Clinical and Neurophysiological Effects of Progressive Movement Imagery Training for Pathological Pain

An overview of the non-procedural treatment options for peripheral neuropathic pain

Peripheral neuropathic pain is common in patients with peripheral nerve injury and can significantly impact both their function and quality of life. There is a wide variety of non-interventional treatment approaches, including pharmacologic therapy, physical/occupational therapy, modalities (therapeutic, mechanical, thermal, etc.), psychology, and lifestyle modification. First line pharmacologic therapy for peripheral neuropathic pain includes gabapentinoids, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors. Other classes of medications, such as topical treatments, opioids, and cannabinoids, have more limited usefulness in treatment but remain part of a treatment regimen. Physical and occupational therapy, psychological interventions, and lifestyle medicine are important adjuncts in the treatment and prevention of future peripheral neuropathic pain. The strength of the evidence supporting each intervention varies, with that for pharmacologic intervention being the strongest. A combination of these options tailored to the individual needs of the patient likely will result in the best treatment outcome for peripheral neuropathic pain.

Feasibility study of a home-based graded motor imagery intervention (GraMI protocol) for amputees with phantom limb pain

INTRODUCTION

Phantom limb pain affects 64% of amputees. Graded Motor Imagery comprises three consecutive application techniques designed to reorganize maladaptive changes that have occurred after the amputation.

OBJECTIVE

To assess the feasibility of a home-based Graded Motor Imagery intervention, the GraMI protocol, for amputee people with phantom limb pain.

METHODS

Twenty individuals over 18 years of age with upper or lower limb amputation, experiencing phantom limb pain, who were pharmacologically stable, and had been discharged from the hospital were recruited. The experimental group followed the GraMI protocol. Primary outcomes included study processes, such as recruitment time and rate, adherence, compliance, and the acceptability of digital technologies as a treatment tool. Secondary outcomes assessed the impact on phantom limb pain, quality of life, functionality, and depressive symptoms.

RESULTS

On average, seven participants were recruited monthly over a three-month period. No losses were recorded throughout the nine weeks of intervention. Treatment adherence averaged 89.32%, and all participants demonstrated familiarity with the usability of digital technologies. No significant differences were observed between groups (p = .054). However, within the experimental group, intragroup analysis revealed a significant (p = .005) and clinically relevant reduction (>2 points) with a large effect size (0.89) in phantom limb pain.

CONCLUSION

Conducting a multicenter study with a home-based intervention using the GraMI protocol is feasible. Future clinical trials are needed to verify its effectiveness in managing phantom limb pain.

Response in Patients With Persistent Pelvic Pain to Motor Imagery Through Auditory or Visual Input-A Pilot Randomized Trial

Purpose: This study evaluates the response to a motor imagery intervention using visual or auditory inputs in patients with persistent pelvic pain. A secondary objective is to assess how patients' mental visualization capacity influences intervention outcomes. Methods: Forty patients diagnosed with persistent pelvic pain were enrolled in a randomized trial with six motor imagery sessions over 2 weeks. Patients were assigned to interventions delivered through images or audio recordings. Pain intensity, attention to pain, and the ability to mentally visualize and perceive movements were assessed. Results: Participants receiving auditory stimulus-based interventions showed a nonsignificant reduction in pain intensity (from 7.1 points [SD: 1.9] to 6.1 points [SD: 2.4]; p=0.091), while those in the visual input group experienced no change. Attention to pain improved in the visual group (from 30.2 points [SD: 6.2] to 27.6 points [SD: 6.8]; p=0.194), whereas it remained stable in the auditory group. Importantly, the participants' ability to mentally visualize and perceive movements did not significantly impact the outcomes. Conclusions: Auditory motor imagery appears to be a promising, less intrusive approach for managing persistent pelvic pain, with home-based interventions showing potential where access to conventional care is limited. This study highlights the importance of personalized motor imagery approaches, demonstrating superior efficacy for auditory interventions compared to visual ones. Limitations include a brief intervention period and recruitment challenges, yet motor imagery remains a viable therapeutic option. Trial Registration: ClinicalTrials.gov identifier: NCT06343649.

