Phantom limb pain, cortical reorganization and the therapeutic effect of mental imagery

K MacIver, D M Lloyd, S Kelly, N Roberts, T Nurmikko, K MacIver, D M Lloyd, S Kelly, N Roberts, T Nurmikko

Abstract

Using functional MRI (fMRI) we investigated 13 upper limb amputees with phantom limb pain (PLP) during hand and lip movement, before and after intensive 6-week training in mental imagery. Prior to training, activation elicited during lip purse showed evidence of cortical reorganization of motor (M1) and somatosensory (S1) cortices, expanding from lip area to hand area, which correlated with pain scores. In addition, during imagined movement of the phantom hand, and executed movement of the intact hand, group maps demonstrated activation not only in bilateral M1 and S1 hand area, but also lip area, showing a two-way process of reorganization. In healthy participants, activation during lip purse and imagined and executed movement of the non-dominant hand was confined to the respective cortical representation areas only. Following training, patients reported a significant reduction in intensity and unpleasantness of constant pain and exacerbations, with a corresponding elimination of cortical reorganization. Post hoc analyses showed that intensity of constant pain, but not exacerbations, correlated with reduction in cortical reorganization. The results of this study add to our current understanding of the pathophysiology of PLP, underlining the reversibility of neuroplastic changes in this patient population while offering a novel, simple method of pain relief.

Figures

Fig. 1
Fig. 1
Scores of constant pain intensity and unpleasantness before and after training, measured by daily pain diaries using numerical rating scores. Reduction in pain intensity was significant (P < 0.0005), as was reduction in pain unpleasantness (P < 0.01).
Fig. 2
Fig. 2
Changes in daily exacerbations of pain—intensity and unpleasantness of pain, using numerical rating scores. Reduction of intensity of exacerbations was significant (P < 0.005) as was the reduction in unpleasantness of exacerbations (P < 0.03).
Fig. 3
Fig. 3
Activations in response to lip purse: patients before and after training: yellow circles indicate M1/S1 lip area. Activation in hand area M1/S1 is shown in axial view (inset). At follow-up activation is less diffuse and more confined to lip area. There is no activation in hand area M1/S1 (inset: shown in axial view). Healthy volunteers show activation in M1 lip area only.
Fig. 4
Fig. 4
Strong bilateral activation in response to left executed hand movement and right imagined hand movement seen in patients as opposed to healthy volunteers.
Fig. 5
Fig. 5
Lip purse: paired t-test of lip purse activations before and after training with pain scores added as covariates. Left map: illustration of activation remaining when follow-up lip purse is subtracted from baseline lip purse, with reduction in contemporaneous pain added as a covariate. Activation remains in right M1 hand area (ipsilateral to amputated side) and left ACC. Right map: illustration of activation remaining when follow-up lip purse is subtracted from baseline lip purse, with reduction in constant pain added as a covariate. Activation remains in bilateral M1 hand/arm area, supplementary motor area (SMA), ipsilateral SI and secondary somatosensory cortex (SII).

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