The Journal of Pain, Vol 14, No 10 (October), 2013: pp 1107-1115 Available online at www.jpain.org and www.sciencedirect.

com

Altered Resting-State Functional Connectivity in Complex Regional Pain Syndrome

fner*,y Anne Bolwerk,*,y Frank Seifert,* and Christian Maiho
*Department of Neurology, University Hospital Erlangen, Erlangen, Germany. y Department of Physiology and Pathophysiology, University of Erlangen-Nuremberg, Erlangen, Germany.

Abstract: This study explored the functional connectivity between brain regions implicated in the
default mode network, the sensorimotor cortex (S1/M1), and the intraparietal sulcus (IPS/MIP) at rest in patients with complex regional pain syndrome. It also investigated how possible alterations are associated with neuropathic pain. Our group used functional magnetic resonance imaging to investigate functional brain connectivity in 12 complex regional pain syndrome patients in comparison with that in 12 age- and sex-matched healthy controls. Data were analyzed using a seed voxel correlation analysis and an independent component analysis. An analysis of covariance was employed to relate alterations in functional connectivity with clinical symptoms. We found signicantly greater reductions in functional default mode network connectivity in patients compared to controls. The functional connectivity maps of S1/M1 and IPS/MIP in patients revealed greater and more diffuse connectivity with other brain regions, mainly with the cingulate cortex, precuneus, thalamus, and prefrontal cortex. In contrast, controls showed greater intraregional connectivity within S1/M1 and IPS/MIP. Furthermore, there was a trend for correlation between alterations in functional connectivity and intensity of neuropathic pain. In our ndings, patients with complex regional pain syndrome have substantial spatial alterations in the functional connectivity between brain regions implicated in the resting-state default mode network, S1/M1, and IPS/ MIP; these alterations show a trend of correlation with neuropathic pain intensity. Perspective: This article presents spatial alterations in the functional resting-state connectivity of complex regional pain syndrome patients. Our results add further insight into the disease states of CRPS and into the functional architecture of the resting state brains of pain patients in general. 2013 by the American Pain Society Key words: Complex regional pain syndrome, resting state, functional magnetic resonance imaging, default mode network, sensorimotor cortex.

omplex regional pain syndrome (CRPS) is a painful disorder. It may develop in about 5% of all upper or lower limb trauma or nerve lesions.24 The clinical presentation of CRPS consists of a relatively characteristic triad of dysfunction in the autonomic (edema; sweating abnormalities; alterations in skin color, skin
Received December 6, 2012; Revised February 27, 2013; Accepted April 16, 2013. This study was supported by the German Research Network on Neuropathic Pain (German Federal Ministry of Education and Research; BMBF), the German Research Foundation (Deutsche Forschungsgemeinschaft, KFO130), and the STAEDTLER-Foundation. The authors have reported no conicts of interest. Supplementary data accompanying this article are available online at www.jpain.org and www.sciencedirect.com. fner, MD, PhD, Department Address reprint requests to Christian Maiho of Neurology, University Hospital Erlangen, Germany, Schwabachanlage 6, D-91054 Erlangen, Germany. E-mail: christian.maihoefner@ uk-erlangen.de 1526-5900/$36.00 2013 by the American Pain Society http://dx.doi.org/10.1016/j.jpain.2013.04.007

temperature, and hair and nail growth), sensory (hyperor hypoalgesia, pain, allodynia), and motor (paresis, tremor, dystonia) systems.24 Neglect-like symptoms have also been reported.11,13 Besides clinical symptoms, CRPS is associated with a signicant reduction in quality of life and capability.4 The pathophysiology of CRPS comprises distinct alterations in the peripheral, autonomic, and central nervous systems.26 Previous functional imaging studies in patients with CRPS affecting the hand showed substantial somatotopic changes in the primary and secondary somatosensory cortices (S1, S2) contralateral to the side with the CRPS symptoms.19,22,30 Magnetoencephalography demonstrated that the cortical hand representation for the side affected with CRPS was signicantly shrunken. Additionally, the hand position was shifted toward the lip. A predictor of the somatotopic reorganization was spontaneous pain, especially mechanical hyperalgesia.22,23 Somatotopic changes 1107

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Altered Functional Connectivity in CRPS proles, suggesting that the pathophysiology of pain and hyperalgesia is similar.14 Clinical symptoms were assessed in a standardized neurologic examination before functional magnetic resonance imaging (fMRI) measurement. Sensory symptoms were examined by stroking with a cotton wisp and by gently brushing rby, the skin with a SENSELab TM brush 05 (Somedic, Ho Sweden). The examination was performed on both the affected and unaffected limbs, and patients were instructed to report side differences, indicative of hyper- or hypoesthesia. Furthermore, the magnitude of CRPS pain was quantied using the German version of the McGill Pain Questionnaire (MPQ),37 which was analyzed using the pain rating index (PRI). Motor function was assessed according to the presence of paresis, tremor, and dystonia as observed in a neurologic examination. For the evaluation of autonomic disturbances, the following symptoms were assessed: 1) difference between skin temperature on the affected and unaffected sides. After acclimatization for at least 30 minutes, skin temperature was recorded on the volar aspect of the unaffected and affected limbs with an infrared thermometer Thermo Hunter HR 1 (ASM, Unterhaching, Germany); 2) difference in skin color (red, livid, or white); 3) presence of sweating abnormalities (hypo- or hyperhidrosis); 4) presence of distal edema; and 5) trophic changes in skin, nails, or hair. Spontaneous pain was quantied after the fMRI scan using a numeric rating scale (NRS) ranging from 0 (no pain) to 10 (worst imaginable pain). Table 1 gives a detailed summary of the epidemiologic data of the patients. All subjects were informed about the procedures of the study and gave their informed written consent in line with the Declaration of Helsinki. The study was approved by the local ethics committees of the University of Erlangen.

were also found in the motor and supplementary motor cortices and in the intraparietal sulcus (IPS).20 In recent years, neuroimaging studies have focused on the functional interplay between certain brain regions at rest, the so-called resting state networks. Resting state networks consist of highly correlated organized brain areas in the low-frequency range (<.1 Hz) of the blood oxygen leveldependent signal.10,33 The default mode network (DMN) is one of several RSNs and is the most thoroughly investigated and stable network, which is suspended during various cognitive tasks.10 It is characterized by balanced positive and negative correlations between activities in the dorsal and ventral medial prefrontal cortex (MPFC), the medial parietal cortex (posterior cingulate cortex [PCC], precuneus [preCUN]), and the inferior parietal cortex.5,10,34 The components of the DMN correlate with behavioral performances and emotional measures and are involved in self-referential processes such as introspection, self-monitoring, autobiographic memory, comprehension of emotional states, intentions of others, and planning for the future.2,5,29,33 Interestingly, pain seems to affect this balanced activity at rest. Previous studies on chronic pain have demonstrated disruption in the temporal and spatial properties of the functional connectivity at rest.2,6,7,25,28,38 The goal of the present study was to investigate whether CRPS patients also demonstrate spatial alterations in functional connectivity of the DMN. Furthermore, because of the clinical presentation of CRPS patients, we also investigated the functional connectivity of the S1/M1 and IPS/MIP. We hypothesized that alterations in the functional connectivity of the DMN, S1/M1, and IPS may be related to the clinical parameters of CRPS, that is, the sensory, motor, and autonomic symptoms.