Online Graded Motor Imagery Is Effective in Women Diagnosed With Pelvic Pain: A Randomized Controlled Trial

OBJECTIVE

Effective therapeutic strategies are crucial for managing genito-pelvic pain/penetration disorder (GPPPD), a condition presenting challenges for both patients and health care providers. This study aims to assess the effectiveness of an online graded motor imagery (GMI) program in alleviating pain intensity and improving sexual function in women diagnosed with GPPPD.

METHODS

Eighty-seven women were randomly assigned to either an online GMI group or a control group. The online GMI protocol involved engaging participants in 2-week segments of left/right judgment exercises, mental simulation of movements, and gradual exposure therapy. After 6 weeks, we assessed pain intensity and sexual function. The control group gained access to the program upon study completion.

RESULTS

The online GMI group demonstrated a significant reduction in pain intensity, coupled with improvements in sexual function. Notably, participants with enhanced movement imagery abilities experienced greater improvements, while those with negative beliefs and thoughts regarding vaginal penetration showed lower sexual function scores.

CONCLUSION

An online GMI program is effective in alleviating the pain burden faced by women dealing with GPPPD.

IMPACT

Effectively addressing pelvic pain in patients remains a daunting challenge for physical therapists. Therefore, implementing efficient and easily accessible strategies is crucial. The incorporation of GMI intervention proves to be an effective approach for improving both pain and sexual functioning in women with GPPPD.

[Cognitive behavioral therapy for complex regional pain syndrome]

Complex regional pain syndrome (CRPS) is often associated with severe mental impairments. Initial pain-related fears in particular appear to be negative predictors for long-term therapy results. Procedures for cognitive behavioral therapy are an important component of treatment. The psychotherapy of CRPS consists of various elements that are implemented in the different phases of treatment. In the beginning the focus is on targeted psychoeducation. In the following activation phase body awareness exercises are accompanied by occupational and physiotherapeutic treatment in order to improve the perception of individual maximum loads. Behavioral analyses are used to uncover dysfunctional coping patterns, such as a fear avoidance coping strategy. In this case the use of graded activity treatment approach is indicated, in which the activity level is gradually increased. In the transfer phase psychotherapy supports affected patients in (re)designing their professional and private environments.

Central mechanisms of muscle tone regulation: implications for pain and performance

Muscle tone represents a foundational property of the motor system with the potential to impact musculoskeletal pain and motor performance. Muscle tone is involuntary, dynamically adaptive, interconnected across the body, sensitive to postural demands, and distinct from voluntary control. Research has historically focused on pathological tone, peripheral regulation, and contributions from passive tissues, without consideration of the neural regulation of active tone and its consequences, particularly for neurologically healthy individuals. Indeed, simplistic models based on the stretch reflex, which neglect the central regulation of tone, are still perpetuated today. Recent advances regarding tone are dispersed across different literatures, including animal physiology, pain science, motor control, neurology, and child development. This paper brings together diverse areas of research to construct a conceptual model of the neuroscience underlying active muscle tone. It highlights how multiple tonic drive networks tune the excitability of complex spinal feedback circuits in concert with various sources of sensory feedback and in relation to postural demands, gravity, and arousal levels. The paper also reveals how tonic muscle activity and excitability are disrupted in people with musculoskeletal pain and how tone disorders can lead to marked pain and motor impairment. The paper presents evidence that integrative somatic methods address the central regulation of tone and discusses potential mechanisms and implications for tone rehabilitation to improve pain and performance.

Psychological, physical and complementary therapies for the management of neuropathic pain

