Abnormal functioning of the thalamocortical system underlies the conscious awareness of the phantom limb phenomenon

Phantom limb (PL), a phenomenon experienced by most patients after amputation, has mostly served as a paradigm to study experiences that appear to be associated with neural plasticity within the CNS. However, the subjective nature of PL experiences has had no definitive means of reliable assessment other than using patients' direct reports, nor was there a way to study the neural mechanisms involved in the conscious awareness of this mental phenomenon. Here we obtained patients' indirect responses to PL experiences for an objective evaluation using functional magnetic resonance imaging (fMRI). Six control subjects and six lower limb (LL) amputees participated in a motor imagery task for both the intact and the particular phantom toes. While all subjects shared neural processing of distinctive regional cerebral activations during motor imagery of the intact toes (prefrontal (PF), supplementary motor area (SMA), primary motor cortex (M1), superior temporal gyrus (STG)), it was only during motor imagery of the amputated toes in amputees that we observed an increased blood oxygen level-dependent (BOLD) signal in the contralateral basal ganglia at the medial globus pallidus (MGP), substantia nigra (SN), and thalamus. This increased BOLD signal in the basal ganglia-thalamus-cortex pathway during imaginary movement of the phantom toes may reflect an abnormal open loop functioning of the thalamocortical system underlying the conscious awareness of the phantom phenomenon. We suggest that the reduction in afferent information contributes to and coalesces with the higher-level reorganization resulting in the subjective conscious awareness of the phantom limb.