RU2824984C1 - Method of phantom pain correction by mirror therapy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention can be used in treating phantom pains. Direct and mirror images of a functioning limb are formed on a computer monitor by shooting a scene with a video camera, containing a direct image of an extremity and its reflection in a flat mirror to obtain a video image of a pair of extremities. Patient is prescribed to continuously monitor the obtained video image of a pair of extremities on a computer monitor to create the illusion that the patient has both extremities capable of moving synchronously. Further, rehabilitation measures for phantom pain therapy are carried out, which include three consecutive stages: sensory stimulation, motor stimulation and activation of tactile sensitivity by recognition of sensations from touching test objects.

EFFECT: method provides simplification of implementation with provision of comfort of posture for patient and higher efficiency of treatment of phantom pains, as well as treatment under non-stationary conditions.

5 cl, 2 dwg, 2 ex

Description

The invention relates to physiotherapy and can be used to correct phantom pain (upper, lower limbs, fingers of the upper and lower limbs).

It is known that phantom pains and sensations are pains and sensations that occur in a patient in an already amputated limb (or body part). Based on observations, such pains and sensations have three main factors that cause them: a deficit of extraceptive and proprioceptive information, normally coming from the superficial and muscle receptors of the limb, while pain, based on physiological data, is a substitute for a deficit of proprioception, thereby the hypothalamus interprets the lack of registration of muscle contractions, if there are no such contractions, it means that the hand is pressed by something, as a result of which a painful stimulus occurs as a warning. Phantom sensations also arise against the background of a deficit of information, but from extraceptive receptors - tactile, temperature, etc. In this case, phantom sensations are a substitute for a deficit of information. It should be noted that sensations and pains can occur in isolation from each other, and also manifest themselves in synergy. The third factor is the actual signals coming from the nerve endings preserved in the amputated arm; in this case, phantom pains and sensations arise due to an error in the hypothalamus's interpretation of the incoming information. Two additional factors that do not form such pains and sensations, but participate in their frequency and intensity, are weather conditions and the patient's psycho-emotional state.

A method of phantom pain management using a mirror is known - "mirror therapy" (MT) (Ramachandran et al., Touching the phantom limb, 1995, DOT 10.1038/377489a0). A mirror is placed in front of a patient with unilateral motor/sensory impairments with the reflective surface facing the healthy arm or leg, the patient looks into the mirror towards his or her non-functioning limb and sees the reflection of the healthy one in it. When performing motor and sensory tasks with the healthy limb, its mirror reflection is perceived as the diseased limb itself, and the patient has a feeling that the diseased arm/leg works like a healthy one. Using visual feedback, it is possible to connect the sent efferent command with positive visual reinforcement, which leads to retraining of the "learned" component of paresis or pain and directly influences the state of the sensorimotor cortex of the affected hemisphere. The role of high-frequency gamma oscillations of the sensorimotor cortex of the “mirror hemisphere” is possible; the role of so-called “mirror neurons” that are activated both when performing an action and when observing this action, the possible involvement of ipsilateral pathways.

ST has a number of disadvantages: the patient's posture is uncomfortable, since in order to see the reflection of the non-functioning limb, he has to turn and bend, the resulting tension interferes with the process of deep immersion in therapy. Secondly, until today, the sequence of exercises and methods of influence has not been scientifically substantiated or prescribed.

Technical means implementing the CT method are known (CN 218944286 (U), AFFILIATED HOSPITAL OF NANTONG UNIV, 2023-05-02), using a glass mirror, gloves with sensors for the angle of flexion of healthy fingers and the generation of electrical control signals for the diseased limb. Through the mirror, the patient can perform synchronous movements of the shoulder joint, elbow joint and wrist joint simultaneously based on motor imagination. There is a computer with a display and a camera, which is designed to record and track the progress of treatment in real time, and the camera is installed at the end of the mirror, focused on creating a visual image of both healthy hands moving synchronously, formed on the screen based on sensors reading the movements of the healthy hand.

Another invention (CN113813584 (A) THE SECOND AFFILIATED HOSPITAL OF CHONGQING MEDICAL UNIV., 2021-12-21) describes a device for ST without the use of glass mirrors, where images are formed on a screen electronically by means of a computer camera and contains a complex system for moving and adjusting the camera for working with the upper limbs.

