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Yang H, Yanagisawa T. Is Phantom Limb Awareness Necessary for the Treatment of Phantom Limb Pain? Neurol Med Chir (Tokyo) 2024; 64:101-107. [PMID: 38267056 PMCID: PMC10992984 DOI: 10.2176/jns-nmc.2023-0206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 10/31/2023] [Indexed: 01/26/2024] Open
Abstract
Phantom limb pain is attributed to abnormal sensorimotor cortical representations. Various feedback treatments have been applied to induce the reorganization of the sensorimotor cortical representations to reduce pain. We developed a training protocol using a brain-computer interface (BCI) to induce plastic changes in the sensorimotor cortical representation of phantom hand movements and demonstrated that BCI training effectively reduces phantom limb pain. By comparing the induced cortical representation and pain, the mechanisms worsening the pain have been attributed to the residual phantom hand representation. Based on our data obtained using neurofeedback training without explicit phantom hand movements and hand-like visual feedback, we suggest a direct relationship between cortical representation and pain. In this review, we summarize the results of our BCI training protocol and discuss the relationship between cortical representation and phantom limb pain. We propose a treatment for phantom limb pain based on real-time neuroimaging to induce appropriate cortical reorganization by monitoring cortical activities.
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Affiliation(s)
- Huixiang Yang
- Institute for Advanced Co-creation Studies, Osaka University
| | - Takufumi Yanagisawa
- Institute for Advanced Co-creation Studies, Osaka University
- Department of Neurosurgery, Graduate School of Medicine, Osaka University
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2
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Sparling T, Iyer L, Pasquina P, Petrus E. Cortical Reorganization after Limb Loss: Bridging the Gap between Basic Science and Clinical Recovery. J Neurosci 2024; 44:e1051232024. [PMID: 38171645 PMCID: PMC10851691 DOI: 10.1523/jneurosci.1051-23.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/28/2023] [Accepted: 09/29/2023] [Indexed: 01/05/2024] Open
Abstract
Despite the increasing incidence and prevalence of amputation across the globe, individuals with acquired limb loss continue to struggle with functional recovery and chronic pain. A more complete understanding of the motor and sensory remodeling of the peripheral and central nervous system that occurs postamputation may help advance clinical interventions to improve the quality of life for individuals with acquired limb loss. The purpose of this article is to first provide background clinical context on individuals with acquired limb loss and then to provide a comprehensive review of the known motor and sensory neural adaptations from both animal models and human clinical trials. Finally, the article bridges the gap between basic science researchers and clinicians that treat individuals with limb loss by explaining how current clinical treatments may restore function and modulate phantom limb pain using the underlying neural adaptations described above. This review should encourage the further development of novel treatments with known neurological targets to improve the recovery of individuals postamputation.Significance Statement In the United States, 1.6 million people live with limb loss; this number is expected to more than double by 2050. Improved surgical procedures enhance recovery, and new prosthetics and neural interfaces can replace missing limbs with those that communicate bidirectionally with the brain. These advances have been fairly successful, but still most patients experience persistent problems like phantom limb pain, and others discontinue prostheses instead of learning to use them daily. These problematic patient outcomes may be due in part to the lack of consensus among basic and clinical researchers regarding the plasticity mechanisms that occur in the brain after amputation injuries. Here we review results from clinical and animal model studies to bridge this clinical-basic science gap.
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Affiliation(s)
- Tawnee Sparling
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814
| | - Laxmi Iyer
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland 20817
| | - Paul Pasquina
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814
| | - Emily Petrus
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland 20814
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3
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Schone HR, Maimon Mor RO, Kollamkulam M, Gerrand C, Woollard A, Kang NV, Baker CI, Makin TR. Stable Cortical Body Maps Before and After Arm Amputation. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.12.13.571314. [PMID: 38168448 PMCID: PMC10760201 DOI: 10.1101/2023.12.13.571314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Neuroscientists have long debated the adult brain's capacity to reorganize itself in response to injury. A driving model for studying plasticity has been limb amputation. For decades, it was believed that amputation triggers large-scale reorganization of cortical body resources. However, these studies have relied on cross-sectional observations post-amputation, without directly tracking neural changes. Here, we longitudinally followed adult patients with planned arm amputations and measured hand and face representations, before and after amputation. By interrogating the representational structure elicited from movements of the hand (pre-amputation) and phantom hand (post-amputation), we demonstrate that hand representation is unaltered. Further, we observed no evidence for lower face (lip) reorganization into the deprived hand region. Collectively, our findings provide direct and decisive evidence that amputation does not trigger large-scale cortical reorganization.
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Affiliation(s)
- Hunter R. Schone
- Institute of Cognitive Neuroscience, University College London, London, UK
- Laboratory of Brain & Cognition, National Institutes of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
| | - Roni O. Maimon Mor
- Institute of Cognitive Neuroscience, University College London, London, UK
- Department of Experimental Psychology, University College London, London, UK
- UCL Institute of Ophthalmology, University College London, London, UK
| | - Mathew Kollamkulam
- Institute of Cognitive Neuroscience, University College London, London, UK
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Craig Gerrand
- Department of Orthopaedic Oncology, Royal National Orthopaedic Hospital NHS Trust, Stanmore, Middlesex, UK
| | | | - Norbert V. Kang
- Plastic Surgery Department, Royal Free Hospital NHS Trust, London, UK
| | - Chris I. Baker
- Laboratory of Brain & Cognition, National Institutes of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Tamar R. Makin
- Institute of Cognitive Neuroscience, University College London, London, UK
- Wellcome Centre for Human Neuroimaging, UCL Institute of Neurology, London, UK
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
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4
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Weiss T, Koehler H, Croy I. Pain and Reorganization after Amputation: Is Interoceptive Prediction a Key? Neuroscientist 2023; 29:665-675. [PMID: 35950521 PMCID: PMC10623598 DOI: 10.1177/10738584221112591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There is an ongoing discussion on the relevance of brain reorganization following amputation for phantom limb pain. Recent attempts to provide explanations for seemingly controversial findings-specifically, maladaptive plasticity versus persistent functional representation as a complementary process-acknowledged that reorganization in the primary somatosensory cortex is not sufficient to explain phantom limb pain satisfactorily. Here we provide theoretical considerations that might help integrate the data reviewed and suppose a possible additional driver of the development of phantom limb pain-namely, an error in interoceptive predictions to somatosensory sensations and movements of the missing limb. Finally, we derive empirically testable consequences based on our considerations to guide future research.
