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Prof. A.V. SRINIVASAN.
MD, DM, PhD, DSc, FRCP (Lond), FAAN, FIAN,
EMERITUS PROFESSOR OF NEUROLOGY
FORMER HEAD AND PROFESSOR OF NEUROLOGY
Institute of Neurology
Chennai
Prof. A.V. SRINIVASAN.
,
EMERITUS PROFESSOR OF NEUROLOGY
FORMER HEAD AND PROFESSOR OF NEUROLOGY
Institute of NeurologyChennai
The sign wasn’t placed there
By the Big Printer in the sky
PharmacologyPharmacology
Physical and NeurologicalPhysical and Neurological
Non PharmacolgicalNon Pharmacolgical
AffectiveAffective
BehaviouralBehavioural
CognitiveCognitive
SocialSocial
Physical Treatments
SimpleMovement-based
Interventional
Ice/Heat ManipulationPeripheral
Spinal
Central
SplintingPhysiotherapy
Acupuncture
Injections Stimulation
Corset/support
Exercise TENS “Pulsing”Psychosurgery
InjectionsNeurolysis
Cryotherapy
Stimulation
Non-pharmacological therapies
Cognitive TreatmentsCognitive Treatments
Individual
Group
Counseling
Pain Management Programs
Transpersonal therapy
Recovery Model (peer-to-peer)
CBT/CAT/ACT
Peer Support
Hypnosis
Modification of the Modification of the sensory sensory aspects of painaspects of pain
Simple measuresSimple measures- heat, ice, massage, - heat, ice, massage, manipulative therapies (e.g. chiropractic, manipulative therapies (e.g. chiropractic, osteopathy), physiotherapy osteopathy), physiotherapy
Treating the primary causeTreating the primary cause- e.g. improve - e.g. improve diabetic control; supplement thiamine; reduce/stop diabetic control; supplement thiamine; reduce/stop alcohol consumption. Treating the primary cause alcohol consumption. Treating the primary cause includes interventional techniques such as surgery includes interventional techniques such as surgery for disc prolapses or spinal stenosis; or nerve for disc prolapses or spinal stenosis; or nerve translocation surgery (e.g. carpal tunnel release)translocation surgery (e.g. carpal tunnel release)
Stimulating inhibitory mechanismsStimulating inhibitory mechanisms in the in the periphery or in the spinal cord: e.g. acupuncture periphery or in the spinal cord: e.g. acupuncture /TENS; electrical peripheral nerve or dorsal column /TENS; electrical peripheral nerve or dorsal column or central (deep-brain) stimulation or central (deep-brain) stimulation
Inhibition or prevention of ascending nerve Inhibition or prevention of ascending nerve transmissiontransmission in the peripheral nervous system, in in the peripheral nervous system, in the dorsal root ganglion or spinal cord: e.g. nerve the dorsal root ganglion or spinal cord: e.g. nerve blocks, neurolysis or rhyzolysisblocks, neurolysis or rhyzolysis
Modification of the Modification of the sensory sensory aspects of painaspects of pain
Alter pain processing at the cortical Alter pain processing at the cortical levellevel, e.g. cognitive therapies, biofeedback, , e.g. cognitive therapies, biofeedback, hypnosis, meditation. It is currently unclear hypnosis, meditation. It is currently unclear the exact way in which these therapies alter the exact way in which these therapies alter sensation, but is assumed to involved both sensation, but is assumed to involved both descending inhibition and alteration of descending inhibition and alteration of sensitivity to ascending stimulussensitivity to ascending stimulus
Modification of the Modification of the sensory sensory aspects of painaspects of pain
Thomas ElbertThomas Elbert
Cortical representation expands linearly with Cortical representation expands linearly with
use.use.
Synchronous inputs lead to fusion of cortical Synchronous inputs lead to fusion of cortical zoneszones
Asynchronous inputs lead to segregation of Asynchronous inputs lead to segregation of cortical zonescortical zones..
Disuse or De-afferentation leads to invasion of Disuse or De-afferentation leads to invasion of
unused cortical area by nearby neurons.unused cortical area by nearby neurons.
