Tonya L. Rich

Background: Phantom limb pain is challenging for clinicians and researchers to measure accurately. Objective(s): The objective of this study was to use focus groups to inform phantom limb pain assessment through exploring first-hand experiences of individuals with lower limb amputation. Study Design: Focus groups were conducted virtually with individuals with lower limb amputation and phantom limb pain across the United States. Methods: Sessions were recorded and transcribed, and qualitative data were analyzed using thematic analysis. Results: Participants (n=13, 54% women, mean age: 61) were involved in one of four focus groups. Six themes were identified that inform measurement strategies for phantom limb pain: 1) phantom limb pain is a moving target, 2) phantom limb pain disrupts my life, 3) I make choices and trade-offs because of phantom limb pain, 4) phantom limb pain makes me feel isolated and unsure, 5) waiting out the storm, and 6) I cope with phantom limb pain by pushing forward and holding hope. Descriptions of phantom limb pain varied between participants and from episode to episode. Conclusions: The heterogeneity of phantom limb pain presentation, intensity, frequency, duration, and interference in daily life suggests comprehensive assessment with traditional pain measures can be challenging. Clinicians and patients would benefit from measurement strategies developed specifically for people with limb amputation that can accurately describe and differentiate pain experiences. Accurate measurement of pain, specifically phantom limb pain, will facilitate development and testing of patient-specific treatments to reduce the impact of pain on the day-to-day life of people with limb amputation.

Pain management is a focus of rehabilitation for Veterans after amputation, and occupational therapy practitioners play a key role in providing this care as part of an interdisciplinary team. However, the evaluation and treatment of phantom limb pain (PLP) after amputation lack guidance with respect to best practices. There is a need for improved identification of factors that contribute to PLP so that treatment targets can be identified. In this column, we discuss the application of the biopsychosocial model to the clinical management of PLP as part of comprehensive care for Veterans after amputation. We present factors associated with PLP, categorized using the biopsychosocial model, and discuss specific considerations for Veterans. We also provide recommendations for the biopsychosocial evaluation of PLP in occupational therapy practice, and we highlight the value of involving occupational therapists in interdisciplinary health care teams. Furthermore, we recommend continued evaluation and discussion to monitor changes in PLP and its associated factors over time.

Importance: Postamputation pain remains a barrier to return to function. Occupational therapy practitioners often include pain neuroscience education (PNE) to support occupational engagement and health literacy. Objective: To assess perspectives about PNE for postamputation pain. Design: We conducted cognitive interviews in which participants viewed PNE videos that are part of a novel graded motor imagery (GMI) mobile application for pain treatment. The videos were designed to prepare for an occupation-based rehabilitation approach. All interviews were recorded, transcribed, and analyzed using rapid-turnaround methods. Setting: Health care institution, telehealth format. Participants: Eleven Veterans (10 males and 1 female), ages 40–75 yr, with unilateral transtibial amputation ≥1 yr, and with moderate or severe phantom limb pain, completed the study. Intervention: We developed amputation-specific PNE in the form of five recorded videos with images and minimal printed words: (1) First Steps Toward Pain Treatment, (2) Why GMI?, (3) Postamputation Pain Education, (4) Toolbox of Strategies, and (5) Your Nervous System. Outcomes and Measures: Cognitive interviews to measure the Veterans’ perceptions of the educational content. Results: Three themes were identified: (1) Veterans are willing to try GMI but have mixed opinions on whether it is worth the effort; (2) information about postamputation pain is comforting, but perceptions of when best to receive that information differ; and (3) the educational content is understandable and relatable with respect to lived experience. Conclusions and Relevance: PNE provides a shared understanding and can be a promising tool for occupational therapy practitioners to help Veterans manage pain. Plain-Language Summary: This study was done to test a new way of teaching Veterans with phantom limb pain following a below knee amputation. The study used videos that explained pain using mostly pictures that were part of a mobile application for pain treatment. Most Veterans in this study said they were willing to try new treatments. They found the information to be understandable and aligned with their experience of living with pain. This approach to education prepares occupational therapy clients to more actively participate in occupation-based pain treatment.