Methods
Participants and Psychophysical Examination
Twelve CRPS patients (5 male, 7 female, mean age 61.08 years 6 11.12 standard deviation [SD]) participated in the study. They met the Budapest criteria for CRPS.16 In order to minimize any bias, we intentionally performed a consecutive sampling of the patients in our specialized CRPS outpatient clinic. Twelve healthy ageand sex-matched subjects served as a control group (5 male, 7 female, mean age 60.92 years 6 10.96 SD). Patients with affected upper (9 patients) and lower (3 patients) limbs and different duration of CRPS symptoms were examined. The median of duration of CRPS symptoms was 15.5 weeks with a range of 4 to 406 weeks. Ten of the patients had been diagnosed with CRPS I, and 2 with CRPS II by an experienced neurologist (C.M.) in the University Hospital Erlangen. hlen and colleagues14 forms A recent study by Gierthmu the rationale for including CRPS I and CRPS II patients. They investigated sensory signs of CRPS and found that CRPS I and II had almost identical somatosensory

fMRI Acquisition
Echoplanar images were collected on a 1.5-T MRI scanner (Magnetom Sonata; Siemens, Erlangen, Germany) using the standard head coil and the Siemens Magnetom gradient overdrive. For each subject, the time-series of 90 whole-brain images were obtained using a gradient-echo, echo-planar scanning sequence (repetition time 3 seconds, time to echo 40 ms, ip angle 90 , eld of view 220 mm2, acquisition matrix 64 64, 16 axial slices, slice thickness 4 mm, gap 1 mm). A T1-weighted 3-dimensional magnetization-prepared rapid acquisition gradient echo sequence scan (voxel size = 1.0 1.0 1.0 mm3) lasting 8 minutes, 21 seconds was recorded for the later overlay between each subjects individual brain anatomy and fMRI data. The fMRI data scan (voxel size = 3.0 3.0 3.0 mm3) lasted 4 minutes, 30 seconds and resulted in 90 functional volumes. All subjects were instructed to keep their eyes closed but to remain awake during the fMRI measurement.

FMRI Data Analysis

Data analysis, registration, and visualization were performed with the fMRI software package BrainVoyager

fner Bolwerk, Seifert, and Maiho Table 1.

PATIENT NO. 1 2 3 4 5 6 7 8 9 10 11 12

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Epidemiologic Data of CRPS Patients

AGE (YEARS) 67 70 64 61 49 56 69 52 72 52 40 81 GENDER Male Female Male Female Female Female Female Male Female Male Female Female DIAGNOSIS CRPS I CRPS I CRPS II CRPS I CRPS I CRPS I CRPS I CRPS I CRPS II CRPS I CRPS I CRPS I AFFECTED LIMB Right hand Right hand Left hand Left hand Left feet Right hand Right arm/shoulder Right hand Left feet Right feet Right hand Left hand INCITING EVENT Pain in shoulder Spontaneous Hand surgery Radius fracture Fracture Radius fracture Distal radius fracture Distal radius fracture Toe surgery Overload Phalanx fracture Radius fracture TIME FROM ONSET (WEEKS) 12 14 17 4 6 49 18 8 12 24 50 406 HAIR/NAIL GROWTH SWEATING [ [ [ Y [ [ [ Y [ [ [ Y Y [ Y SPONTANEOUS PAIN NRS = 5 / MPQ = 18 (PRI(R)) NRS = 7 / MPQ = 17 (PRI(R)) NRS = 7 / MPQ = 7 (PRI(R)) NRS = 5 / MPQ = 12 (PRI(R)) NRS = 3 / MPQ = 15 (PRI(R)) NRS = 3 / MPQ = 9 (PRI(R)) NRS = 10 / MPQ = 9 (PRI(R)) NRS = 5 / MPQ = 18 (PRI(R)) NRS = 3 / MPQ = 14 (PRI(R)) NRS = 4 / MPQ = 13 (PRI(R)) NRS = 8 / MPQ = 8 (PRI(R)) NRS = 4 / MPQ = 14 (PRI(R))

PATIENT NO. 1 2 3 4 5 6 7 8 9 10 11 12

SENSORY SIGNS Hyperalgesia/allodynia None Hypoalgesia Hyperalgesia Hyperalgesia Hyperalgesia/allodynia Hyperalgesia/allodynia Hyperalgesia/allodynia Hyperalgesia/allodynia Hypoalgesia Hyperalgesia/allodynia Hypoalgesia

MOTOR SIGNS Paresis/tremor Paresis Paresis/dystonia Paresis/tremor Paresis/tremor/dystonia Paresis/dystonia Tremor Paresis/tremor/dystonia Paresis Paresis/dystonia Paresis

EDEMA SKIN TEMP SKIN COLOR Yes Yes No Yes Yes Yes No Yes Yes Yes Yes No [ Y [ Y [ Y Red Red Livid Red Livid Red Livid

THERAPY PT PT/NSAID PT/NSAID PT NSAID NSAID PT/NSAID PT PT PT PT/NSAID PT

COMORBIDITY Epilepsy Hypertension Carotid stenosis None None None Esophagitis Hypertension None Hypertension None None

Abbreviations: PRI(R), pain rating index based on the rank value of the words; PT, physical therapy; NSAID, nonsteroidal anti-inammatory drug.

QX version 1.10 (Brain Innovation, Maastricht, The Netherlands). For group analysis, fMRI data from patients with CRPS on the left body side were rightleft ipped to correspond to data from patients with rightsided CRPS. The data were then motion corrected using sinc interpolation. Preprocessing included Gaussian spatial (full width at half maximum = 4 mm) and temporal (full width at half maximum = 3 volumes) smoothing of the functional data to reduce artifacts. After preprocessing, the functional data were transformed into a standard stereotactic space and linear-interpolated to 3 3 3 mm3.39 The data from each subject were averaged for group analysis. As implemented in the BrainVoyager software package, a z transformation of the functional volume time course for each subject was applied to account for different baseline signal levels. Functional connectivity maps of the DMN, S1/M1, and IPS/MIP at rest were calculated by using a seed voxel correlation analysis (SCA). After extracting the individual signal time course of each subject from 3 dened seed clusters (regions of interest [ROIs]), the signal time course was correlated with the signal time course of every other voxel within the whole brain. Using the general linear model, the individual analysis resulted in a t-statistic map. Subsequently, connectivity analysis at the group level was performed. Group-level contrast maps based on the connectivity maps of the ROIs were calculated in order to identify signicant group-related differences.

A 2-sample t-test was used to compare the correlation maps from CRPS patients with the maps from controls. Connectivity maps of the patients and controls were thresholded at P < .0001 (after Bonferroni correction) and visualized at 7.00 < T > 12.00. Group-level contrast maps (patients vs controls) were determined by using a (q < .01) false discovery rate (FDR) corrected threshold and were visualized at 3.22 < T > 8.00. To test our results regarding the functional connectivity within the DMN, we additionally carried out an independent component analysis (ICA) for both groups using the ICA plug-in. A single-subject ICA as implemented in the BrainVoyager software package was used to analyze the entire blood oxygen leveldependent-signal data set for each subject, and each data set was then broken down into 30 components, which were of maximal statistical independence.18 Using the self-organizing group-level ICA plug-in in BrainVoyager QX version 1.10, the individual ICA-decomposed data sets were summarized at the group level.8 The group components were calculated as random effect maps (threshold of P < .001), dividing the mean ICA z value by its standard error to produce a t statistic. The resulting functional connectivity maps of t values were visualized at 2.00 < T > 10.00 (1-tailed). After ICA, the components were visually evaluated by 2 independent investigators. A minimum cluster size of 108 mm3 (4 voxels) was applied for all group analyses. The cluster size criterion was used as a conservative

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measure to minimize false positive activations due to type I errors.21 The corresponding P values at the cluster level were corrected for multiple comparisons using Bonferroni correction.