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Affiliation(s)
- Thomas Weiss
- Department of Psychology, Clinical Psychology, Friedrich Schiller University Jena, Jena, Germany
| | - Hanna Koehler
- Department of Psychology, Clinical Psychology, Friedrich Schiller University Jena, Jena, Germany
- Biomagnetic Center, Jena University Hospital, Jena, Germany
| | - Ilona Croy
- Department of Psychology, Clinical Psychology, Friedrich Schiller University Jena, Jena, Germany
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5
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Limakatso K, Cashin AG, Williams S, Devonshire J, Parker R, McAuley JH. The Efficacy of Graded Motor Imagery and Its Components on Phantom Limb Pain and Disability: A Systematic Review and Meta-Analysis. Can J Pain 2023; 7:2188899. [PMID: 37214633 PMCID: PMC10193907 DOI: 10.1080/24740527.2023.2188899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/28/2023] [Accepted: 03/06/2023] [Indexed: 03/17/2023]
Abstract
Introduction Graded Motor Imagery (GMI) is a non-invasive and inexpensive therapy used to treat Phantom Limb Pain (PLP) by sequentially activating motor networks in such a way that movement and pain are unpaired. The objective of this systematic review was to critically appraise relevant data on the efficacy of GMI and its components for reducing PLP and disability in amputees. Methods We searched 11 electronic databases for controlled trials investigating GMI and its components in amputees with PLP from inception until February 2023. Two reviewers independently screened studies and extracted relevant data. Study-level data were entered using the inverse variance function of the Review Manager 5 and pooled with the random effects model. Results Eleven studies with varying risk of bias were eligible. No eligible study considered left/right judgement tasks in isolation. Studies showed no effect for imagined movements, but positive effects were seen for GMI [weighted mean difference: -21.29 (95%CI: -31.55, -11.02), I2= 0%] and mirror therapy [weighted mean difference: -8.55 (95%CI: -14.74, -2.35, I2= 61%]. A comparison of mirror therapy versus sham showed no difference [weighted mean difference: -4.43 (95%CI: -16.03, 7.16), I2= 51%]. Conclusion Our findings suggest that GMI and mirror therapy may be effective for reducing PLP. However, this conclusion was drawn from a limited body of evidence, and the certainty of the evidence was very low. Therefore, rigorous, high-quality trials are needed to address the gap in the literature and inform practice.
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Affiliation(s)
- Katleho Limakatso
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia (NeuRA), Sydney, Australia
| | - Aidan G. Cashin
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia (NeuRA), Sydney, Australia
| | - Sam Williams
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia (NeuRA), Sydney, Australia
| | - Jack Devonshire
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia (NeuRA), Sydney, Australia
| | - Romy Parker
- Pain Management Unit, Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - James H. McAuley
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia (NeuRA), Sydney, Australia
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Root V, Muret D, Arribas M, Amoruso E, Thornton J, Tarall-Jozwiak A, Tracey I, Makin TR. Complex pattern of facial remapping in somatosensory cortex following congenital but not acquired hand loss. eLife 2022; 11:76158. [PMID: 36583538 PMCID: PMC9851617 DOI: 10.7554/elife.76158] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/29/2022] [Indexed: 12/31/2022] Open
Abstract
Cortical remapping after hand loss in the primary somatosensory cortex (S1) is thought to be predominantly dictated by cortical proximity, with adjacent body parts remapping into the deprived area. Traditionally, this remapping has been characterised by changes in the lip representation, which is assumed to be the immediate neighbour of the hand based on electrophysiological research in non-human primates. However, the orientation of facial somatotopy in humans is debated, with contrasting work reporting both an inverted and upright topography. We aimed to fill this gap in the S1 homunculus by investigating the topographic organisation of the face. Using both univariate and multivariate approaches we examined the extent of face-to-hand remapping in individuals with a congenital and acquired missing hand (hereafter one-handers and amputees, respectively), relative to two-handed controls. Participants were asked to move different facial parts (forehead, nose, lips, tongue) during functional MRI (fMRI) scanning. We first confirmed an upright face organisation in all three groups, with the upper-face and not the lips bordering the hand area. We further found little evidence for remapping of both forehead and lips in amputees, with no significant relationship to the chronicity of their phantom limb pain (PLP). In contrast, we found converging evidence for a complex pattern of face remapping in congenital one-handers across multiple facial parts, where relative to controls, the location of the cortical neighbour - the forehead - is shown to shift away from the deprived hand area, which is subsequently more activated by the lips and the tongue. Together, our findings demonstrate that the face representation in humans is highly plastic, but that this plasticity is restricted by the developmental stage of input deprivation, rather than cortical proximity.
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Affiliation(s)
- Victoria Root
- WIN Centre, University of OxfordOxfordUnited Kingdom
- Institute of Cognitive Neuroscience, University College LondonLondonUnited Kingdom
- Medical Research Council Cognition and Brain Sciences Unit (CBU), University of CambridgeCambridgeUnited Kingdom
| | - Dollyane Muret
- Institute of Cognitive Neuroscience, University College LondonLondonUnited Kingdom
| | - Maite Arribas
- Institute of Cognitive Neuroscience, University College LondonLondonUnited Kingdom
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College LondonLondonUnited Kingdom
| | - Elena Amoruso
- Institute of Cognitive Neuroscience, University College LondonLondonUnited Kingdom
- Medical Research Council Cognition and Brain Sciences Unit (CBU), University of CambridgeCambridgeUnited Kingdom
| | - John Thornton
- Wellcome Trust Centre for Neuroimaging, University College LondonLondonUnited Kingdom
| | | | - Irene Tracey
- WIN Centre, University of OxfordOxfordUnited Kingdom
| | - Tamar R Makin
- Institute of Cognitive Neuroscience, University College LondonLondonUnited Kingdom
- Medical Research Council Cognition and Brain Sciences Unit (CBU), University of CambridgeCambridgeUnited Kingdom
- Wellcome Trust Centre for Neuroimaging, University College LondonLondonUnited Kingdom
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7
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Vittersø AD, Halicka M, Buckingham G, Proulx MJ, Bultitude JH. The sensorimotor theory of pathological pain revisited. Neurosci Biobehav Rev 2022; 139:104735. [PMID: 35705110 DOI: 10.1016/j.neubiorev.2022.104735] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/13/2022] [Accepted: 06/07/2022] [Indexed: 01/31/2023]
Abstract
Harris (1999) proposed that pain can arise in the absence of tissue damage because changes in the cortical representation of the painful body part lead to incongruences between motor intention and sensory feedback. This idea, subsequently termed the sensorimotor theory of pain, has formed the basis for novel treatments for pathological pain. Here we review the evidence that people with pathological pain have changes to processes contributing to sensorimotor function: motor function, sensory feedback, cognitive representations of the body and its surrounding space, multisensory processing, and sensorimotor integration. Changes to sensorimotor processing are most evident in the form of motor deficits, sensory changes, and body representations distortions, and for Complex Regional Pain Syndrome (CRPS), fibromyalgia, and low back pain. Many sensorimotor changes are related to cortical processing, pain, and other clinical characteristics. However, there is very limited evidence that changes in sensorimotor processing actually lead to pain. We therefore propose that the theory is more appropriate for understanding why pain persists rather than how it arises.