This chapter aims to explain and evaluate the evidence for psychological, physical and complementary therapies as part of a holistic plan for managing neuropathic pain. Psychological therapies refer to interventions targeting mental health, while physical therapies refer to interventions designed to target movement and functional ability, and complementary therapies are those that attempt to target key mechanisms of change to alter brain and body functioning, or thought processes related to the experience of pain. Each therapeutic modality is discussed to narratively report on the evidence and provide implications for clinicians. Where evidence was unavailable for neuropathic pain populations, evidence from chronic pain populations more broadly was considered. Although promising, there is a lack of high-quality evidence investigating the benefits and safety of psychological, physical and complementary therapies for the management of neuropathic pain. The low certainty evidence and lack of evidence across different neuropathic pain conditions impacts the ability to make recommendations for clinical practice. However, there are several potential areas for future research. Psychological therapies that focus on the underlying mechanisms related to emotion regulation may improve mood and pain, while cognitive and behavioural based approaches may improve psychological comorbidities such as anxiety and depression. Physical therapies involving physical activity and exercise, education, and graded motor imagery may improve functioning and reduce pain. Finally, complementary therapies including electroencephalography neurofeedback, acupuncture, virtual reality, hypnosis and transcutaneous electrical nerve stimulation may provide promising reductions in pain. There is a clear need for further high-quality trials to evaluate the benefits and safety of psychological, physical and complementary therapies to guide the management of neuropathic pain.

Role of Immersive Virtual Reality in Motor Behaviour Decision-Making in Chronic Pain Patients

Primary chronic pain is a major contributor to disability worldwide, with an estimated prevalence of 20-33% of the world's population. The high socio-economic impact of musculoskeletal pain justifies seeking an appropriate therapeutic strategy. Immersive virtual reality (VR) has been proposed as a first-line intervention for chronic musculoskeletal pain. However, the growing literature has not been accompanied by substantial progress in understanding how VR exerts its impact on the pain experience and what neurophysiological mechanisms might be involved in the clinical effectiveness of virtual reality interventions in chronic pain patients. The aim of this review is: (i) to establish the state of the art on the effects of VR on patients with chronic pain; (ii) to identify neuroplastic changes associated with chronic pain that may be targeted by VR intervention; and (iii) to propose a hypothesis on how immersive virtual reality could modify motor behavioral decision-making through an interactive experience in patients with chronic pain.

Modern Principles of Diagnosis and Treatment in Complex Regional Pain Syndrome

BACKGROUND

Background: Complex regional pain syndrome (CRPS) is a relatively common complication, occurring in 5% of cases after injury or surgery, particularly in the limbs. The incidence of CPRS is around 5-26/100 000. The latest revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) now categorizes CRPS as a primary pain condition of multifactorial origin, rather than a disease of the skeletal system or the autonomic nervous system.

METHODS

Method: Based on a selective search of the literature, we summarize current principles for the diagnosis and treatment of CRPS.

RESULTS

Results: Regional findings in CRPS are accompanied by systemic symptoms, especially by neurocognitive disorders of body perception and of symptom processing. The therapeutic focus is shifting from predominantly passive peripheral measures to early active treatments acting both centrally and peripherally. The treatment is centered on physiotherapy and occupational therapy to improve sensory perception, strength, (fine) motor skills, and sensorimotor integration/ body perception. This is supported by stepped psychological interventions to reduce anxiety and avoidance behavior, medication to decrease inflammation and pain, passive physical measures for reduction of edema and of pain, and medical aids to improve functioning in daily life. Interventional procedures should be limited to exceptional cases and only be performed in specialized centers. Spinal cord and dorsal root ganglion stimulation, respectively, are the interventions with the best evidence.

CONCLUSION

Conclusion: The modern principles for the diagnosis and treatment of CRPS consider both, physiological and psychological mechanisms, with the primary goal of restoring function and participation. More research is needed to strengthen the evidence base in this field.

Functional MRI in Radiology—A Personal Review

We, here, provide a personal review article on the development of a functional MRI in the radiology departments of two German university medicine units. Although the international community for human brain mapping has met since 1995, the researchers fascinated by human brain function are still young and innovative. However, the impact of functional magnetic resonance imaging (fMRI) on prognosis and treatment decisions is restricted, even though standardized methods have been developed. The tradeoff between the groundbreaking studies on brain function and the attempt to provide reliable biomarkers for clinical decisions is large. By describing some historical developments in the field of fMRI, from a personal view, the rise of this method in clinical neuroscience during the last 25 years might be understandable. We aim to provide some background for (a) the historical developments of fMRI, (b) the establishment of two research units for fMRI in the departments of radiology in Germany, and (c) a description of some contributions within the selected fields of systems neuroscience, clinical neurology, and behavioral psychology.