The closest analogue of the invention is the CT in restoring hand function in patients with upper limb paresis (RU 2767139 FGBU NNPC MSE and RI of the Ministry of Labor of Russia 03/16/2022 - prototype). The method for restoring hand function in patients with upper limb paresis includes placing the patient in front of a mirror so that the healthy limb is fully reflected in it, and the paralyzed limb is hidden, the patient performs various movements with the healthy hand, observing the movements of the healthy hand and its reflection in the mirror, getting the illusion of movement with both hands, work is carried out with the soft tissues of the paralyzed upper limb: performing myofascial stretching (MFR) and post-isometric relaxation (PIR) techniques with the help of an instructor. However, this method does not imply transfer to other etiologies, which is typical, for example, for the CT itself.

The present invention is aimed at simplifying the implementation while ensuring convenience for the patient and increasing the effectiveness of treating phantom pain. The method is implemented in non-stationary conditions for both the upper and lower extremities.

The patented method for rehabilitating a patient with phantom limb pain using mirror therapy includes the formation in the patient's field of vision of a direct image and one reflected in a flat mirror of a functioning limb with the isolation of the image of a non-functioning limb, and the implementation of rehabilitation measures.

The difference is as follows. Direct and mirror images of a functioning limb are formed on a computer monitor screen by filming a scene with a video camera containing a direct image of the limb and its reflection in a flat mirror to obtain a video image of a pair of limbs, while the patient is instructed to continuously watch the resulting video image of the pair of limbs on the computer monitor screen to create the illusion that the patient has both limbs capable of moving synchronously.

Next, rehabilitation measures are carried out to treat phantom pain, including three successive stages: sensory stimulation, motor stimulation and activation of tactile sensitivity by recognizing sensations from touching test objects.

The method can be characterized by the fact that the computer is a laptop equipped with a front video camera.

The method can also be characterized by the fact that sensory stimulation of the limb includes exposure to alternately warm and cold air, followed by tingling and stroking movements for 5-10 minutes.

The method can also be characterized by the fact that motor stimulation of the upper limb includes a set of exercises for dynamic and postural fist-rib-palm praxis with pauses between exercises of 2-3 minutes.

The method can also be characterized by the fact that the motor stimulation of the lower limb includes a set of exercises for alternately raising the toes, alternately raising the toe and heel, turning the toe left and right with the heel pressed to the floor, turning the heel left and right with the toe pressed to the floor, exercises for static tension and manipulation with the ball.

The technical result is a simplification of implementation while ensuring a comfortable posture for the patient and an increase in the effectiveness of treating phantom pain. An additional technical result is the possibility of performing treatment in non-hospital conditions.

The essence of the invention is explained in the drawings, where:

Fig. 1 - patient positioning relative to the mirror and computer;

Fig. 2 - an example of an image on a computer screen that the patient sees.

Of the technical means for implementing the method and conducting therapy, it is sufficient to have a flat mirror of a size sufficient to display the upper and lower extremities, as well as a computer with a front camera. This eliminates the main drawback of the ST - the inability of the patient to adopt a comfortable position for observation due to the fact that the patient must look at the mirror from top to bottom.

Fig. 1 shows a diagram of the patient's placement relative to the mirror and the computer, where the following positions are designated: 1 - flat mirror; 2 - computer; 3 - video camera; 4 - computer screen; 5 - video camera's viewing area of the flat mirror surface; 6 - patient; 7 - functioning (intact, healthy) limb of the patient; 71 - reflection of limb 7 in the mirror; 72 - image reflected in the mirror on the computer screen; 73 - direct image of the limb on the computer screen; 8 - non-functioning (amputated) limb; 9 - patient's viewing area of the computer screen.

The method uses a set of exercises in the rehabilitation process, based on the activation of numerous modalities of sensory perception: tactile, temperature, pain, pressure. This contributes to the emergence of a more complete and detailed image of the damaged limb, which leads to a more productive “replacement” of information from the missing/paralyzed limb with visual and tactile "analogues". An additional feature of the patented method is its versatility for the treatment of phantom pain not only of the limbs, but also of other parts of the body amputated as a result of oncology (here we note that such phantom pains are experienced especially hard, and are difficult to curate [Tkachenko G.A., Stepanova A.M., Merzlyakova A.M. Psychological correction of phantom pain in cancer patients // Sarcomas of bones, soft tissues and skin tumors. - 2022-№3. - P. 38-42.], as well as not only amputated, but also paralyzed areas.