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Affiliation(s)
- Axel D Vittersø
- Centre for Pain Research, University of Bath, Bath, Somerset, United Kingdom; Department of Psychology, University of Bath, Bath, Somerset, United Kingdom; Department of Sport & Health Sciences, University of Exeter, Exeter, Devon, United Kingdom; Department of Psychology, Oslo New University College, Oslo, Norway.
| | - Monika Halicka
- Centre for Pain Research, University of Bath, Bath, Somerset, United Kingdom; Department of Psychology, University of Bath, Bath, Somerset, United Kingdom
| | - Gavin Buckingham
- Department of Sport & Health Sciences, University of Exeter, Exeter, Devon, United Kingdom
| | - Michael J Proulx
- Department of Psychology, University of Bath, Bath, Somerset, United Kingdom; Centre for Real and Virtual Environments Augmentation Labs, Department of Computer Science, University of Bath, Bath, Somerset, United Kingdom
| | - Janet H Bultitude
- Centre for Pain Research, University of Bath, Bath, Somerset, United Kingdom; Department of Psychology, University of Bath, Bath, Somerset, United Kingdom
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8
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Schone HR, Baker CI, Katz J, Nikolajsen L, Limakatso K, Flor H, Makin TR. Making sense of phantom limb pain. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2021-328428. [PMID: 35609964 PMCID: PMC9304093 DOI: 10.1136/jnnp-2021-328428] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/04/2022] [Indexed: 01/01/2023]
Abstract
Phantom limb pain (PLP) impacts the majority of individuals who undergo limb amputation. The PLP experience is highly heterogenous in its quality, intensity, frequency and severity. This heterogeneity, combined with the low prevalence of amputation in the general population, has made it difficult to accumulate reliable data on PLP. Consequently, we lack consensus on PLP mechanisms, as well as effective treatment options. However, the wealth of new PLP research, over the past decade, provides a unique opportunity to re-evaluate some of the core assumptions underlying what we know about PLP and the rationale behind PLP treatments. The goal of this review is to help generate consensus in the field on how best to research PLP, from phenomenology to treatment. We highlight conceptual and methodological challenges in studying PLP, which have hindered progress on the topic and spawned disagreement in the field, and offer potential solutions to overcome these challenges. Our hope is that a constructive evaluation of the foundational knowledge underlying PLP research practices will enable more informed decisions when testing the efficacy of existing interventions and will guide the development of the next generation of PLP treatments.
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Affiliation(s)
- Hunter R Schone
- NIMH, National Institutes of Health, Bethesda, Maryland, USA
- Institute of Cognitive Neuroscience, University College London, London, UK
| | - Chris I Baker
- NIMH, National Institutes of Health, Bethesda, Maryland, USA
| | - Joel Katz
- Department of Psychology, York University, Toronto, Ontario, Canada
- Transitional Pain Service, Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Lone Nikolajsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Katleho Limakatso
- Department of Anaesthesia and Perioperative Medicine, Pain Management Unit, Neuroscience Institute, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Herta Flor
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health/Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Center for Neuroplasticity and Pain, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Tamar R Makin
- Institute of Cognitive Neuroscience, University College London, London, UK
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Ambron E, Buxbaum LJ, Miller A, Stoll H, Kuchenbecker KJ, Coslett HB. Virtual Reality Treatment Displaying the Missing Leg Improves Phantom Limb Pain: A Small Clinical Trial. Neurorehabil Neural Repair 2021; 35:1100-1111. [PMID: 34704486 DOI: 10.1177/15459683211054164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Phantom limb pain (PLP) is a common and in some cases debilitating consequence of upper- or lower-limb amputation for which current treatments are inadequate. OBJECTIVE This small clinical trial tested whether game-like interactions with immersive VR activities can reduce PLP in subjects with transtibial lower-limb amputation. METHODS Seven participants attended 5-7 sessions in which they engaged in a visually immersive virtual reality experience that did not require leg movements (Cool! TM), followed by 10-12 sessions of targeted lower-limb VR treatment consisting of custom games requiring leg movement. In the latter condition, they controlled an avatar with 2 intact legs viewed in a head-mounted display (HTC Vive TM). A motion-tracking system mounted on the intact and residual limbs controlled the movements of both virtual extremities independently. RESULTS All participants except one experienced a reduction of pain immediately after VR sessions, and their pre session pain levels also decreased over the course of the study. At a group level, PLP decreased by 28% after the treatment that did not include leg movements and 39.6% after the games requiring leg motions. Both treatments were successful in reducing PLP. CONCLUSIONS This VR intervention appears to be an efficacious treatment for PLP in subjects with lower-limb amputation.
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Affiliation(s)
- Elisabetta Ambron
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,University of Delaware, Newark, DE, USA
| | - Laurel J Buxbaum
- Moss Rehabilitation Research Institute, Elkins Park, Philadelphia, PA, USA.,Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander Miller
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Harrison Stoll
- Moss Rehabilitation Research Institute, Elkins Park, Philadelphia, PA, USA
| | | | - H Branch Coslett
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Duarte D, Bauer CCC, Pinto CB, Saleh Velez FG, Estudillo-Guerra MA, Pacheco-Barrios K, Gunduz ME, Crandell D, Merabet L, Fregni F. Cortical plasticity in phantom limb pain: A fMRI study on the neural correlates of behavioral clinical manifestations. Psychiatry Res Neuroimaging 2020; 304:111151. [PMID: 32738724 PMCID: PMC9394643 DOI: 10.1016/j.pscychresns.2020.111151] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 12/29/2022]
Abstract
The neural mechanism of phantom limb pain (PLP) is related to the intense brain reorganization process implicating plasticity after deafferentation mostly in sensorimotor system. There is a limited understanding of the association between the sensorimotor system and PLP. We used a novel task-based functional magnetic resonance imaging (fMRI) approach to (1) assess neural activation within a-priori selected regions-of-interested (motor cortex [M1], somatosensory cortex [S1], and visual cortex [V1]), (2) quantify the cortical representation shift in the affected M1, and (3) correlate these changes with baseline clinical characteristics. In a sample of 18 participants, we found a significantly increased activity in M1 and S1 as well as a shift in motor cortex representation that was not related to PLP intensity. In an exploratory analyses (not corrected for multiple comparisons), they were directly correlated with time since amputation; and there was an association between increased activity in M1 with a lack of itching sensation and V1 activation was negatively correlated with PLP. Longer periods of amputation lead to compensatory changes in sensory-motor areas; and itching seems to be a protective marker for less signal changes. We confirmed that PLP intensity is not associated with signal changes in M1 and S1 but in V1.