Basic Basic PrinciplesPrinciples
Sensory modulation in spatial Sensory modulation in spatial neglectneglect
Peripheral somatosensory- Magnetic Peripheral somatosensory- Magnetic stimulationstimulation
Repetitive optokinetic stimulation Repetitive optokinetic stimulation
Neck Vibration trainingNeck Vibration training
Drug Treatment is currently unsuccessful
Novel TechniquesNovel Techniques
Sensory modulation and Sensory modulation and StrokeStroke
Rehabilitation aimed to increase use of Rehabilitation aimed to increase use of paretic handparetic hand
Virtual reality Virtual reality
Motor imagery Motor imagery
Prof. Prof. V.S..Ramachandran’sV.S..Ramachandran’s virtual reality virtual reality boxbox
Phantom limb phenomenon Phantom limb phenomenon
Other techniquesOther techniques
Caloric tests for balanceCaloric tests for balance Brings awareness of illness to patient.Brings awareness of illness to patient.
Kinesthetic, visual, and auditory Kinesthetic, visual, and auditory cues to improve Parkinsonian gait.cues to improve Parkinsonian gait.
INTERMANUAL REFERRAL OF INTERMANUAL REFERRAL OF SENSATION AND EXTINCTION OF SENSATION AND EXTINCTION OF PAIN IN PERIPHERAL AND PAIN IN PERIPHERAL AND CENTRAL LESIONS OF SOMATO CENTRAL LESIONS OF SOMATO SENSORY SYSTEMSENSORY SYSTEM
INTERMANUAL REFERRAL OF INTERMANUAL REFERRAL OF SENSATION AND EXTINCTION OF SENSATION AND EXTINCTION OF PAIN IN PERIPHERAL AND PAIN IN PERIPHERAL AND CENTRAL LESIONS OF SOMATO CENTRAL LESIONS OF SOMATO SENSORY SYSTEMSENSORY SYSTEM
BACKGROUNDBACKGROUND
Allesthesia and extinction of referral Allesthesia and extinction of referral sensation in brachial plexus lesions sensation in brachial plexus lesions A.V. Srinivasan and V.S. Ramachandran et al A.V. Srinivasan and V.S. Ramachandran et al (1998) (1998)
Intermanual referral of sensations Intermanual referral of sensations after central lesions of the somato after central lesions of the somato sensory system sensory system K. Sathian et al (2000) K. Sathian et al (2000)
METHODS METHODS
8 patients (19-51 years)8 patients (19-51 years) Brachial plexus lesion Brachial plexus lesion – one– one AmputationAmputation – two– two StrokeStroke – five– five
Patients were video filmed in the Patients were video filmed in the movement disorder clinic. Pinprick, cold, movement disorder clinic. Pinprick, cold, vibration and kinesthesis were testedvibration and kinesthesis were tested
MRI & ENMG in all cases MRI & ENMG in all cases
CENTRAL LESIONCENTRAL LESION
StrokeStrokeThalamic stroke Thalamic stroke - three- threeTemparo parietalTemparo parietal - two- two
Three to four months laterThree to four months later
Ipsilateral arm Ipsilateral arm - no referral- no referral to legto leg
STROKE STROKE Contd…Contd…
Intense pressure on the normal hand Intense pressure on the normal hand
resulted in extinction of pain in the resulted in extinction of pain in the
stroke sidestroke side
Pain returned within one Pain returned within one
minute of the pressure minute of the pressure
Intense pressure improved Intense pressure improved
sensory and motor sensory and motor
phenomenonphenomenon
AMPUTATIONAMPUTATION
Both the patients (below Both the patients (below
elbow & knee amputation) elbow & knee amputation)
showed intermanual showed intermanual
referral of sensation within referral of sensation within
10 days. The referred 10 days. The referred
sensations of touch and sensations of touch and
vibration lacked spatial vibration lacked spatial
organization and poor organization and poor
localization with a localization with a
relatively high threshold relatively high threshold
CASE VIGNETTE (BRACHIAL PLEXUS CASE VIGNETTE (BRACHIAL PLEXUS LESION)LESION)
21 year old girl, after total 21 year old girl, after total
brachial plexus lesion was brachial plexus lesion was
examined 6 months, 1 ½ & examined 6 months, 1 ½ &
2 ½ years after the lesion2 ½ years after the lesion
She had sensations She had sensations
intermanually referred in a intermanually referred in a
topographically organized topographically organized