This technology involves the use of a camera and a computer/tablet/laptop screen, which simplifies the process of the patient's perception of the reflection. Firstly, the process of observing the movements of a healthy and "mirror" limb in a mirror is quite inconvenient for the patient, since it is necessary to maintain a certain pose for realistic perception. Observation "from the side" (from the screen of the camera recording the reflection) allows the patient to take a more comfortable pose. Also, this angle of perception contributes to a more successful formation of the image of a healthy limb (it looks more real from this angle). Secondly, the recording of movements creates a certain time delay, which leads to a minimal, but still present desynchronization between the hands (this dissonance is more typical of real human actions). This feature leads to an easier perception of the reflection of the healthy limb as absent. Thirdly, the above-described limitations of classical mirror therapy cannot be corrected by a second mirror placed perpendicular to the first, since the effect of a "mirror corridor" will be created. Using a camera and a laptop screen allows you to avoid this problem.

A series of procedures is used aimed at forming not only a visual image of the affected limb, but also involving basic sensory stimulation (warm/cold, sharp/soft). As described above, the inclusion of different channels of perception in the process of creating an image of both limbs has a significantly greater efficiency compared to using only the visual format. In the study by Rock and Victor [Rock I., Victor J. Vision and touch: an experimentally created conflict between the two senses // Science. - 1964. - №143. - P. 594-596] it is declared that visual information has an advantage over proprioception and tactile sensitivity, however, in our opinion, the use of several modalities simultaneously increases the efficiency of mirror therapy.

The method is implemented as follows.

A session with a new patient begins with collecting anamnesis and assessing the intensity, quantitative and qualitative characteristics of phantom pain. All information is recorded in order to track the dynamics of changes during sessions. At each subsequent session, the patient's symptoms and the presence/absence of changes are clarified.

Further, before the procedure itself, patients who have not had previous experience with CT are introduced to the essence of the method and the main mechanisms of phantom pain. Since phantom pain has a large psychological context, it is necessary to explain to the patient the importance of including him in joint productive work. If it is possible to imagine with the help of imagination that he has both hands at his disposal, with his faith in the result, the effect of therapy can be significantly higher.

After the preparatory procedures, the equipment is installed and the exercises themselves are started. The mirror is installed perpendicular to the work surface, the size of the mirror should allow the patient to see the healthy arm/leg in its entirety (from the shoulder/pelvis to the fingertips). The laptop/tablet/computer (any device equipped with a front camera) is installed in such a way that the patient sees his healthy limb and its reflection on the screen. Further switching on of the camera is accompanied by an explanation to the patient of the need to look only at the screen during the session, on the basis of which he should clearly form the idea that the arm in the reflection is his intact arm, and the arm in the image is his amputated arm. As a result, the illusion will be created that the patient has both arms and both hands and they are able to move.

The method of conducting therapy for phantom pain of the upper and lower extremities includes three modules: Module 1 - sensory stimulation; Module 2 - motor stimulation; Module 3 - activation of tactile sensitivity or stimulation/practicing interaction with objects. During the entire therapy, the patient must look at the computer screen.

Sensory stimulation. The functioning (healthy) limb is exposed to alternately warm and cold air for 5-10 minutes, then tingling and stroking movements are performed for the same amount of time. The deficit of extraceptive information is compensated for through tactile sensations and the visual channel. Sensory stimulation is identical when working with the upper and lower limbs.

Motor stimulation. The first exercise for working with the upper limbs is “fist-edge-palm” (palm clenched into a fist, palm edge on the table plane, straightened palm on the table plane), which is repeated 21 times. Praxis exercises in this case are a replacement for proprioceptive information from the arm muscles (through the visual channel, a demonstration of the safety and ability of the arm to move occurs). The second exercise is “fist-victory-ring” (palm clenched into a fist; palm with fingers 1, 4 and 5 connected, and 2 and 3 straightened; palm with fingers 1 and 2 connected, and 3, 4 and 5 straightened). The third exercise is the “goat pistol” (1 finger is straightened and abducted, 2 and 3 are straightened and connected, 4 and 5 are bent; 1, 3 and 4 fingers are bent, 2 and 5 are straightened). Between exercises it is necessary to take a break of 2-3 minutes.

Activation of tactile sensitivity by recognizing sensations from touching test objects. The patient is asked to identify tactile sensations with closed eyes (while the person performing the procedure touches the hand with test objects: cold and warm, sharp and dull, smooth and rough, etc.). This exercise allows activating a large area of the brain.

Motor stimulation. Exercises for working with the lower limbs include: alternately raising the toes; the heel is pressed to the floor, the toe is turned left and right; the toe is pressed to the floor, the heel is turned left and right; put the foot on the toe, tense the leg muscles up to the buttock (at least 5 repetitions); put the foot on the heel, tense the leg muscles up to the buttock (at least 5 repetitions).