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Affiliation(s)
- D Duarte
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School. 96 13th Street, Charlestown, Boston, MA 02129, USA; Department of Psychiatry and Behavioural Neurosciences, McMaster University. 100 West 5th Street, Hamilton, ON L8N 3K7, Canada
| | - C C C Bauer
- McGovern Institute for Brain Research, MIT. 43 Vassar St, Cambridge, MA 02139, USA; Instituto de Neurobiología, Universidad Nacional Autónoma de México, Campus UNAM 3001, 76230 Juriquilla, Querétaro, 76230, México; Department of Psychology, Northeastern University, 805 Columbus Avenue, Boston, MA 02139, USA.
| | - C B Pinto
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School. 96 13th Street, Charlestown, Boston, MA 02129, USA
| | - F G Saleh Velez
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School. 96 13th Street, Charlestown, Boston, MA 02129, USA; University of Chicago Medical Center, Department of Neurology, University of Chicago. 5841 S Maryland Ave # C411, Chicago, IL 60637, USA
| | - M A Estudillo-Guerra
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School. 96 13th Street, Charlestown, Boston, MA 02129, USA
| | - K Pacheco-Barrios
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School. 96 13th Street, Charlestown, Boston, MA 02129, USA; Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud. Lima, Peru. Av. La Fontana 750 Edificio El Cubo, La Molina - Perú
| | - M E Gunduz
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School. 96 13th Street, Charlestown, Boston, MA 02129, USA
| | - D Crandell
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School. 96 13th Street, Charlestown, Boston, MA 02129, USA
| | - L Merabet
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School. 243 Charles St, Boston, MA 02114, USA
| | - F Fregni
- Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School. 96 13th Street, Charlestown, Boston, MA 02129, USA; Massachusetts General Hospital, Harvard Medical School. 55 Fruit St, Boston, MA 02114, USA.
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11
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Makin TR, Flor H. Brain (re)organisation following amputation: Implications for phantom limb pain. Neuroimage 2020; 218:116943. [PMID: 32428706 PMCID: PMC7422832 DOI: 10.1016/j.neuroimage.2020.116943] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 05/10/2020] [Accepted: 05/11/2020] [Indexed: 12/11/2022] Open
Abstract
Following arm amputation the region that represented the missing hand in primary somatosensory cortex (S1) becomes deprived of its primary input, resulting in changed boundaries of the S1 body map. This remapping process has been termed 'reorganisation' and has been attributed to multiple mechanisms, including increased expression of previously masked inputs. In a maladaptive plasticity model, such reorganisation has been associated with phantom limb pain (PLP). Brain activity associated with phantom hand movements is also correlated with PLP, suggesting that preserved limb functional representation may serve as a complementary process. Here we review some of the most recent evidence for the potential drivers and consequences of brain (re)organisation following amputation, based on human neuroimaging. We emphasise other perceptual and behavioural factors consequential to arm amputation, such as non-painful phantom sensations, perceived limb ownership, intact hand compensatory behaviour or prosthesis use, which have also been related to both cortical changes and PLP. We also discuss new findings based on interventions designed to alter the brain representation of the phantom limb, including augmented/virtual reality applications and brain computer interfaces. These studies point to a close interaction of sensory changes and alterations in brain regions involved in body representation, pain processing and motor control. Finally, we review recent evidence based on methodological advances such as high field neuroimaging and multivariate techniques that provide new opportunities to interrogate somatosensory representations in the missing hand cortical territory. Collectively, this research highlights the need to consider potential contributions of additional brain mechanisms, beyond S1 remapping, and the dynamic interplay of contextual factors with brain changes for understanding and alleviating PLP.
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Affiliation(s)
- Tamar R Makin
- Institute of Cognitive Neuroscience, University College London, London, United Kingdom; Wellcome Centre for Human Neuroimaging, University College London, London, UK.
| | - Herta Flor
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; Department of Psychology, School of Social Sciences, University of Mannheim, Germany; Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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12
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Assessment of cortical reorganization and preserved function in phantom limb pain: a methodological perspective. Sci Rep 2020; 10:11504. [PMID: 32661345 PMCID: PMC7359300 DOI: 10.1038/s41598-020-68206-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 06/19/2020] [Indexed: 02/07/2023] Open
Abstract
Phantom limb pain (PLP) has been associated with reorganization in primary somatosensory cortex (S1) and preserved S1 function. Here we examined if methodological differences in the assessment of cortical representations might explain these findings. We used functional magnetic resonance imaging during a virtual reality movement task, analogous to the classical mirror box task, in twenty amputees with and without PLP and twenty matched healthy controls. We assessed the relationship between task-related activation maxima and PLP intensity in S1 and motor cortex (M1) in individually-defined or group-conjoint regions of interest (ROI) (overlap of task-related activation between the groups). We also measured cortical distances between both locations and correlated them with PLP intensity. Amputees compared to controls showed significantly increased activation in M1, S1 and S1M1 unrelated to PLP. Neural activity in M1 was positively related to PLP intensity in amputees with PLP when a group-conjoint ROI was chosen. The location of activation maxima differed between groups in S1 and M1. Cortical distance measures were unrelated to PLP. These findings suggest that sensory and motor maps differentially relate to PLP and that methodological differences might explain discrepant findings in the literature.
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13
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Münger M, Pinto CB, Pacheco-Barrios K, Duarte D, Gunduz ME, Simis M, Battistella LR, Fregni F. Protective and Risk Factors for Phantom Limb Pain and Residual Limb Pain Severity. Pain Pract 2020; 20:578-587. [PMID: 32176435 PMCID: PMC7363546 DOI: 10.1111/papr.12881] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/29/2020] [Accepted: 03/04/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The exact mechanisms underlying the development and maintenance of phantom limb pain (PLP) are still unclear. This study aimed to identify the factors affecting pain intensity in patients with chronic, lower limb, traumatic PLP. METHODS This is a cross-sectional analysis of patients with PLP. We assessed amputation-related and pain-related clinical and demographic variables. We used univariate and multivariate models to evaluate the associated factors modulating PLP and residual limb pain (RLP) intensity. RESULTS We included 71 unilateral traumatic lower limb amputees. Results showed that (1) amputation-related perceptions were experienced by a large majority of the patients with chronic PLP (sensations: 90.1%, n = 64; residual pain: 81.7%, n = 58); (2) PLP intensity has 2 significant protective factors (phantom limb movement and having effective treatment for PLP previously) and 2 significant risk factors (phantom limb sensation intensity and age); and (3) on the other hand, for RLP, risk factors are different: presence of pain before amputation and level of amputation (in addition to the same protective factors). CONCLUSION These results suggest different neurobiological mechanisms to explain PLP and RLP intensity. While PLP risk factors seem to be related to maladaptive plasticity, since phantom sensation and older age are associated with more pain, RLP risk factors seem to have components leading to neuropathic pain, such as the amount of neural lesion and previous history of chronic pain. Interestingly, the phantom movement appears to be protective for both phenomena.