manner in the phantom manner in the phantom
limb limb
INTERMANUAL REFERAL AND EXTINCTION OF INTERMANUAL REFERAL AND EXTINCTION OF PAIN SENSATIONPAIN SENSATION
Hemiparesis with Hemiparesis with hemisensory hemisensory
deficitdeficitAmputationAmputation
Brachial Brachial plexusplexus
Spatial organi-Spatial organi-sationsation
PoorPoor PoorPoor ExcellentExcellent
LocalisationLocalisation GoodGood PoorPoor ExcellentExcellent
Time of Time of occuranceoccurance
After 3 to 4 After 3 to 4 monthsmonths
Immediate Immediate with in 7 with in 7
daysdays
Immediate Immediate with in with in 7days7days
PainPainExtinction Extinction
After a delay of After a delay of
3 - 5 seconds3 - 5 secondsImmediateImmediate ImmediateImmediate
DISCUSSIONDISCUSSION
Anatomical facts Anatomical facts
1. Primary somato sensory area 3b1. Primary somato sensory area 3b
2. A. Primary somato sensory area 1 & 22. A. Primary somato sensory area 1 & 22. B. Second somato sensory cortex and 2. B. Second somato sensory cortex and
parietal operculumparietal operculum
In 2a & 2b the receptive fields are largerIn 2a & 2b the receptive fields are largerbilateral and callosal connection arebilateral and callosal connection areabundant abundant
DISCUSSION DISCUSSION Contd…Contd…
Contralateral referral of sensations Contralateral referral of sensations
was not found in normal subjects or in was not found in normal subjects or in
hemiparetic patients without hemi hemiparetic patients without hemi
sensory losssensory loss
Neural mechanisms for perceptual Neural mechanisms for perceptual
alteration not clear alteration not clear
It appears that a decrease It appears that a decrease in somatosensory input to in somatosensory input to one cerebral hemisphere one cerebral hemisphere from the contralateral hand from the contralateral hand allows responsiveness of allows responsiveness of neurons in this hemisphere neurons in this hemisphere to moderately intense to moderately intense tactile stimuli on the tactile stimuli on the ipsilateral hand to exceed ipsilateral hand to exceed perceptual threshold perceptual threshold (which does not normally (which does not normally occur).occur).
DISCUSSION DISCUSSION Contd…Contd…
CONCLUSIONCONCLUSION
Intermanual referral & extinction of pain Intermanual referral & extinction of pain occurred immediately in amputation and occurred immediately in amputation and brachial plexus lesions and after a delay brachial plexus lesions and after a delay in strokein stroke
Intermanual referral of sensation Intermanual referral of sensation occurred topographicaly organised occurred topographicaly organised manner in brachial plexus lesions but not manner in brachial plexus lesions but not in amputation and strokein amputation and stroke
READ not to contradict or confuteNor to Believe and Take for
Grantedbut TO WEIGH AND CONSIDER
THANK YOU
CASE VIGNETTE (BRACHIAL PLEXUS CASE VIGNETTE (BRACHIAL PLEXUS LESION)LESION)
21 year old girl, after total 21 year old girl, after total
brachial plexus lesion was brachial plexus lesion was
examined 6 months, 1 ½ & examined 6 months, 1 ½ &
2 ½ years after the lesion2 ½ years after the lesion
She had sensations She had sensations
intermanually referred in a intermanually referred in a
topographically organized topographically organized
manner in the phantom manner in the phantom
limb limb
INTERMANUAL REFERAL AND EXTINCTION OF INTERMANUAL REFERAL AND EXTINCTION OF PAIN SENSATIONPAIN SENSATION
Hemiparesis with Hemiparesis with hemisensory hemisensory
deficitdeficitAmputationAmputation
Brachial Brachial plexusplexus
Spatial organi-Spatial organi-sationsation
PoorPoor PoorPoor ExcellentExcellent
LocalisationLocalisation GoodGood PoorPoor ExcellentExcellent
Time of Time of occuranceoccurance
After 3 to 4 After 3 to 4 monthsmonths
Immediate Immediate with in 7 with in 7
daysdays
Immediate Immediate with in with in 7days7days
PainPainExtinction Extinction
After a delay of After a delay of
3 - 5 seconds3 - 5 secondsImmediateImmediate ImmediateImmediate