Functional Connectivity
DMN
For detection of DMN using SCA, we chose a seed cluster within the PCC/preCUN as described in the Methods section. Contrast maps and brain areas with signicant functional connectivity to PCC/preCUN in controls and patients are shown in Fig 1A. The corresponding Talairach coordinates, Brodmann areas (BAs), cluster sizes, T scores, and P values are listed in Supplementary Table e-1. We were able to identify the DMN in both groups. The resting state networks included the prefrontal cortex, the thalamus in both hemispheres, and the inferior parietal lobule (IPL) with extension across the superior temporal gyri to the PCC and anterior cingulate cortex (ACC). Patients, however, showed reduced spatial extension and activation in several above-mentioned brain areas. In group-level comparison, CRPS patients had signicantly increased functional connectivity on both sides, particularly to the ventromedial prefrontal cortex (BA 10; P < .01) and to the IPL (BA 39 and 40; P < .01). Controls, on the other hand, showed signicantly stronger functional connectivity on both sides to the thalamus, cingulate cortices (ACC, BA 32 and 24; PCC, BA 29, 30, 31; P < .01), and MPFC (BA 8 and 9; P < .01). In line with the described results of the SCA, the additional ICA revealed similar ndings. In patients, the spatial extension and activation of the DMN was also reduced, mainly in the frontal cortices (P < .001; see Fig 2 and Supplementary Table e-2).

Denition of ROIs
We examined the functional connectivity associated with 3 dened ROIs (10 10 10 mm3): PCC/preCUN (x = 67, y = 54, z = 32), S1/M1 (x = 632, y = 30, z = 44), and IPS/MIP (x = 630, y = 47, z = 43). The 3 ROIs were selected according to previously reported ndings in the literature. The PCC/preCUN coordinates for investigating functional connectivity within the DMN were adopted from an fMRI study by Pyka et al.32 The coordinates were extracted from 4 previous studies that consistently reported the spatial distribution of the DMN. The coordinates of S1/M1 and IPS/MIP were fner et al determined from an fMRI study by Maiho in which our group sought to characterize motor dysfunction in CRPS patients, as previously described in the introduction.20

Statistical Analysis
Demographic data were analyzed by basic descriptive statistics using SPSS v.18.0.0 (SPSS Inc, Chicago, IL). The descriptive data are presented as mean 6 SD. To measure correlations between functional connectivity of the ROIs and the assessed clinical parameters (sensory, motor, and autonomic symptoms), an analysis of covariance (ANCOVA) was performed as implemented in the software package BrainVoyager QX version 1.10. The covariates of interest were the intensity of pain (NRS, MPQ), motor dysfunction, autonomic disturbances, and the duration of CRPS. The ANCOVA was performed as a random effects analysis. After multiple comparison correction, an FDR (q < .05) threshold was considered to be statistically signicant. For visualization purposes, the maps were thresholded at .58 < R > 1.00 (P < .05, uncorrected). At the cluster level, values of P < .05 were considered to be statistically signicant, with a minimum cluster size of 108 mm3 (4 voxels).

Sensorimotor Cortex (S1/M1)

For our investigation, the functional connectivity maps of the S1/M1 by SCA were based on the selection of a seed cluster within S1/M1, as described in the Methods section (Fig 1B and Supplementary Table e-3). In controls, the SCA showed intraregional connectivity within S1/M1, with bilateral functional connectivity to the cingulate cortices (ACC, BA 24 and 32; PCC, BA 31), to the right primary somatosensory cortex (S1, BA 2), and to the IPL (BA 39 and 40). Patients also showed an intraregional connectivity within S1/M1, as well as a more diffuse functional connectivity to the cingulate cortices (PCC, BA 23 and 31; ACC, BA 24), parietal cortex (IPL and superior parietal lobule [SPL]), temporal cortex (BA 22 and 41), frontal cortex (BA 6, 8, 9, 10), and thalamus. In CRPS patients, group-level contrast maps showed a signicantly stronger functional connectivity of S1/M1 to the right insula (BA 13; P < .01), PCC (BA 31 and 23; P < .01), SPL (P < .01), and motor areas (premotor cortex, BA 6; M1, BA 4; P < .01). Controls, however, had stronger intraregional connectivity within S1/M1 (BA 2 and 3, P < .01) (see Fig 1B).

Results
Examined Clinical Symptoms
All patients reported spontaneous pain (NRS = 5.33 6 2.13 SD) in the affected limb. The mean MPQ PRI was 11.67 points (65.10 SD). In the affected extremity, 8 patients had hyperalgesia to punctate stimulation with von Frey laments, that is, pinprick hyperalgesia. Three patients showed hypoalgesia, whereas 6 presented with dynamic mechanical allodynia. In addition to paresis (present in 10 patients), 5 patients showed tremor and 4 showed dystonia. Edema was present in 9 patients; trophic changes were observed in 10. All other relevant epidemiologic data on the patients are listed in detail in Table 1. None of the controls showed abnormalities on neurologic examination.

Intraparietal Sulcus (IPS/MIP)

As described in the Methods section, the IPS/MIP was chosen as a seed cluster for the detection of the functional connectivity pattern of the intraparietal sulcus (Fig 1C and Supplementary Table e-4). The brain areas with signicant bilateral functional connectivity

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Figure 1. SCA. Brain regions that show signicant functional connectivity with PCC/preCUN, S1/M1, and IPS/MIP. The corresponding Talairach coordinates, BAs, cluster sizes, T scores, and P values are depicted in Supplementary Tables e-1, e-3, and e-4. Contra, contralateral to affected side; ipsi, ipsilateral to affected side. (A) Functional connectivity of PCC/preCUN in controls, CRPS patients, and contrast maps controls (red) versus CRPS patients (blue). (B) Functional connectivity of S1/M1 in controls, CRPS patients, and contrast maps controls (red) versus CRPS patients (blue). (C) Functional connectivity of IPS/MIP in controls, CRPS patients, and contrast maps controls (red) versus CRPS patients (blue). to IPS/MIP in controls were IPL (BA 39 and 40), prefrontal cortex (BA 6, 8, 9), PCC (BA 31), ACC (BA 32), and thalamus (see Fig 1C). The functional connectivity pattern in patients was markedly more diffuse. In group-level contrast maps, patients showed signicant correlations between IPS/MIP and the above-mentioned brain regions and also between IPS/MIP and the parietal cortex (PCC, BA 23 and 31; SPL, BA 7; IPL, BA 39 and 40; P < .01) with extensions across the superior temporal gyri and the inferior frontal gyri to MPFC (P < .01; see Fig 1C). ANCOVA did not survive correction for multiple comparisons after FDR correction (q < .05). Thus, the following results show a trend of correlation at P <.05 (uncorrected). We found that greater pain intensity, as measured with the MPQ, showed a trend of positive association with greater functional connectivity of PCC/preCUN with the posterior parietal cortex (BA 32, r = .61), IPL (BA 39 and 40, r = .61), thalamus (r = .59), ACC (BA 32, r = .59), sensory cortex (BA 3, r = .62), motor cortex (BA 4, r = .60), and prefrontal cortex (BA 6, r = .61; BA 8, r = .60; BA 9, r = .62) (P < .05, uncorrected; see Fig 3A). A trend of negative correlation (ie, higher spontaneous pain levels on the NRS in relation to fewer functional connectivity of S1/M1) was noted for the functional connectivity of S1/M1 with the posterior insula (BA 13, r = .60) and with the dorsolateral prefrontal cortex (DLPFC; BA 9, r = .62) (P < .05, uncorrected; see Fig 3B). Furthermore, the ANCOVA demonstrated a trend of positive correlation between greater intensity of spontaneous pain on the NRS and greater functional connectivity of IPS/MIP with the frontal cortex (BA 6, r = .62; BA 32, r = .63; BA 24, r = .61), thalamus (r = .60),