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Affiliation(s)
- Marionna Münger
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Neuropsychology, Institute of Psychology, University of Zurich, 8050 Zurich, Switzerland
| | - Camila B. Pinto
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kevin Pacheco-Barrios
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
- Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud. Lima, Peru
| | - Dante Duarte
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Muhamed Enes Gunduz
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marcel Simis
- Department of Physical Medicine and Rehabilitation, Instituto de Reabilitação Lucy Montoro
| | | | - Felipe Fregni
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
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14
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Liu H, Andoh J, Lyu Y, Milde C, Desch S, Zidda F, Schmelz M, Curio G, Flor H. Peripheral input and phantom limb pain: A somatosensory event-related potential study. Eur J Pain 2020; 24:1314-1329. [PMID: 32335979 DOI: 10.1002/ejp.1579] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 04/06/2020] [Accepted: 04/17/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Following amputation, nearly all amputees report nonpainful phantom phenomena and many of them suffer from chronic phantom limb pain (PLP) and residual limb pain (RLP). The aetiology of PLP remains elusive and there is an ongoing debate on the role of peripheral and central mechanisms. Few studies have examined the entire somatosensory pathway from the truncated nerves to the cortex in amputees with PLP compared to those without PLP. The relationship among afferent input, somatosensory responses and the change in PLP remains unclear. METHODS Transcutaneous electrical nerve stimulation was applied on the truncated median nerve, the skin of the residual limb and the contralateral homologous nerve in 22 traumatic upper-limb amputees (12 with and 10 without PLP). Using somatosensory event-related potentials, the ascending volley was monitored from the brachial plexus, the spinal cord, the brainstem and the thalamus to the primary somatosensory cortex. RESULTS Peripheral input could evoke PLP in amputees with chronic PLP (7/12), but not in amputees without a history of PLP (0/10). The amplitudes of the somatosensory components were comparable between amputees with and without PLP. In addition, evoked potentials from the periphery through the spinal, subcortical and cortical segments were not significantly associated with PLP. CONCLUSIONS Peripheral input can modulate PLP but seems insufficient to cause PLP. These findings suggest the multifactorial complexity of PLP and different mechanisms for PLP and RLP. SIGNIFICANCE Peripheral afferent input plays a role in PLP and has been assumed to be sufficient to generate PLP. In this study we found no significant differences in the electrical potentials generated by peripheral stimulation from the truncated nerve and the skin of the residual limb in amputees with and without PLP. Peripheral input could enhance existing PLP but could not cause it. These findings indicate the multifactorial complexity of PLP and an important role of central processes in PLP.
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Affiliation(s)
- Hongcai Liu
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Jamila Andoh
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Yuanyuan Lyu
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Christopher Milde
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Department of Biopsychology, Clinical Psychology and Psychotherapy, University of Koblenz-Landau, Landau, Germany
| | - Simon Desch
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Francesca Zidda
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Martin Schmelz
- Department of Experimental Pain Research, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Gabriel Curio
- Neurophysics Group, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Herta Flor
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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15
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Maimon-Mor RO, Schone HR, Moran R, Brugger P, Makin TR. Motor control drives visual bodily judgements. Cognition 2020; 196:104120. [PMID: 31945591 PMCID: PMC7033558 DOI: 10.1016/j.cognition.2019.104120] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 11/17/2022]
Abstract
The 'embodied cognition' framework proposes that our motor repertoire shapes visual perception and cognition. But recent studies showing normal visual body representation in individuals born without hands challenges the contribution of motor control on visual body representation. Here, we studied hand laterality judgements in three groups with fundamentally different visual and motor hand experiences: two-handed controls, one-handers born without a hand (congenital one-handers) and one-handers with an acquired amputation (amputees). Congenital one-handers, lacking both motor and first-person visual information of their missing hand, diverged in their performance from the other groups, exhibiting more errors for their intact hand and slower reaction-times for challenging hand postures. Amputees, who have lingering non-visual motor control of their missing (phantom) hand, performed the task similarly to controls. Amputees' reaction-times for visual laterality judgements correlated positively with their phantom hand's motor control, such that deteriorated motor control associated with slower visual laterality judgements. Finally, we have implemented a computational simulation to describe how a mechanism that utilises a single hand representation in congenital one-handers as opposed to two in controls, could replicate our empirical results. Together, our findings demonstrate that motor control is a driver in making visual bodily judgments.
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Affiliation(s)
- Roni O Maimon-Mor
- Institute of Cognitive Neuroscience, University College London, London WC1N 3AZ, UK; WIN Centre, Nuffield Department of Clinical Neuroscience, University of Oxford, Headington, Oxford OX3 9DU, UK.
| | - Hunter R Schone
- Institute of Cognitive Neuroscience, University College London, London WC1N 3AZ, UK
| | - Rani Moran
- Max Planck University College London Centre for Computational Psychiatry and Ageing Research, University College London, London WC1B 5EH, UK
| | - Peter Brugger
- Department of Neurology, Neuropsychology Unit, University Hospital Zurich, Switzerland
| | - Tamar R Makin
- Institute of Cognitive Neuroscience, University College London, London WC1N 3AZ, UK; WIN Centre, Nuffield Department of Clinical Neuroscience, University of Oxford, Headington, Oxford OX3 9DU, UK
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16
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Suppressing movements with phantom limbs and existing limbs evokes comparable electrophysiological inhibitory responses. Cortex 2019; 117:64-76. [DOI: 10.1016/j.cortex.2019.02.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/29/2018] [Accepted: 02/24/2019] [Indexed: 11/17/2022]
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17
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Abstract
Post-amputation phantom limb pain (PLP) is highly prevalent and very difficult to treat. The high-prevalence, high-pain intensity levels, and decreased quality of life associated with PLP compel us to explore novel avenues to prevent, manage, and reverse this chronic pain condition. This narrative review focuses on recent advances in the treatment of PLP and reviews evidence of mechanism-based treatments from randomized controlled trials published over the past 5 years. We review recent evidence for the efficacy of targeted muscle reinnervation, repetitive transcranial magnetic stimulation, imaginal phantom limb exercises, mirror therapy, virtual and augmented reality, and eye movement desensitization and reprocessing therapy. The results indicate that not one of the above treatments is consistently better than a control condition. The challenge remains that there is little level 1 evidence of efficacy for PLP treatments and most treatment trials are underpowered (small sample sizes). The lack of efficacy likely speaks to the multiple mechanisms that contribute to PLP both between and within individuals who have sustained an amputation. Research approaches are called for to classify patients according to shared factors and evaluate treatment efficacy within classes. Subgroup analyses examining sex effects are recommended given the clear differences between males and females in pain mechanisms and outcomes. Use of novel data analytical approaches such as growth mixture modeling for multivariate latent classes may help to identify sub-clusters of patients with common outcome trajectories over time.