Number of repetitions 25-30, breaks 2-3 sec.

The first and second repetitions are separated by a 15-minute break: the patient can read a book, engage in conversation and any other calm activity that excludes interaction with the screen of a laptop, phone, tablet or computer). Modules 2 and 3 can be repeated 2-4 times depending on the patient's condition and capabilities.

Third module (work with lower limbs): (playful movements with a ball or balloon)

Clinical example 1.

Patient G.V., 42 years old. Diagnosis: bone fragmentation and partial severance of the bone of the right hand as a result of a mine-explosive wound, amputation. Phantom pains appeared 3 weeks after the limb amputation surgery.

During the first session, anamnesis was collected and an assessment of the intensity, quantitative and qualitative characteristics of phantom pain was carried out using adapted versions of the NDI questionnaire and the short form of the McGill Pain Questionnaire. The survey revealed that the pain was very pronounced. On average, there was a constant burning pain with an intensity of 5 points out of 10, in bad weather it reached 7. Additional sensations: tingling, burning, itching (at each subsequent session, the patient's symptoms were clarified and a survey was conducted on the presence/absence of changes). After collecting the anamnesis, the patient was familiarized with the essence of the technique and the main mechanisms of phantom pain.

The patient was then asked to sit at a table with pre-installed equipment (a 0.4×0.9 m mirror is installed perpendicular to the work surface, the size of the mirror allows the patient to see the healthy arm (from the shoulder to the fingertips), an Acer Aspire laptop with a screen resolution of 1920×1080 and an enabled front camera is installed so that the patient sees an image of two limbs on the screen: his healthy limb and its reflection in the mirror. The patient was then instructed that during the session he should look only at the screen, on the basis of which he should clearly form the illusion of the presence of both limbs.

Next, a series of three repeating procedures is carried out, each of which consisted of three modules: 1st module - sensory stimulation; 2nd module - motor stimulation; 3rd module - activation of tactile sensitivity or stimulation/practicing of object interaction.

In the first module, the healthy limb was exposed to alternately warm and cold air for 5-10 minutes, then tingling and stroking movements were performed for the same amount of time.

In the second module, the following exercises were used for the implementation of motor stimulation: “fist-edge-palm” praxis (palm clenched into a fist, palm edge on the table plane, palm straightened on the table plane), “fist-victory-ring” (palm clenched into a fist; palm with fingers 1, 4 and 5 connected, and 2 and 3 straightened; palm with fingers 1 and 2 connected, and 3, 4 and 5 straightened), “gun-goat” (1 finger straightened and abducted, 2 and 3 straightened and connected, 4 and 5 bent; fingers 1, 3 and 4 bent, 2 and 5 straightened). Each of the exercises was repeated 21 times.

The third module involved activating tactile sensitivity by recognizing sensations from touching test objects/feeling test objects for recognition (smooth stone, pen, paper, etc., the set of objects could change from session to session). The patient was asked to identify tactile sensations with his eyes closed.

Between modules the patient was given time to rest (5-10 minutes).

A total of 3 sessions were performed (including all the above blocks) with a break of 1 and 3 days. As a result of the first session, the intensity of pain decreased sharply, it appeared episodically during the day, but caused almost no discomfort while maintaining phantom sensations such as scratching and itching.

After the second session, positive dynamics were observed: phantom sensations arose rarely and were not intense, the pain disappeared. The third session was the final one, as phantom pain and sensations completely disappeared.

Clinical example 2.

Patient A.P., 27 years old. Diagnosis: mine blast wound, amputation of the left lower limb.

The first session consisted of collecting anamnesis and assessing the intensity, quantitative and qualitative characteristics of phantom pain using adapted versions of the NDI questionnaire and the short form of the McGill Pain Questionnaire. As a result of the survey, intense pain of various natures was identified:

pulsating (10 intensity, 9 frequency of occurrence),

shooting (10 intensity, 4 frequency, until loss of consciousness),

stabbing (10 intensity, 9 frequency, the patient described it as follows: “As if in a vice, in a meat grinder”),

convulsions (10 intensity, 5 frequency),

burning sensation (the patient described it as follows: “It burns like in a stove”, 10 intensity, 10 frequency of occurrence),

pain resembling an electric shock.

The localization of pain was observed mainly in the big toe, heel and little finger. There were also phantom sensations in the form of itching and numbness. The pain led to insomnia and nervousness.