Functional Connectivity and Associated Clinical Symptoms

In order to link the clinical symptoms with the functional connectivity of the ROIs in CRPS patients, we applied an ANCOVA. The results of correlation analysis between the functional connectivity of DMN, S1/M1, IPS/MIP, and the covariates with the corresponding Talairach coordinates, BAs, cluster sizes, correlation coefcients r, and P values are shown in Fig 3 and listed in Supplementary Table e-5. However, the results of the

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Altered Functional Connectivity in CRPS interplay between brain regions in the resting state. Disruptions in resting state networks were found in several previous studies on pain patients.2,7,25,28,38 For example, Cauda and colleagues found that diabetic neuropathic pain patients had increased DMN connectivity in lateral parietal and frontal pole areas.7 Compared to controls, our CRPS patients also had signicantly stronger functional connectivity to MPFC (mainly with the ventromedial prefrontal cortex, BA 10) and to the IPL. Additionally, we found a trend of positive correlation between the increased functional connectivity of the PCC/preCUN to the prefrontal cortex (BA 6, 8, 9) and the reported intensity of pain in CRPS patients. The MPFC is a major part of the medial pain systems and is associated with the processing of emotional information. It is implicated in mediating the functional interactions between the brain regions of the pain system.3,6 The increased frontal brain activity in our CRPS patients may be a reection of pain being accompanied by more intense processing of emotional information.1 More broadly, our ndings may have implications for therapeutic interventions that attempt to modulate pain syndromes by modifying the emotional response to pain rather than the sensory input. We also demonstrated a trend of positive correlation between greater pain intensity and greater functional connectivity of PCC/preCUN with the motor areas (BA 4 and 6) and with the dorsal ACC (BA 32), known as the midcingulate cortex (MCC).40 The MCC is separated into 2 cingulate motor areas that have connectivity with the spinal cord and motor cortices.27 It is activated during anxiety and is associated with aversive stimuli.31,35 The current trend of correlation may reect the avoidance behavior accompanying pain, where patients no longer move their affected limb when experiencing intense pain.

Figure 2. ICA. Functional connectivity maps of the DMN. The

corresponding Talairach coordinates, BAs, cluster sizes, T scores, and P values are depicted in Supplementary Table e-2. Contra, contralateral to affected side; ipsi, ipsilateral to affected side. (A) DMN of controls. (B) DMN of CRPS patients.

and angular gyrus (BA 39, r = .61) (P < .05, uncorrected; see Fig 3C). Additionally, we observed no trend of correlations in CRPS patients between the functional connectivity of the ROIs and the duration of CRPS, number of motor disturbances (paresis, tremor, dystonia), or number of autonomic symptoms (edema; sweating abnormalities; alterations in skin color, skin temperature, and hair and nail growth) at P < .05 (uncorrected).

Discussion
In the current study, we used resting-state fMRI to explore the functional connectivity between brain regions implicated in the DMN, as well as the functional connectivity of the S1/M1 and the IPS/MIP in 12 CRPS patients as well as in 12 age- and sex-matched healthy controls. We demonstrated a substantial spatial alteration in the functional interplay of DMN regions in CRPS patients. Moreover, the functional connectivity of the S1/ M1 and the IPS/MIP in the patient group revealed greater and more diffuse connectivity with other brain regions, mainly with the cingulate cortex, preCUN, thalamus, and prefrontal cortex. Controls meanwhile showed greater intraregional connectivity within the relevant areas. This is the rst study, to our knowledge, to demonstrate that CRPS patients have severe spatial alterations in the functional connectivity within the DMN, S1/M1, and IPS/MIP at rest. Furthermore, we detected a trend of correlation between the intensity of pain in CRPS patients and alterations in functional connectivity.

Functional Connectivity of S1/M1and Intensity of Pain

In controls, we identied greater intraregional functional connectivity within the S1/M1. Patients, in contrast, showed reduced intraregional connectivity in this cortex area and a signicantly stronger functional connectivity of S1/M1 with the parietal cortices and with the motor areas (BA 4 and 6). Although we cannot provide mechanistic explanations, the alterations in functional connectivity of S1/M1 observed in patients may be related to the earlier observation of somatotopic changes associated with pain intensity. There are several studies that indicate that somatotopic reorganization in the primary and secondary sensory areas develops in a response to chronic pain and even to experimentally induced acute pain.9,22,36 Future studies will be required to explore the relationship between disruption in resting state functional connectivity and somatotopic changes. Studies will also be needed to determine whether intervention in a disrupted DMN may provide a means of correcting somatotopic reorganization. Furthermore, we observed a trend of correlation between greater pain intensity and lower functional

Functional Connectivity of DMN and Intensity of Pain

Our ndings conrm the hypothesis that CRPS patients also demonstrate spatial alterations in the functional

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Figure 3. ANCOVA. Trend of correlation between functional connectivity of PCC/preCUN, S1/M1, IPS/MIP, and pain intensity, as measured by MPQ and NRS (P < .05, uncorrected). The corresponding Talairach coordinates, BAs, cluster sizes, correlation coefcients r, and P values are depicted in Supplementary Table e-5. Contra, contralateral to affected side; ipsi, ipsilateral to affected side. Red = trend of positive correlation; blue = trend of negative correlation. (A) Trend of correlation between functional connectivity of PCC/perCUN and MPQ. (B) Trend of correlation between functional connectivity of S1/M1 and NRS. (C) Trend of correlation between functional connectivity of IPS/MIP and NRS. connectivity of S1/M1 with posterior insula (BA 13) and DLPFC (BA 9). Basically, the DLPFC is involved in attention, mood, and expectations and embeds, for example, the experience of pain in a context. A recent fMRI study showed activations of DLPFC in patients who were successfully suppressing pain.41,42 Furthermore, Freund and colleagues demonstrated a shift of activations from the anterior insula to the posterior insula during successful pain suppression.12 The observed trend of negative correlation between higher NRS scores and lower connectivity of S1/M1 with DLPFC and the posterior insula in our study may therefore imply a dysfunctional modulation of pain in CRPS patients. has been proposed that S1 and PCC play a critical role in the integration of multimodal information for constructing a spatial representation of personal and extrapersonal space.15 Regions of the IPS serve as an interface between perceptive and motor systems for controlling eye and hand movements.15 It has been suggested that lesions in these areas lead to neglect syndromes.17 Thus, we assume that the altered functional connectivity of IPS/MIP could give further insight into and evidence for a dysfunction in PCC sensorimotor integration in CRPS patients. Future studies will be needed to investigate whether the reported neglectlike symptoms can be correlated with the alterations in functional connectivity. Additionally, the ANCOVA demonstrated a trend of positive correlation between greater intensity of spontaneous pain on the NRS and greater functional connectivity of IPS/MIP with the premotor area (BA 6) and the ACC (BA 24 and 32). As described above, the ACC is a major part of the medial pain system, and its activations have been associated with the mediating of affective responses.40 One limitation of the present study is the investigation of a heterogeneous patient group comprising different CRPS types and different affected extremities. However,

Functional Connectivity of IPS/MIP and Intensity of Pain

Interestingly, we demonstrated that the IPS/MIP in CRPS patients had signicantly stronger connectivity with the parietal cortex (IPL and SPL) than it did in controls. The alterations in functional connectivity of S1/M1 and IPS/MIP may well explain sensory disturbances common in CRPSfor example, the neglect-like symp h et al11 and Galer et al.11,13 It toms reported by Frethlo