Background: Nonpharmacologic interventions are important for treating knee pain due to osteoarthritis or after total knee arthroplasty (TKA), and extended reality (XR) technology may enhance treatments for these indications. Objective: This systematic review aimed to evaluate XR interventions for pain due to knee osteoarthritis (KOA) or for recovery after TKA. Methods: Databases were searched through May 2023 and updated in December 2025. Eligible trials evaluated XR interventions to treat KOA pain or after TKA. We classified interventions by depth of immersion and clinical mechanism. We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria to determine the certainty of evidence for prioritized outcomes. Meta-analyses were performed when ≥3 studies evaluated similar comparisons, outcomes, and time points. Results: Eligible trials addressed KOA (k=12) or recovery after TKA (k=9). Sample sizes ranged from 36 to 306 participants, and most studies had a follow-up of ≤3 months. Nineteen studies assessed pain-related functioning and pain intensity, and 5 assessed adverse events (AEs). For KOA, 10 studies examined interactive digital rehabilitation (IDR), and 2 examined virtual reality (VR)–digitally augmented exercise (DAE). IDR for KOA may result in better pain-related functioning (low certainty of evidence [COE]; pooled standardized mean difference [SMD] −0.59, 95% CI −1.11 to −0.06; prediction interval [PI] −1.72 to 0.55; k=5) and lower pain intensity at 6‐8 weeks (low COE; pooled SMD −0.46, 95% CI −0.92 to 0.00; PI −1.39 to 0.47; k=4). VR-DAE for KOA (k=2) produced inconsistent results (very low COE). For post-TKA studies, 5 examined IDR, 2 examined VR-DAE, 1 examined VR-distraction, and 1 examined VR-psychoeducation. Post-TKA IDR may result in better pain-related functioning (low [k=4] and moderate COE [k=1]) but little to no difference in pain intensity (low-moderate COE; pooled SMD at 3‐4 months −0.12, 95% CI −0.75 to 0.52; PI –1.63 to 1.27; k=3). VR-psychoeducation probably results in lower pain at 4 weeks (moderate COE; k=1), and VR-distraction may result in 6 months (low COE; k=1), whereas VR-DAE produced mixed findings (k=2; very low COE). IDR was not associated with AEs, and VR may not be associated with AEs for KOA (high and low COE), though AE reporting was uncommon (k=5) and evidence was very uncertain for post-TKA. Conclusions: IDR may augment treatment for KOA and post-TKA recovery, and VR may benefit post-TKA rehabilitation. This review is the first to stratify by level of immersion, clinical mechanism, and follow-up duration and to systematically evaluate AEs. IDR may be ready for integration into KOA care, while use after TKA needs more evidence. Randomized controlled trials with implementation outcomes could determine how XR interventions can be used for KOA, whereas trials evaluating efficacy and AEs are needed before their use for post-TKA.

BACKGROUND Non-pharmacologic interventions are important for treating knee pain due to osteoarthritis (OA) or after total knee arthroplasty (TKA). Extended reality (XR) technology may enhance the efficacy of non-pharmacologic treatments including rehabilitation for these indications, but a review of current evidence is needed to evaluate benefits and harms of XR-based interventions. OBJECTIVE We conducted a systematic review to assess benefits and harms of XR interventions for pain due to knee OA or recovery after TKA. METHODS We searched MEDLINE, Embase, CINHAL, PsycINFO, and Scopus databases from inception to May 2023. Eligible studies included randomized controlled trials (RCTs) that evaluated XR interventions to treat pain due to knee OA or after TKA and reported at least one eligible outcome (eg, pain-related functioning or interference, pain intensity, or adverse events). Risk of bias (RoB) was assessed using the Cochrane RoB 2 tool. Data were abstracted by one reviewer and verified by a second. We classified interventions as either virtual reality (VR, fully immersive) or augmented reality (AR, partially immersive). We used GRADE criteria to determine certainty of evidence (COE) for prioritized outcomes. RESULTS We identified eligible RCTs addressing pain due to knee OA (k=5) or recovery after TKA (k=7). All studies were rated some concerns (k=6) or high (k=6) RoB. Sample sizes ranged from 52-306 participants and most (k=8) had a follow-up of ≤3 months. Guiding and engaging physical activity was the primary mechanism of interventions in 11 of the studies and 1 study utilized distraction only. Ten studies assessed pain-related functioning and 11 assessed pain intensity or severity. Two assessed adverse events. In the knee OA group 1 study examined VR and 4 examined AR. Compared with conventional therapy, VR physical activity may result in better pain-related functioning and greater decreases in pain intensity (low COE); evidence is very uncertain on the effects of AR physical activity on pain-related functioning, pain intensity, and adverse events (very low COE). For post-TKA, 2 studies examined VR and 5 examined AR. Compared with standard rehabilitation, AR physical activity may result in better pain-related functioning (low COE), but evidence is very uncertain on its effects on pain intensity and adverse events. The evidence is very uncertain on the effects of VR physical activity on pain-related functioning and pain intensity. CONCLUSIONS Trials commonly evaluated XR interventions facilitating physical activity, and most often compared XR to standard, non-XR exercise or rehabilitation. Evidence on benefits and harms of XR interventions to treat pain in knee OA and post-TKA is limited due to methodological concerns, small study size, and lack of reporting on adverse events. Larger high-quality RCTs with longer follow-up are needed to improve understanding of benefits and harms of XR interventions in knee OA or post-TKA. CLINICALTRIAL PROSPERO registration number CRD42023439903