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Affiliation(s)
- Andrea Aternali
- Department of Psychology, York University, Toronto, Ontario, Canada
| | - Joel Katz
- Department of Psychology, York University, Toronto, Ontario, Canada
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18
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Chan AWY, Bilger E, Griffin S, Elkis V, Weeks S, Hussey-Anderson L, Pasquina PF, Tsao JW, Baker CI. Visual responsiveness in sensorimotor cortex is increased following amputation and reduced after mirror therapy. NEUROIMAGE-CLINICAL 2019; 23:101882. [PMID: 31226622 PMCID: PMC6587025 DOI: 10.1016/j.nicl.2019.101882] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 04/17/2019] [Accepted: 05/25/2019] [Indexed: 11/07/2022]
Abstract
Phantom limb pain (PLP) following amputation, which is experienced by the vast majority of amputees, has been reported to be relieved with daily sessions of mirror therapy. During each session, a mirror is used to view the reflected image of the intact limb moving, providing visual feedback consistent with the movement of the missing/phantom limb. To investigate potential neural correlates of the treatment effect, we measured brain responses in volunteers with unilateral leg amputation using functional magnetic resonance imaging (fMRI) during a four-week course of mirror therapy. Mirror therapy commenced immediately following baseline scans, which were repeated after approximately two and four week intervals. We focused on responses in the region of sensorimotor cortex corresponding to primary somatosensory and motor representations of the missing leg. At baseline, prior to starting therapy, we found a strong and unexpected response in sensorimotor cortex of amputees to visually presented images of limbs. This response was stronger for images of feet compared to hands and there was no such response in matched controls. Further, this response to visually presented limbs was no longer present at the end of the four week mirror therapy treatment, when perceived phantom limb pain was also reduced. A similar pattern of results was also observed in extrastriate and parietal regions typically responsive to viewing hand actions, but not in regions corresponding to secondary somatosensory cortex. Finally, there was a significant correlation between initial visual responsiveness in sensorimotor cortex and reduction in PLP suggesting a potential marker for predicting efficacy of mirror therapy. Thus, enhanced visual responsiveness in sensorimotor cortex is associated with PLP and modulated over the course of mirror therapy. Visual responsiveness to the sight of limbs in sensorimotor cortex of leg amputees but not matched controls Consistent with prior studies, mirror therapy over 4 weeks reduced phantom limb pain Visual responsiveness in sensorimotor cortex of amputees diminished following mirror therapy Visual responsiveness in sensorimotor cortex might be useful in predicting the potential efficacy of mirror therapy
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Affiliation(s)
- Annie W-Y Chan
- Laboratory of Brain and Cognition, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA; Department of Life Sciences, Division of Psychology, Centre for Cognitive Neuroscience, Brunel University London, UK; University of Tennessee Health Science Center, Department of Radiology, Memphis, TN, USA.
| | - Emily Bilger
- Laboratory of Brain and Cognition, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA; George Washington University Hospital, USA
| | - Sarah Griffin
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Viktoria Elkis
- Laboratory of Brain and Cognition, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Sharon Weeks
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - Paul F Pasquina
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jack W Tsao
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA; University of Tennessee Health Science Center, Department of Neurology, Memphis, TN, USA; Le Bonheur Children's Hospital, Memphis, TN, USA; Memphis Veterans Affairs Medical Center, Memphis, TN, USA
| | - Chris I Baker
- Laboratory of Brain and Cognition, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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19
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Rothgangel A, Bekrater-Bodmann R. Mirror therapy versus augmented/virtual reality applications: towards a tailored mechanism-based treatment for phantom limb pain. Pain Manag 2019; 9:151-159. [DOI: 10.2217/pmt-2018-0066] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Phantom limb pain (PLP) is a clinically relevant consequence of limb amputation and its treatment is still challenging. Mirror therapy, in other words, observing and engaging in the intact limb's mirrored movements, offers a promising, mechanism-based treatment for PLP. However, intervention and patient characteristics, such as the realism of mirrored exercises and perceptions related to the phantom limb, might influence treatment effectiveness. Novel approaches using augmented and virtual reality setups represent an alternative to traditional mirror therapy. In this paper, based on recent studies in the field, we compare both approaches and discuss their unique advantages and disadvantages. We argue for the necessity of a tailored treatment for PLP that is personalized to the patients’ characteristics, preferences and psychological needs.
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Affiliation(s)
- Andreas Rothgangel
- Research Centre for Nutrition, Lifestyle and Exercise, Department of Health, Zuyd University of Applied Sciences, Heerlen, The Netherlands
- CAPHRI School for Public Health and Primary Care, Department of Rehabilitation Medicine, Maastricht University, Maastricht, The Netherlands
| | - Robin Bekrater-Bodmann
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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20
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Kikkert S, Mezue M, O'Shea J, Henderson Slater D, Johansen-Berg H, Tracey I, Makin TR. Neural basis of induced phantom limb pain relief. Ann Neurol 2019; 85:59-73. [PMID: 30383312 PMCID: PMC6492189 DOI: 10.1002/ana.25371] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/29/2018] [Accepted: 10/29/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Phantom limb pain (PLP) is notoriously difficult to treat, partly due to an incomplete understanding of PLP-related disease mechanisms. Noninvasive brain stimulation (NIBS) is used to modulate plasticity in various neuropathological diseases, including chronic pain. Although NIBS can alleviate neuropathic pain (including PLP), both disease and treatment mechanisms remain tenuous. Insight into the mechanisms underlying both PLP and NIBS-induced PLP relief is needed for future implementation of such treatment and generalization to related conditions. METHODS We used a within-participants, double-blind, and sham-controlled design to alleviate PLP via task-concurrent NIBS over the primary sensorimotor missing hand cortex (S1/M1). To specifically influence missing hand signal processing, amputees performed phantom hand movements during anodal transcranial direct current stimulation. Brain activity was monitored using neuroimaging during and after NIBS. PLP ratings were obtained throughout the week after stimulation. RESULTS A single session of intervention NIBS significantly relieved PLP, with effects lasting at least 1 week. PLP relief associated with reduced activity in the S1/M1 missing hand cortex after stimulation. Critically, PLP relief and reduced S1/M1 activity correlated with preceding activity changes during stimulation in the mid- and posterior insula and secondary somatosensory cortex (S2). INTERPRETATION The observed correlation between PLP relief and decreased S1/M1 activity confirms our previous findings linking PLP with increased S1/M1 activity. Our results further highlight the driving role of the mid- and posterior insula, as well as S2, in modulating PLP. Lastly, our novel PLP intervention using task-concurrent NIBS opens new avenues for developing treatment for PLP and related pain conditions. ANN NEUROL 2019;85:59-73.