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Altered Functional Connectivity in CRPS essential part of CRPS treatment, it cannot be excluded when investigating functional connectivity in CRPS patients.

in order to minimize any bias, we intentionally performed a consecutive sampling of the patients in our outpatients clinic. With this approach, no inclusion criteria such as pain intensity or sensory disturbances, which may go along with central changes, were applied. Furthermore, 1 major parameter of interest in our study was pain. We investigated if and how pain in CRPS (independent of the body region) affects the functional connectivity of the brain at rest. As a recent study by hlen and colleagues showed, CRPS I and CRPS Gierthmu II have very similar sensory patterns, that is, they may have a similar pathophysiology of pain and hyperalgesia. CRPS I and CRPS II only differ in that the loss of mechanical detection is stronger in CRPS II, probably the result of the underlying nerve lesion.14 Nevertheless, given the heterogeneity of our study population, we found a uniformly altered pattern of functional connectivity in the DMN of CRPS patients. Another limitation is that some CRPS patients were already on medication. The use of medication may have inuenced the functional structure of the brain at rest. Future studies should investigate whether the use of analgesics inuences the resting state network. However, because pharmacotherapy is an

Conclusion
In the present study, we demonstrate substantial spatial alterations in the functional connectivity between brain regions implicated in the DMN, S1/M1, and IPS/MIP at rest in CRPS. These alterations show a trend of correlation with the intensity of neuropathic pain.

Acknowledgments
We thank Professor Dr. Walter Huk (former head of the Department of Neuroradiology, University of Erlangen) for giving us access to the MRI unit. The authors thank fer for excellent Cornelia Hofmann and Dr. Iris Scha technical assistance.

Supplementary Data
Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jpain.2013.04.007.

References
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31. Porro CA, Cettolo V, Francescato MP, Baraldi P: Functional activity mapping of the mesial hemispheric wall during anticipation of pain. NeuroImage 19:1738-1747, 2003 32. Pyka M, Burgmer M, Lenzen T, Pioch R, Dannlowski U, Peiderer B, Ewert AW, Heuft G, Arolt V, Konrad C: Brain correlates of hypnotic paralysisA resting-state fMRI study. NeuroImage 56:2173-2182, 2011 33. Raichle ME: The brains dark energy. Science 314: 1249-1250, 2006 34. Raichle ME, MacLeod AM, Snyder AZ, Powers WJ, Gusnard DA, Shulman GL: A default mode of brain function. Proc Natl Acad Sci U S A 98:676-682, 2001 35. Sawamoto N, Honda M, Okada T, Hanakawa T, Kanda M, Fukuyama H, Konishi J, Shibasaki H: Expectation of pain enhances responses to nonpainful somatosensory stimulation in the anterior cingulate cortex and parietal operculum/posterior insula: An event-related functional magnetic resonance imaging study. J Neurosci 20:7438-7445, 2000 ro s P, Knecht S, Bantel C, Imai T, Wu sten R, Pantev C, 36. So ner B, Bu tkenho rkle H, Henningsen H: Functional reorgaLu nization of the human primary somatosensory cortex after acute pain demonstrated by magnetoencephalography. Neurosci Lett 298:195-198, 2001 37. Stein C, Mendl G: The German counterpart to McGill Pain Questionnaire. Pain 32:251-255, 1988 38. Tagliazucchi E, Balenzuela P, Fraiman D, Chialvo DR: Brain resting state is disrupted in chronic back pain patients. Neurosci Lett 485:26-31, 2010 39. Talairach J, Tournoux P: Co-Planar Stereotaxic Atlas of the Human Brain. New York, NY, Thieme Medical Publishers, 1988 40. Vogt BA: Pain and emotion interactions in subregions of the cingulate gyrus. Nat Rev Neurosci 6:533-544, 2005 41. Wager TD, Rilling JK, Smith EE, Sokolik A, Casey KL, Davidson RJ, Kosslyn SM, Rose RM, Cohen JD: Placeboinduced changes in FMRI in the anticipation and experience of pain. Science 303:1162-1167, 2004 42. Wiech K, Kalisch R, Weiskopf N, Pleger B, Stephan KE, Dolan RJ: Anterolateral prefrontal cortex mediates the analgesic effect of expected and perceived control over pain. J Neurosci 26:11501-11509, 2006

1115.e1 Supplementary Table e-1.

REGION A: Controls PCC seed PMC PMC PMC PMC MPFC MPFC MPFC/DLPFC MPFC/DLPFC INS ACC ACC ACC PCC PCC IPL IPL Th Th B: CRPS patients PCC seed PMC PMC MPFC MPFC/DLPFC MPFC/DLPFC MPFC/DLPFC ACC PCC PCC SPL SPL IPL IPL IPL STG Th Th Caudate C: Contrast PCC seed controls vs patients M1 M1 M1 PMC PMC PMC PMC PMC PMC PMC PMC PMC PMC PMC PMC MPFC/DLPFC MPFC MPFC MPFC DLPFC VPFC VPFC VPFC

Altered Functional Connectivity in CRPS

Regions of Functional Connectivity at Rest Depicted in Fig 1A

SIDE contra ipsi contra ipsi ipsi contra contra ipsi ipsi contra ipsi contra ipsi contra contra ipsi ipsi contra contra ipsi ipsi contra ipsi contra contra ipsi contra contra contra contra ipsi contra ipsi ipsi contra ipsi ipsi contra ipsi contra ipsi contra ipsi contra ipsi contra contra contra ipsi contra contra ipsi ipsi contra ipsi contra ipsi contra ipsi X 19 21 5 5 10 2 3 6 46 5 6 1 9 5 42 41 4 7 36 29 10 34 8 7 2 10 6 7 24 33 43 42 51 11 9 1 37 25 27 3 48 22 6 11 7 19 27 42 31 37 54 39 26 13 14 42 28 30 22 Y 21 20 23 17 43 42 45 45 47 31 15 6 50 50 56 55 18 17 4 11 34 17 46 52 18 56 52 44 59 48 53 56 33 16 3 3 21 27 27 5 5 12 9 21 19 20 13 3 10 5 8 30 32 29 28 30 41 45 54 Z 51 54 50 60 41 38 23 24 19 5 37 37 23 22 22 34 14 14 48 50 48 29 21 21 21 27 25 56 45 33 13 15 6 12 10 3 37 56 58 55 10 44 60 47 49 61 59 38 53 52 28 30 46 43 41 8 20 14 15 BA 6 6 6 6 8 8 9 9 13 24 24 24 23/31 23/31 39/40 39/40 6 6 8 9 9 9 24 23/31 23/31 5 7 40 39/40 39/40 22 4 4 4 6 6 6 6 6 6 6 6 6 6 6 6 9 8 8 8 46 10 10 10
T-SCORE

P VALUE (CORR.) <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001

SIZE (MM3) 2746 1165 1471 2141 2987 5184 5321 8271 1972 226 3195 2554 30120 25915 3593 471 3768 2954 668 338 1947 117 7485 4394 439 29470 11760 216 112 781 1700 5652 374 694 290 150 504 243 178 947 365 180 4635 347 3307 158 268 160 388 229 1337 705 230 14881 189 698 439 2070 293

8,742 8,986 8,995 8,818 10,715 10,896 11,514 12,123 10,107 7,089 11,558 10,070 22,273 18,961 9,787 8,113 10,466 10,415 10,864 9,770 13,076 8,808 14,691 12,107 10,474 23,101 17,572 9,451 8,290 11,671 13,010 13,658 8,976 11,365 9,544 7,859 5,223 4,976 6,056 5,105 3,891 4,163 5,228 5,324 4,996 4,694 3,243 4,915 5,654 5,183 7,404 3,988 3,742 4,716 4,157 3,505 3,759 4,984 4,777

fner Bolwerk, Seifert, and Maiho Supplementary Table e-1.