Individuals with chronic conditions have long-term needs which can be addressed by maintenance rehabilitation. The 2013 Jimmo v Sebelius settlement in the United States (US) clarified the Medicare coverage of maintenance rehabilitation as a skilled service, even when no improvement is expected. A scoping review was conducted to describe maintenance rehabilitation. A systematic search was performed across 9 databases. Maintenance rehabilitation was defined as services (e.g. occupational, physical, or speech language therapies), intended to maintain a person's condition and prevent decline. Studies focused on medical, or non-rehabilitative, interventions (e.g. opioid cessation or chemotherapy) were excluded. Of the 734 abstracts reviewed, 90 met inclusion criteria. Two reviewers extracted data and used descriptive statistics. An exploratory thematic analysis in a convenience sample contextualized the works. Most works (90%) were peer-reviewed publications. The works represented 12,638 individuals, with predominant populations being cardiac (4,122 individuals) and pulmonary (2,324 individuals). Physical activity interventions were identified most frequently (87%). Outcome measures primarily focused on activities (49%) or body systems (42%). Thematic analysis suggests maintenance rehabilitation may support domains contributing to quality of life. While evidence exists for maintenance therapy, future research on intervention design will guide implementation by health systems.

People experience a range of pain and sensation following major limb amputation. These amputation-related experiences are often described as: residual limb pain (i.e., pain felt in the remaining li...

Phantom limb pain (PLP) is treated with medications and non-drug treatments. Best clinical practices for measuring treatment outcomes have not been defined. The objective of this study was to evaluate the internal consistency of patient-reported outcomes measures (PROMs) in a sample of Veterans with lower limb amputation. The Veteran phone survey included administering PROMs [1) PLP numeric rating scale (NRS), 2) general pain NRS, 3) Pain, Enjoyment, and General Activity (PEG) scale, 4) Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference Short Form 6b Replacement, 5) PROMIS Short Form Depression 4a and 6) PROMIS Short Form Anxiety 4a]. Fifty Veterans (48 male, 2 female; average age: 66 years) completed PROMs. In our sample, 40 Veterans (80%) experienced PLP with an average PLP NRS of 5 (±3.4). Internal consistency of each measure was good to excellent based on Cronbach's alpha co-efficient of >0.80. Correlations were moderate between PLP NRS and all other measures (≤0.32). Although many Veterans expressed bothersome PLP, the scores reflecting pain interference and impact on function were lower than pain intensity. Consistent use of outcome measures is needed to determine the effect of interventions for amputation-related pain.

This project explored the selection process of commercially available virtual reality (VR) games for traumatic brain injury rehabilitation. Occupational therapy practitioners (OTPs) developed a classification framework that they used to evaluate VR games. The classification framework focused on movements required to effectively play the game, cognitive demand, position for game play, ease in menu navigation, and perceived therapeutic applications. OTPs used the ratings to aid in game selection and identified relevant game examples that allowed customizable settings and basic navigation with a game focus on functional activities. The OTPs and the research team identified the need for further work on accessibility and adaptability of game features (e.g., difficulty and limb usage) allowing for more individualization to optimize outcomes of VR-enhanced rehabilitation. The classification framework was useful in evaluating the potential therapeutic benefit of commercially available VR games. However, trial of the game by clinicians prior to use was still warranted.

Objective: Three-phase graded motor imagery (limb laterality, explicit motor imagery, and mirror therapy) has been successful in chronic pain populations. However, when applied to phantom limb pain, an amputation-related pain, investigations often use mirror therapy alone. We aimed to explore evidence for graded motor imagery and its phases to treat phantom limb pain. Data Sources: A scoping review was conducted following the JBI Manual of Synthesis and Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews. Thirteen databases, registers, and websites were searched. Review Methods: Published works on any date prior to the search (August 2023) were included that involved one or more graded motor imagery phases for participants ages 18+ with amputation and phantom limb pain. Extracted data included study characteristics, participant demographics, treatment characteristics, and outcomes. Results: Sixty-one works were included representing 19 countries. Most were uncontrolled studies (31%). Many participants were male (75%) and had unilateral amputations (90%) of varying levels, causes, and duration. Most works examined one treatment phase (92%), most often mirror therapy (84%). Few works (3%) reported three-phase intervention. Dosing was inconsistent across studies. The most measured outcome was pain intensity (95%). Conclusion: Despite the success of three-phase graded motor imagery in other pain populations, phantom limb pain research focuses on mirror therapy, largely ignoring other phases. Participant demographics varied, making comparisons difficult. Future work should evaluate graded motor imagery effects and indicators of patient success. The represented countries indicate that graded motor imagery phases are implemented internationally, so future work could have a widespread impact.