PLP and phantom limb symptoms for individuals with upper limb loss

Analysis of post-deployment cognitive performance and symptom recovery in U.S. Marines.

BACKGROUND: Computerized neurocognitive testing (NCAT) has been proposed to be useful as a screening tool for post-deployment cognitive deficits in the setting of mild traumatic brain injury (mTBI). We assessed the clinical utility of post-injury/post-deployment Automated Neurocognitive Assessment Metric (ANAM) testing, using a longitudinal design to compare baseline ANAM tests with two post-deployment ANAM tests in a group of Marines who experienced combat during deployment. METHODS AND FINDINGS: Post-deployment cognitive performance and symptom recovery were compared in a subsample of 1324 U.S. Marines with high rates of combat exposure during deployment. Of the sample, 169 Marines had available baseline and twice repeated post-deployment ANAM results. A retrospective analysis of the ANAM data, which consisted of a self-report questionnaire about deployment-related blast exposure, recent history of mTBI, current clinical symptoms, and cognitive performance. Self-reported concussion sustained anytime during deployment was associated with a decrease in cognitive performance measured between 2-8 weeks post-deployment. At the second post-deployment test conducted on average eight months later, performance on the second simple reaction time test, in particular, remained impaired and was the most consistent and sensitive indicator of the cognitive decrements. Additionally, post-concussive symptoms were shown to persist in injured Marines with a self-reported history of concussion for an additional five months after most cognitive deficits resolved. Results of this study showed a measurable deployment effect on cognitive performance, although this effect appears to resolve without lasting clinical sequelae in those without history of deployment-related concussion. CONCLUSIONS: These results highlight the need for a detailed clinical examination for service members with history of concussion and persistent clinical symptoms. Reliance solely upon computerized neurocognitive testing as a method for identifying service members requiring clinical follow-up post-concussion is not recommended, as cognitive functioning only slowly returned to baseline levels in the setting of persistent clinical symptoms

ANAM4 TBI-MIL Questionnaire and ACSI Symptomology for Concussed Service Members (N = 76).

<p>Note: *p<.002. W =  Wilcoxon Rank-Sum Statistic. T1 =  pre-deployment. T2 =  post-deployment assessment. T3 =  second post-deployment assessment</p

Sample characteristics (<i>n</i> = 169).

<p>Sample characteristics (<i>n</i> = 169).</p

Throughput Means (SE) for Non-Concussed Service Members.

<p>Note: No significant findings. PT =  performance test. T1 =  pre-deployment. T2 =  post-deployment assessment. T3 =  second post-deployment assessment. Δ (T2-T1) =  change from T1 to T2. Δ (T3-T1) =  change from T1 to T3. cdd =  coded substitution delayed. cds =  coded substitution. m2s =  matching to sample. pro =  procedural reaction time. srt =  simple reaction time. srt =  simple reaction time repeated.</p

Throughput Means (SE) for Concussed Service Members.

<p>Note: SE =  standard error. PT =  performance test. T1 =  pre-deployment. T2 =  post-deployment assessment. T3 =  second post-deployment assessment. Δ (T2-T1) =  change from T1 to T2. Δ (T3-T1) =  change from T1 to T3. cdd =  coded substitution delayed. cds =  coded substitution. m2s =  matching to sample. pro =  procedural reaction time. srt =  simple reaction time. srt =  simple reaction time repeated. * <i>p</i> = 0.0001. **<i>p</i> = 0.000001. ***<i>p</i> = 0.005.</p

Symptoms of PTSD associated with painful and nonpainful vicarious reactivity following amputation

Although the experience of vicarious sensations when observing another in pain have been described postamputation, the underlying mechanisms are unknown. We investigated whether vicarious sensations are related to posttraumatic stress disorder (PTSD) symptoms and chronic pain. In Study 1, 236 amputees completed questionnaires about phantom limb phenomena and vicarious sensations to both innocuous and painful sensory experiences of others. There was a 10.2% incidence of vicarious sensations, which was significantly more prevalent in amputees reporting PTSD-like experiences, particularly increased arousal and reexperiencing the event that led to amputation (&phi; = .16). In Study 2, 63 amputees completed the Empathy for Pain Scale and PTSD Checklist-Civilian Version. Cluster analyses revealed 3 groups: 1 group did not experience vicarious pain or PTSD symptoms, and 2 groups were vicarious pain responders, but only 1 had increased PTSD symptoms. Only the latter group showed increased chronic pain severity compared with the nonresponder group (p&nbsp;=&nbsp;.025) with a moderate effect size (r = .35). The findings from both studies implicated an overlap, but also divergence, between PTSD symptoms and vicarious pain reactivity postamputation. Maladaptive mechanisms implicated in severe chronic pain and physical reactivity posttrauma may increase the incidence of vicarious reactivity to the pain of others