REGION INS INS INS INS ACC ACC ACC ACC ACC PCC PCC PCC PCC PCC PCC PCC PCC SPL SPL SPL IPL IPL IPL IPL IPL IPL Th Th CUN MTG

1115.e2

Continued
SIDE ipsi ipsi contra ipsi contra ipsi contra ipsi contra contra ipsi ipsi contra ipsi contra ipsi contra contra contra contra contra ipsi contra ipsi contra contra ipsi contra contra contra X 30 45 45 52 44 12 12 3 13 7 5 22 14 29 18 10 2 13 19 31 48 31 48 26 41 38 5 2 10 57 Y 24 47 6 32 11 41 13 27 36 48 47 57 57 72 36 43 46 57 45 41 54 42 34 39 67 56 6 8 76 36 Z 5 19 1 19 28 7 22 22 25 28 27 12 22 8 2 9 9 52 56 56 36 37 37 57 13 26 19 19 10 4 BA 13 13 13 13 24 32 24 24 32 31 31 30 31 30 30 29 29 7 7 5 40 40 40 40 39 39 17 21
T-SCORE

P VALUE (CORR.) <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001

SIZE (MM3) 211 1146 1852 1300 538 192 1988 1721 3549 9053 12703 556 1669 597 794 5812 3279 439 234 124 111 380 3321 125 681 368 2453 1130 2813 168

4,437 4,377 3,515 4,017 5,163 3,987 4,268 4,379 4,667 4,262 4,339 4,459 4,677 4,860 5,801 6,392 5,743 5,559 3,607 4,256 4,914 6,801 6,994 4,610 6,576 3,966 5,145 5,435 4,181 3,953

Abbreviations: S1, primary somatosensory cortex; ACC, anterior cingulate cortex; MPFC, medial prefrontal cortex; DLPFC, dorsolateral prefrontal cortex; VPFC, ventral prefrontal cortex; VLPFC, ventrolateral prefrontal cortex; PCC, posterior cingulate cortex; M1, primary motor cortex; PMC, premotor cortex; IPL, inferior parietal lobule; SPL, superior parietal lobule; INS, insula; Th, thalamus; preCUN, precuneus; CUN, cuneus; INS, insula; MTG, middle temporal gyrus; STG, superior temporal gyrus.

1115.e3 Supplementary Table e-2.

REGION A: Controls ICA PMC PMC PMC PMC PMC MPFC MPFC MPFC/DLPFC MPFC/DLPFC MPFC/DLPFC VLPFC VLPFC PCC PCC IPL IPL IPL MTG MTG MTG MTG Th Th Ph Ph B: CRPS patients ICA PMC PMC MPFC/DLPFC MPFC/DLPFC MPFC/DLPFC MPFC MPFC MPFC MPFC VPFC VPFC VPFC VLPFC SPL SPL preCUN preCUN PCC PCC PCC IPL IPL IPL STG STG MTG MTG Caudate Ph Ph SIDE contra ipsi contra ipsi contra ipsi contra ipsi contra ipsi contra contra ipsi contra ipsi contra ipsi contra ipsi contra ipsi ipsi contra ipsi contra ipsi ipsi contra ipsi contra ipsi contra ipsi contra ipsi contra ipsi contra contra contra ipsi contra ipsi contra ipsi contra ipsi contra contra ipsi contra ipsi contra ipsi contra

Altered Functional Connectivity in CRPS

Regions of Functional Connectivity at Rest Depicted in Fig 2

X 3 2 37 39 31 9 5 33 7 7 51 41 8 2 46 39 49 47 63 56 57 6 2 20 18 36 31 41 38 21 43 39 3 1 22 14 7 54 28 24 7 10 2 2 9 40 33 49 63 58 49 62 8 10 9 Y 33 39 6 9 6 22 32 6 50 51 26 25 58 48 64 69 50 60 26 12 2 19 25 15 16 10 15 30 45 60 16 17 22 16 62 59 59 8 57 62 72 77 50 53 68 58 72 71 24 37 43 48 2 34 33 Z 66 63 53 48 46 56 53 33 27 27 10 3 20 16 32 35 17 15 3 7 11 13 10 11 12 54 59 35 33 28 44 44 45 45 20 1 1 5 55 51 36 36 34 35 11 39 33 12 2 11 12 10 15 1 2 BA 6 6 6 6 6 8 8 9 9 9 45 47 31 31 39 39 39 19 21 21 21 6 6 9 9 9 8 8 8 8 10 10 10 44 7 7 7 7 31 31 30 39/40 39/40 39/40 22 22 21 21
T-SCORE

P VALUE (CORR.) <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001

SIZE (MM3) 689 600 1576 1557 1814 8529 7094 181 12154 21347 166 355 4669 10314 3381 703 152 949 2480 3824 845 1166 1952 1159 307 273 331 260 2681 1872 450 1110 431 648 1980 444 479 2520 260 301 4792 6388 3274 3089 402 3074 2397 242 411 434 724 551 290 357 184

7,245 7,593 4,549 6,124 6,125 8,834 7,415 5,227 11,500 13,078 4,659 4,429 23,409 19,217 8,474 5,007 5,351 8,079 6,636 5,718 7,768 8,703 8,641 6,919 6,266 5,008 5,650 4,900 4,341 9,323 6,503 5,135 5,871 4,896 7,705 8,052 6,779 4,363 4,655 6,703 13,634 9,269 27,344 14,517 10,527 7,900 10,247 4,999 5,877 8,034 9,812 7,581 7,327 5,424 4,223

Abbreviations: MPFC, medial prefrontal cortex; DLPFC, dorsolateral prefrontal cortex; VPFC, ventral prefrontal cortex; VLPFC, ventrolateral prefrontal cortex, PCC, posterior cingulate cortex; PMC, premotor cortex; IPL, inferior parietal lobule; Th, thalamus; preCUN, precuneus; STG, superior temporal gyrus; MTG, middle temporal gyrus; Ph, parahippocampal gyrus.

fner Bolwerk, Seifert, and Maiho Supplementary Table e-3.

