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Brain Advance Access originally published online on June 20, 2008
Brain 2008 131(8):2181-2191; doi:10.1093/brain/awn124
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© 2008 The Author(s)
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/2.0/uk/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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

K. MacIver1, D. M. Lloyd2, S. Kelly1, N. Roberts3 and T. Nurmikko1

1Pain Research Institute, Unit of Neuroscience, School of Clinical Sciences, Lower Lane, Liverpool, L9 7AL, 2School of Psychological Sciences, Zochonis Building, The University of Manchester, Brunswick Street, Manchester, M13 9PL and 3Magnetic Resonance and Image Analysis Research Centre (MARIARC), University of Liverpool, 2 Abercromby Square, Liverpool, L69 3BX, UK

Correspondence to: Kate MacIver, Pain Research Institute, Unit of Neuroscience, School of Clinical Sciences, Lower Lane, Liverpool, L9 7AL, UK E-mail: kmaciver{at}liverpool.ac.uk

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.

Key Words: functional magnetic resonance imaging; phantom limb pain; mental imagery; cortical reorganization

Abbreviations: PLP, phantom limb pain; NRS, Numerical rating scale; BOLD, blood oxygenation level-dependent; ACC, anterior cingulate cortex; SMA, supplementary motor area

Received January 16, 2008. Revised May 14, 2008. Accepted May 16, 2008.


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