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Affiliation(s)
- Sanne Kikkert
- Wellcome Centre for Integrative Neuroimaging, FMRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.,Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen, Nijmegen, the Netherlands.,Neural Control of Movement Laboratory, Department of Health Sciences and Technology, ETH Zürich, Zürich, Switzerland
| | - Melvin Mezue
- Wellcome Centre for Integrative Neuroimaging, FMRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Jacinta O'Shea
- Wellcome Centre for Integrative Neuroimaging, FMRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | | | - Heidi Johansen-Berg
- Wellcome Centre for Integrative Neuroimaging, FMRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Irene Tracey
- Wellcome Centre for Integrative Neuroimaging, FMRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Tamar R Makin
- Wellcome Centre for Integrative Neuroimaging, FMRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.,Institute of Cognitive Neuroscience, University College London, London, United Kingdom.,Wellcome Centre for Human Neuroimaging, University College London, London, United Kingdom
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21
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Osumi M, Inomata K, Inoue Y, Otake Y, Morioka S, Sumitani M. Characteristics of Phantom Limb Pain Alleviated with Virtual Reality Rehabilitation. PAIN MEDICINE 2018; 20:1038-1046. [DOI: 10.1093/pm/pny269] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Michihiro Osumi
- Graduate School of Health Science, Kio University, Nara, Japan
- Neurorehabilitation Research Center, Kio University, Nara, Japan
| | - Kazunori Inomata
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan
- KIDS Co., Ltd
| | - Yuji Inoue
- Visualization Design Department, Power Place Inc., Tokyo, Japan
| | - Yuko Otake
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Shu Morioka
- Graduate School of Health Science, Kio University, Nara, Japan
- Neurorehabilitation Research Center, Kio University, Nara, Japan
| | - Masahiko Sumitani
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan
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22
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Touillet A, Peultier-Celli L, Nicol C, Jarrassé N, Loiret I, Martinet N, Paysant J, De Graaf JB. Characteristics of phantom upper limb mobility encourage phantom-mobility-based prosthesis control. Sci Rep 2018; 8:15459. [PMID: 30337602 PMCID: PMC6193985 DOI: 10.1038/s41598-018-33643-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 09/26/2018] [Indexed: 12/20/2022] Open
Abstract
There is an increasing need to extend the control possibilities of upper limb amputees over their prosthetics, especially given the development of devices with numerous active joints. One way of feeding pattern recognition myoelectric control is to rely on the myoelectric activities of the residual limb associated with phantom limb movements (PLM). This study aimed to describe the types, characteristics, potential influencing factors and trainability of upper limb PLM. Seventy-six below- and above-elbow amputees with major amputation underwent a semi-directed interview about their phantom limb. Amputation level, elapsed time since amputation, chronic pain and use of prostheses of upper limb PLM were extracted from the interviews. Thirteen different PLM were found involving the hand, wrist and elbow. Seventy-six percent of the patients were able to produce at least one type of PLM; most of them could execute several. Amputation level, elapsed time since amputation, chronic pain and use of myoelectric prostheses were not found to influence PLM. Five above-elbow amputees participated in a PLM training program and consequently increased both endurance and speed of their PLM. These results clearly encourage further research on PLM-associated muscle activation patterns for future PLM-based modes of prostheses control.
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Affiliation(s)
- Amélie Touillet
- IRR Louis Pierquin - UGECAM Nord-est, 75 Boulevard Lobau, CS 34209, 54042, Nancy Cedex, France.
| | - Laetitia Peultier-Celli
- Development, Adaptation and Handicap, University of Lorraine, 30 Rue du Jardin Botanique CS 30156, 54603, Nancy, France
| | | | - Nathanaël Jarrassé
- Sorbonne Université, CNRS, INSERM, Institut des Systèmes Intelligents et de Robotique, ISIR, 75005, Paris, France
| | - Isabelle Loiret
- IRR Louis Pierquin - UGECAM Nord-est, 75 Boulevard Lobau, CS 34209, 54042, Nancy Cedex, France
| | - Noël Martinet
- IRR Louis Pierquin - UGECAM Nord-est, 75 Boulevard Lobau, CS 34209, 54042, Nancy Cedex, France
| | - Jean Paysant
- IRR Louis Pierquin - UGECAM Nord-est, 75 Boulevard Lobau, CS 34209, 54042, Nancy Cedex, France
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23
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Zhang J, Zhang Y, Wang L, Sang L, Li L, Li P, Yin X, Qiu M. Brain Functional Connectivity Plasticity Within and Beyond the Sensorimotor Network in Lower-Limb Amputees. Front Hum Neurosci 2018; 12:403. [PMID: 30356798 PMCID: PMC6189475 DOI: 10.3389/fnhum.2018.00403] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 09/20/2018] [Indexed: 12/12/2022] Open
Abstract
Cerebral neuroplasticity after amputation has been elucidated by functional neuroimaging. However, little is known concerning how brain network-level functional reorganization of the sensorimotor system evolves following lower-limb amputation. We studied 32 unilateral lower-limb amputees (LLAs) and 32 matched healthy controls (HCs) using resting-state functional magnetic resonance imaging (rs-fMRI). A regions of interest (ROI)-wise connectivity analysis was performed with ROIs in eight brain regions in the sensorimotor network to investigate intra-network changes, and seed-based whole-brain functional connectivity (FC) with a seed in the contralateral primary sensorimotor cortex (S1M1) was used to study the FC reorganization between the sensorimotor region (S1M1) and other parts of the brain in the LLAs. The ROI-wise connectivity analysis showed that the LLAs had decreased FC, mainly between the subcortical nuclei and the contralateral S1M1 (p < 0.05, FDR corrected). Seed-based whole-brain FC analysis revealed that brain regions with decreased FC with the contralateral S1M1 extended beyond the sensorimotor network to the prefrontal and visual cortices (p < 0.05, FDR corrected). Moreover, correlation analysis showed that decreased FC between the subcortical and the cortical regions in the sensorimotor network progressively increased in relation to the time since amputation. These findings indicated a cascade of cortical reorganization at a more extensive network level following lower-limb amputation, and also showed promise for the development of a possible neurobiological marker of changes in FC related to motor function recovery in LLAs.