REGION A: Controls S1/M1 seed S1 S1 PMC PMC PMC PMC PMC MPFC MPFC MPFC MPFC MPFC/DLPFC MPFC/DLPFC VLPFC INS INS ACC ACC ACC CUN PCC PCC PCC PCC SPL SPL IPL IPL IPL IPL Th Th B: Patients S1/M1 seed S1 M1 M1 PMC PMC PMC PMC PMC PMC PMC MPFC MPFC/DLPFC MPFC/DLPFC MPFC/DLPFC VPFC ACC PCC PCC PCC PCC SPL SPL SPL IPL IPL TTG TTG STG

1115.e4

Regions of Functional Connectivity S1/M1 Depicted in Fig 1B

SIDE contra ipsi ipsi ipsi contra ipsi ipsi contra ipsi contra contra ipsi ipsi contra contra contra contra ipsi contra ipsi contra contra ipsi contra ipsi contra ipsi contra ipsi ipsi ipsi contra contra ipsi contra ipsi contra ipsi contra ipsi contra ipsi ipsi contra contra contra ipsi ipsi contra contra contra contra ipsi ipsi ipsi ipsi contra ipsi ipsi contra X 31 49 6 14 1 44 22 11 18 24 34 47 10 35 35 34 14 4 3 9 8 3 27 21 6 3 24 40 32 44 14 6 32 29 44 16 26 45 23 32 21 32 43 32 46 11 29 5 25 2 7 8 11 25 7 38 46 51 48 54 Y 30 23 11 14 12 5 4 28 32 27 25 7 44 26 7 23 35 6 10 81 30 44 65 72 60 38 42 51 49 34 11 5 30 25 12 28 16 14 7 8 8 31 9 9 11 52 48 5 71 15 55 46 60 48 34 57 59 18 29 14 Z 46 28 49 59 52 39 58 43 50 51 46 27 21 2 10 11 7 31 32 7 36 42 19 16 39 55 54 6 34 45 13 13 44 50 39 37 53 34 48 45 54 35 42 38 22 28 25 44 27 43 14 43 42 39 42 22 9 14 5 6 BA 3 2 6 6 6 6 6 8 8 8 8 9 9 47 13 13 32 24 24 17 31 31 31 31 7 5 40 39 40 40 3 4 4 6 6 6 6 6 6 6 8 9 9 9 10 24 31 31 23 31 7 7 7 39 39 41 41 22
T-SCORE

P VALUE (CORR.) <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001

SIZE (MM3) 12774 3825 780 641 1558 133 906 205 362 188 193 367 1619 287 1543 1078 642 298 515 207 112 272 2605 1539 362 874 325 2195 4704 309 818 1120 12545 461 2815 2781 138 1063 628 297 834 1209 167 1551 904 197 130 3522 492 2392 2849 6998 3330 1369 3529 873 977 511 183 1669

28,987 9,147 9,745 8,693 10,603 7,171 9,285 8,083 7,784 7,658 7,217 6,744 8,883 7,534 7,764 9,178 8,685 8,073 8,370 7,225 7,320 6,789 10,448 9,422 7,336 9,552 8,599 8,966 12,902 6,483 9,021 8,615 24,842 11,480 13,897 11,580 8,885 13,496 12,404 11,452 12,177 13,192 9,136 12,414 9,713 7,522 8,112 13,406 9,373 12,349 9,838 11,580 11,738 10,749 11,759 11,293 10,020 10,661 9,180 11,549

1115.e5 Supplementary Table e-3.

REGION STG Th Th C 1: Contrast S1/M1 seed controls vs patients S1 S1 S1 S1 M1 M1 PMC PMC PMC PMC PMC VLPFC VLPFC MPFC MPFC MPFC/DLPFC MPFC/DLPFC INS INS ACC ACC ACC SPL SPL PCC PCC PCC PCC PCC PCC MTG Th Th

Altered Functional Connectivity in CRPS

Continued
SIDE contra ipsi contra contra ipsi contra ipsi ipsi contra ipsi ipsi contra ipsi contra contra contra ipsi contra ipsi ipsi ipsi ipsi contra contra ipsi ipsi contra ipsi contra ipsi contra ipsi contra contra contra ipsi X 34 13 10 31 30 21 50 26 56 4 15 12 8 52 36 50 10 25 17 6 40 37 18 6 18 15 14 1 11 9 7 6 18 48 16 6 Y 52 11 9 27 31 32 26 22 11 1 13 9 28 2 25 13 43 26 30 55 1 9 35 4 37 60 60 21 43 30 51 33 54 61 26 36 Z 14 15 16 45 58 61 32 44 30 46 61 65 51 30 2 23 47 52 34 29 2 19 5 43 8 44 50 45 43 39 21 28 32 12 5 12 BA 22 3 3 3 2 4 4 6 6 6 6 6 47 45 8 8 9 9 13 13 32 24 32 7 7 31 31 31 31 23 31 21
T-SCORE

P VALUE (CORR.) <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001

SIZE (MM3) 782 2338 3034 308 119 775 120 170 126 115 779 444 146 139 136 476 180 115 1237 348 199 379 552 153 463 529 302 267 1099 263 2139 160 143 455 331 194

10,085 12,946 12,781 5,449 4,388 6,514 4,512 4,933 4,562 5,115 5,110 6,124 4,473 4,687 4,729 5,779 4,638 4,715 6,140 4,987 5,577 5,290 5,081 5,191 5,754 6,277 4,672 4,888 4,870 5,583 5,716 4,637 5,868 5,500 5,690 4,049

Abbreviations: S1, primary somatosensory cortex; ACC, anterior cingulate cortex; MPFC, medial prefrontal cortex; DLPFC, dorsolateral prefrontal cortex; VLPFC, ventrolateral prefrontal cortex; PCC, posterior cingulate cortex; M1, primary motor cortex; PMC, premotor cortex; IPL, inferior parietal lobule; SPL, superior parietal lobule; Th, thalamus; preCUN, precuneus; INS, insula; INS, insula; STG, superior temporal gyrus; TTG, transversal temporal gyrus.

fner Bolwerk, Seifert, and Maiho Supplementary Table e-4.

REGION A: Controls IPS/MIP seed PMC PMC PMC PMC PMC MPFC MPFC/DLPFC MPFC/DLPFC MPFC/DLPFC VPFC INS INS ACC ACC preCUN preCUN PCC PCC PCC IPS/MIP IPS/MIP IPL IPL TTG STG MTG MTG Th Th Caudate Caudate B: Patients IPS/MIP seed S1 S1 PMC PMC VPFC VPFC MPFC MPFC/DLPFC MPFC/DLPFC INS ACC ACC preCUN preCUN PCC PCC IPS/MIP IPS/MIP IPL STG Caudate Caudate Th Th C 1: Contrast IPS/MIP seed controls vs patients S1 M1 M1 M1

1115.e6

Regions of Functional Connectivity IPS Depicted in Fig 1C

SIDE ipsi contra ipsi ipisi ipsi ipsi contra ipsi contra ipsi ipsi contra ipsi contra contra ipsi contra ipsi ipsi ipsi contra ipsi contra contra contra contra contra ipsi contra ipsi contra contra ipsi contra ipsi contra ipsi contra contra ipsi ipsi ipsi contra contra ipsi contra ipsi contra ipsi contra contra contra ipsi contra ipsi contra ipsi contra ipsi X 44 32 14 26 6 10 32 46 35 33 51 36 3 2 15 7 6 2 24 34 31 47 56 32 55 49 38 12 6 8 5 32 48 39 40 29 33 20 35 40 47 7 3 15 19 6 6 30 36 49 47 15 15 9 12 25 36 37 36 Y 2 11 13 4 20 42 36 9 8 43 24 11 10 9 69 62 35 39 61 50 43 46 22 27 1 46 59 18 20 3 5 30 25 3 7 43 45 37 11 20 24 15 9 75 71 34 35 47 47 25 47 2 1 11 11 33 16 19 15 Z 44 47 57 56 55 48 34 28 36 25 15 10 39 40 29 40 40 44 24 40 42 27 15 10 5 6 5 12 15 15 14 33 30 41 42 25 23 40 36 36 17 43 43 29 30 40 36 43 45 19 13 15 15 17 16 61 46 52 46 BA 6 6 6 6 6 8 9 9 9 10 13 13 32 32 7 7 31 31 31 40 40 39/40 39/40 41 22 21 21 2 2 6 6 10 10 8 9 9 13 32 32 7 7 31 31 40 40 39/40 22 3 4 4 4
T-SCORE

P VALUE (CORR.) <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001

SIZE (MM3) 303 783 751 1963 1595 390 6969 1061 1707 497 6648 6934 1075 851 7047 3367 1974 6351 4072 5226 17373 228 704 1441 224 1195 585 574 936 1445 758 19756 19543 19699 8552 15063 6788 1812 17444 11886 8772 7665 7032 30123 30409 20444 25789 20002 16999 14646 9260 2234 2256 6490 5306 252 2864 3552 2805

6,916 9,323 8,589 11,260 8,966 8,260 12,188 7,861 8,804 7,314 10,291 10,583 8,003 8,125 12,670 8,904 10,115 9,142 11,383 11,233 29,995 8,524 7,819 8,892 6,602 8,084 8,761 8,046 8,959 9,046 8,332 21,457 15,666 19,764 16,775 14,987 9,819 12,307 16,888 12,333 14,718 10,232 9,566 12,999 12,886 19,148 19,556 29,356 19,001 15,530 12,857 12,897 12,901 15,919 15,175 4,068 9,072 9,819 9,086

1115.e7 Supplementary Table e-4.