After collecting the anamnesis, the patient was introduced to the essence of the technique and the main mechanisms of occurrence of phantom pain.

Next, the patient was asked to sit on a chair next to the installed equipment. A 0.9×0.4 m mirror was installed perpendicular to the work surface; the size of the mirror allowed the patient to see the healthy leg completely (from the pelvis to the tips of the toes). An Acer.Aspire laptop with a screen resolution of 1920×1080 and an enabled front camera was installed so that the patient could see his healthy limb on the laptop screen and its reflection in the mirror.

After collecting the anamnesis and conducting the survey, the essence of the method and his actions during its implementation were explained to the patient: based on the perceived image, the patient had to clearly form an association where the leg in the mirror reflection is intact, and the leg visible in the image (and actually intact) is his amputated limb. It was also emphasized that throughout the therapy the patient should look at the computer screen to create the illusion that he has both legs capable of moving synchronously.

Next, a method was implemented that included a procedure repeated 3 times, consisting of three modules (sensory, motor and tactile).

Sensory stimulation included exposure of the healthy limb to alternately warm and cold air for 5-10 minutes, followed by tingling and stroking movements carried out for the same amount of time (to compensate for the deficit of extraceptive information).

Motor stimulation included performing a set of exercises: alternately raising the toes (30 repetitions); pressing the heel to the floor and turning the toe left and right (30 repetitions); pressing the toe to the floor and turning the heel left and right (30 repetitions); raising the leg onto the toe and tensing the leg muscle all the way to the buttock (10 repetitions); placing the foot on the heel and tensing the leg muscle all the way to the buttock (10 repetitions). With a rest of 2-3 seconds between approaches.

Activation of tactile sensitivity was realized by manipulations with a ball or a balloon. The patient was asked to roll the ball with the intact leg, play with it, etc.

Six sessions were conducted, during the first session there were painful and phantom sensations, including "pleasant tingling" (according to the patient). There were also phantom sensations of muscle activation, the "walking" effect, etc. The patient noted that the pain was relieved. After the second session, there was sometimes shooting pain at 7, the pain in the big toe disappeared, the nature of the pain changed from constant to wave-like. By the end of the exercises, the pain intensity decreased by 3.

The third session, 3 days after the second, was marked by a decrease in effectiveness (intense pain (9) arose, described by the patient as "like in a vice"). During the exercises, spasms and stabbing pain in the heel, little finger and foot were observed (8-9 points). At the end of the session, the intensity of the pain decreased.

The fourth session was characterized by an increase in the intensity of pain. The changes were in the nature of the pain and its localization: wave-like intense pain (10 out of 10), spreading throughout the entire leg (i.e. not localized in the little toe, heel as it was before).

During the fifth session, the patient noted the absence of pain and phantom sensations at rest, the occurrence of a buzzing and tingling sensation when exposed to air flow from a hair dryer. As a result of the sessions, the pain became rare and much less intense (3-4 points out of 10). Sleep also returned to normal.

During the final session, pain appeared only during moments of sensory and tactile stimulation.

Claims (5)

1. A method for rehabilitating a patient with phantom limb pain using mirror therapy, including the formation in the patient's field of vision of a direct image and an image reflected in a flat mirror of a functioning limb with the isolation of the image of a non-functioning limb and the implementation of rehabilitation measures, characterized in that the direct and mirror images of the functioning limb are formed on a computer monitor screen by filming a scene with a video camera containing a direct image of the limb and its reflection in a flat mirror to obtain a video image of a pair of limbs, wherein the patient continuously watches the obtained video image of the pair of limbs on the computer monitor screen to create the illusion that the patient has both limbs capable of moving synchronously, then rehabilitation measures are carried out for the therapy of phantom pain, including three successive stages: sensory stimulation, motor stimulation and activation of tactile sensitivity by recognizing sensations from touching with test objects. 2. The method according to paragraph 1, characterized in that the computer is a laptop equipped with a front video camera. 3. The method according to claim 1, characterized in that the sensory stimulation of the limb includes exposure to alternately warm and cold air followed by tingling and stroking movements. 4. The method according to item 1, characterized in that the motor stimulation of the upper limb includes a set of exercises for dynamic and postural praxis fist - edge - palm. 5. The method according to item 1, characterized in that the motor stimulation of the lower limb includes a set of exercises for alternately raising the toes, alternately raising the toe and heel, turning the toe left and right with the heel pressed to the floor, turning the heel left and right with the toe pressed to the floor, exercises for static tension and manipulation with the ball.