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Affiliation(s)
- Jingna Zhang
- Department of Medical Imaging, College of Biomedical Engineering, Army Medical University, Chongqing, China.,Department of Rehabilitation, Southwest Hospital, Army Medical University, Chongqing, China
| | - Ye Zhang
- Department of Medical Imaging, College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Li Wang
- Department of Medical Imaging, College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Linqiong Sang
- Department of Medical Imaging, College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Lei Li
- Department of Rehabilitation, Southwest Hospital, Army Medical University, Chongqing, China
| | - Pengyue Li
- Department of Medical Imaging, College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Xuntao Yin
- Department of Radiology, Southwest Hospital, Army Medical University, Chongqing, China
| | - Mingguo Qiu
- Department of Medical Imaging, College of Biomedical Engineering, Army Medical University, Chongqing, China
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24
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Ortiz-Catalan M. The Stochastic Entanglement and Phantom Motor Execution Hypotheses: A Theoretical Framework for the Origin and Treatment of Phantom Limb Pain. Front Neurol 2018; 9:748. [PMID: 30237784 PMCID: PMC6135916 DOI: 10.3389/fneur.2018.00748] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 08/17/2018] [Indexed: 12/28/2022] Open
Abstract
Phantom limb pain (PLP) is a debilitating condition common after amputation that can considerably hinder patients' quality of life. Several treatments have reported promising results in alleviating PLP. However, clinical evaluations are usually performed in small cohorts and rigorous clinical trials are scarce. In addition, the underlying mechanisms by which novel interventions alleviate PLP are often unclear, potentially because the condition itself is poorly understood. This article presents a theoretical framework of PLP that can be used as groundwork for hypotheses of novel treatments. Current hypotheses on the origins of PLP are discussed in relation to available clinical findings. Stochastic entanglement of the pain neurosignature, or connectome, with impaired sensorimotor circuitry is proposed as an alternative hypothesis for the genesis of PLP, and the implications and predictions this hypothesis entails are examined. In addition, I present a hypothesis for the working mechanism of Phantom Motor Execution (PME) as a treatment of PLP, along with its relation to the aforementioned stochastic entanglement hypothesis, which deals with PLP's incipience. PME aims to reactivate the original central and peripheral circuitry involved in motor control of the missing limb, along with increasing dexterity of stump muscles. The PME hypothesis entails that training of phantom movements induces gradual neural changes similar to those of perfecting a motor skill, and these purposefully induced neural changes disentangle pain processing circuitry by competitive plasticity. This is a testable hypothesis that can be examined by brain imaging and behavioral studies on subjects undergoing PME treatment. The proposed stochastic entanglement hypothesis of PLP can be generalized to neuropathic pain due to sensorimotor impairment, and can be used to design suitable therapeutic treatments.
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Affiliation(s)
- Max Ortiz-Catalan
- Biomechatronics and Neurorehabilitation Laboratory, Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden.,Integrum AB, Mölndal, Sweden
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Andoh J, Milde C, Tsao J, Flor H. Cortical plasticity as a basis of phantom limb pain: Fact or fiction? Neuroscience 2018; 387:85-91. [DOI: 10.1016/j.neuroscience.2017.11.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 10/04/2017] [Accepted: 11/09/2017] [Indexed: 12/12/2022]
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Kikkert S, Johansen-Berg H, Tracey I, Makin TR. Reaffirming the link between chronic phantom limb pain and maintained missing hand representation. Cortex 2018; 106:174-184. [PMID: 30005369 PMCID: PMC6143485 DOI: 10.1016/j.cortex.2018.05.013] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 04/16/2018] [Accepted: 05/23/2018] [Indexed: 12/20/2022]
Abstract
Phantom limb pain (PLP) is commonly considered to be a result of maladaptive brain plasticity. This model proposes that PLP is mainly caused by reorganisation in the primary somatosensory cortex, presumably characterised by functional degradation of the missing hand representation and remapping of other body part representations. In the current study, we replicate our previous results by showing that chronic PLP correlates with maintained representation of the missing hand in the primary sensorimotor missing hand cortex. We asked unilateral upper-limb amputees to move their phantom hand, lips or other body parts and measured the associated neural responses using functional magnetic resonance imaging (fMRI). We confirm that amputees suffering from worse chronic PLP have stronger activity in the primary sensorimotor missing hand cortex while performing phantom hand movements. We find no evidence of lip representation remapping into the missing hand territory, as assessed by measuring activity in the primary sensorimotor missing hand cortex during lip movements. We further show that the correlation between chronic PLP and maintained representation of the missing hand cannot be explained by the experience of chronic non-painful phantom sensations or compensatory usage of the residual arm or an artificial arm (prosthesis). Together, our results reaffirm a likely relationship between persistent peripheral inputs pertaining to the missing hand representation and chronic PLP. Our findings emphasise a need to further study the role of peripheral inputs from the residual nerves to better understand the mechanisms underlying chronic PLP.
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Affiliation(s)
- Sanne Kikkert
- Wellcome Centre for Integrative Neuroimaging, MRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Heidi Johansen-Berg
- Wellcome Centre for Integrative Neuroimaging, MRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Irene Tracey
- Wellcome Centre for Integrative Neuroimaging, MRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom; Nuffield Division of Anaesthetics, University of Oxford, Oxford, United Kingdom
| | - Tamar R Makin
- Wellcome Centre for Integrative Neuroimaging, MRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom; Institute of Cognitive Neuroscience, University College London, London, United Kingdom.
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Imaizumi S, Asai T, Koyama S. Agency over Phantom Limb Enhanced by Short-Term Mirror Therapy. Front Hum Neurosci 2017; 11:483. [PMID: 29046630 PMCID: PMC5632822 DOI: 10.3389/fnhum.2017.00483] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 09/19/2017] [Indexed: 12/28/2022] Open
Abstract
Most amputees experience phantom limb, whereby they feel that the amputated limb is still present. In some cases, these experiences include pain that can be alleviated by "mirror therapy." Mirror therapy consists of superimposing a mirrored image of the moving intact limb onto the phantom limb. This therapy provides a closed loop between the motor command to the amputated limb and its predicted visual feedback. This loop is also involved in the sense of agency, a feeling of controlling one's own body. However, it is unclear how mirror therapy is related to the sense of agency over a phantom limb. Using mirror therapy, we investigated phantom limb pain and the senses of agency and ownership (i.e., a feeling of having one's own body) of the phantom limb. Nine upper-limb amputees, five of whom reported recent phantom limb pain, underwent a single 15-min trial of mirror therapy. Before and after the trial, the participants completed a questionnaire regarding agency, ownership, and pain related to their phantom limb. They reported that the sense of agency over the phantom limb increased following the mirror therapy trial, while the ownership slightly increased but not as much as did the agency. The reported pain did not change; that is, it was comparably mild before and after the trial. These results suggest that short-term mirror therapy can, at least transiently, selectively enhance the sense of agency over a phantom limb, but may not alleviate phantom limb pain.
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Affiliation(s)
- Shu Imaizumi
- Graduate School of Arts and Sciences, The University of Tokyo, Tokyo, Japan.,Japan Society for the Promotion of Science, Tokyo, Japan
| | - Tomohisa Asai
- Cognitive Mechanisms Laboratories, Advanced Telecommunications Research Institute International, Kyoto, Japan
| | - Shinichi Koyama
- School of Art and Design, University of Tsukuba, Tsukuba, Japan.,Graduate School of Engineering, Chiba University, Chiba, Japan
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