REGION PMC PMC PMC PMC PMC PMC PMC PMC PMC MPFC MPFC MPFC MPFC MPFC MPFC MPFC/DLPFC MPFC/DLPFC MPFC/DLPFC DLPFC VPFC INS INS ACC SPL SPL SPL SPL IPL IPL IPL PCC PCC PCC PCC PCC PCC IPS/MIP TTG TTG Caudate Caudate Caudate Caudate Caudate Ncl Ncl Th Th Th Th

Altered Functional Connectivity in CRPS

Continued
SIDE ipsi contra ipsi contra ipsi contra ipsi contra ipsi contra ipsi contra ipsi contra ipsi contra ipsi contra contra contra contra ipsi contra contra ipsi contra ipsi contra ipsi contra ipsi contra ipsi contra ipsi contra contra contra contra contra ipsi contra ipsi contra ipsi contra ipsi Contra ipsi contra X 6 1 41 52 50 31 16 45 31 2 4 20 26 12 10 25 25 48 48 19 36 30 8 26 30 25 11 45 37 50 23 20 16 7 8 7 45 49 61 1 5 16 11 14 25 28 6 8 13 12 Y 5 4 6 1 1 5 16 2 13 23 24 14 25 37 43 33 39 16 31 51 23 25 20 54 44 57 69 54 55 28 38 60 55 72 35 42 38 28 19 1 3 2 16 20 1 2 34 37 7 9 Z 51 50 32 23 36 55 59 41 50 45 45 40 38 52 46 28 18 27 13 19 1 15 39 53 42 29 38 27 32 22 30 9 25 29 41 31 41 11 10 19 19 27 9 11 10 1 14 10 12 17 BA 6 6 6 6 6 6 6 6 6 8 8 8 8 8 8 9 9 9 46 10 13 13 24 7 7 7 7 39/40 39/40 39/40 31 30 31 31 31 31 40 41 42
T-SCORE

P VALUE (CORR.) <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001

SIZE (MM3) 2206 2840 328 3425 469 7275 1004 7091 424 937 705 234 2924 272 986 362 1016 2324 480 2287 162 2156 258 403 5574 2785 563 5355 1642 1181 674 614 313 208 4584 5032 6211 469 201 278 474 1131 1051 3029 1407 1102 3074 2880 1244 557

7,990 8,655 5,241 6,984 6,219 10,281 4,956 9,352 5,880 6,062 6,087 4,917 6,413 4,069 4,111 4,856 4,946 5,963 3,302 6,877 4,496 6,886 5,550 6,283 11,786 9,473 5,754 8,376 6,789 6,479 6,918 4,755 3,489 4,820 11,068 10,618 10,930 5,620 5,150 5,718 6,214 6,247 5,933 7,328 6,207 5,014 7,185 6,788 7,411 6,337

Abbreviations: S1, primary somatosensory cortex; ACC, anterior cingulate cortex; MPFC, medial prefrontal cortex; DLPFC, dorsolateral prefrontal cortex; VPFC, ventral prefrontal cortex; VLPFC, ventrolateral prefrontal cortex; PCC, posterior cingulate cortex; M1, primary motor cortex; PMC, premotor cortex; IPL, inferior parietal lobule; SPL, superior parietal lobule; Th, thalamus; preCUN, precuneus; CUN, cuneus; Ncl, Lentiform nucleus; INS, insula; IPS/MIP, intraparietal sulcus; TTG, transversal temporal gyrus.

fner Bolwerk, Seifert, and Maiho Supplementary Table e-5.

1115.e8

Trend of Correlation Between Functional Connectivity and Clinical Parameters Depicted in Fig 3 (P < .05, Uncorrected)
REGION SIDE X Y Z BA
R

P VALUE

SIZE (MM3)

A: Trend of correlation between functional connectivity of PCC and intensity of pain (MPQ) S1 S1 M1 PMC PMC PMC PMC MPFC MPFC MPFC/DLPFC MPFC/DLPFC MPFC/DLPFC INS dACC CUN preCUN preCUN preCUN preCUN PCC IPL IPL IPL IPL IPL Th B: Trend of correlation between functional connectivity of S1/M1 and intensity of spontaneous pain (NRS) MPFC/DLPFC MPFC/DLPFC MPFC/DLPFC pINS C: Trend of correlation between functional connectivity of IPS/MIP and intensity of spontaneous pain (NRS) ACC dACC dACC PMC Broca AG Th

contra ipsi ipsi contra ipsi contra ipsi contra ipsi contra ipsi contra contra ipsi ipsi contra ipsi contra ipsi contra contra ipsi contra contra contra contra

19 33 52 32 27 5 3 2 4 40 47 48 37 10 4 30 34 5 2 2 46 38 35 56 53 20

29 30 15 16 15 1 6 20 25 4 8 4 21 9 78 63 64 70 61 32 56 45 58 27 51 23

58 53 25 45 47 53 52 46 39 37 33 20 15 40 19 40 31 27 45 31 35 42 33 27 20 15

3 3 4 6 6 6 6 8 8 9 9 9 13 32 19 31 31 31 31 31 39/40 39/40 39/40 39/40 39/40

.62 .62 .60 .60 .61 .60 .60 .60 .60 .61 .62 .61 .61 .59 .61 .60 .61 .61 .59 .60 .61 .61 .61 .60 .60 .59

<.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05 <.05

130 234 106 124 274 239 843 480 435 510 1141 379 227 249 115 116 276 299 134 128 109 1127 748 193 246 215

ipsi ipsi contra ipsi

16 30 50 45

47 35 6 39

31 33 28 20

9 9 9 13

.62 .62 .61 .60

<.05 <.05 <.05 <.05

327 240 182 158

ipsi ipsi contra ipsi contra contra ipsi

5 2 2 30 50 38 15

7 27 24 15 8 59 35

31 34 35 54 14 34 16

24 32 32 6 44 39

.61 .62 .63 .62 .60 .61 .60

<.05 <.05 <.05 <.05 <.05 <.05 <.05

133 275 223 629 234 213 130

Abbreviations: MPFC, medial prefrontal cortex; VPFC, ventral prefrontal cortex; DLPFC, dorsolateral prefrontal cortex; IPL, inferior parietal lobule; Th, thalamus; preCUN, precuneus; CUN, cuneus; PCC, posterior cingulate cortex; AG, angular gyrus; ACC, anterior cingulate cortex; dACC, dorsal anterior cingulate cortex; S1, primary somatosensory cortex; M1, primary motor cortex; IPS/MIP, intraparietal sulcus; pINS, posterior insula; NRS, numeric rating scale; MPQ, McGill Pain Questionnaire.