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Non pharmacological management of neurogenic pain
1. The sign wasn't placed there
By the Big Printer in the sky
Prof. A.V. SRINIVASAN,
MD, DM, Ph.D, DSc(hon) F.R.C.P(LONDON)
F.A.A.N, F.I.AN.
Emeritus Professor - The Tamilnadu DR MGR
Medical University
11th MAY, 2012
2.
3.
4.
5. Thomas Elbert
Basic Principles
•Cortical representation expands linearly with
use.
• Synchronous inputs lead to fusion of cortical
zones
• Asynchronous inputs lead to segregation of
cortical zones.
•Disuse or De-afferentation leads to invasion
of unused cortical area by nearby neurons.
6. Sensory modulation in spatial
neglect
Novel Techniques
• Peripheral somatosensory- Magnetic
stimulation
• Repetitive optokinetic stimulation
• Neck Vibration training
Drug Treatment is currently unsuccessful
7. Sensory modulation and
Stroke
Rehabilitation aimed to increase use of
paretic hand
Virtual reality
Motor imagery
Prof. V.S..Ramachandran’s virtual reality
box
• Phantom limb phenomenon
8. Other techniques
Caloric tests for balance
• Brings awareness of illness to
patient.
Kinesthetic, visual, and auditory cues
to improve Parkinsonian gait.
9.
10. INTERMANUAL REFERRAL OF
SENSATION AND EXTINCTION OF
PAIN IN PERIPHERAL AND
CENTRAL LESIONS OF SOMATO
SENSORY SYSTEM
Whatever the Mind can conceive and Believe,
the mind can Achieve
Napoleon Hill
11. BACKGROUND
Allesthesia and extinction of referral
sensation in brachial plexus lesions
A.V. Srinivasan and V.S. Ramachandran et al (1998)
Intermanual referral of sensations after
central lesions of the somato sensory
system
K. Sathian et al (2000)
Every discovery contains an irrational element or 4 creative intuition
Khrl Popper
12. METHODS
8 patients (19-51 years)
Brachial plexus lesion – one
Amputation – two
Stroke – five
Patients were video filmed in the
movement disorder clinic. Pinprick, cold,
vibration and kinesthesis were tested
MRI & ENMG in all cases
Science is below the mind;
Spirituality is beyond the mind
13. CENTRAL LESION
Stroke
Thalamic stroke - three
Temparo parietal - two
Three to four months later
Ipsilateral arm - no
referral
to leg
When they tell you to grow up, they mean stop growing
14. STROKE Contd…
Intense pressure on the normal hand
resulted in extinction of pain in the stroke
side
Pain returned within one
minute of the pressure
Intense pressure improved
sensory and motor
phenomenon
One is the most independent, unconventional and individualistic of all numbers
15. AMPUTATION
Both the patients (below
elbow & knee amputation)
showed intermanual referral
of sensation within 10 days.
The referred sensations of
touch and vibration lacked
spatial organization and
poor localization with a
relatively high threshold
The Truth is Fear & Immorality are two of the greatest inhibitors of
Performance to progress
16. CASE VIGNETTE (BRACHIAL
PLEXUS LESION)
21 year old girl, after total
brachial plexus lesion was
examined 6 months, 1 ½ &
2 ½ years after the lesion
She had sensations
intermanually referred in a
topographically organized
manner in the phantom limb
“Social Isolation is in itself a pathogenic
Factor for disease production”
18. INTERMANUAL REFERAL AND
EXTINCTION OF PAIN SENSATION
Hemiparesis with Brachial
hemisensory Amputation plexus
deficit
Spatial organi- Poor Poor Excellent
sation
Localisation Good Poor Excellent
Time of After 3 to 4 Immediate Immediate
occurance months with in 7 days with in 7days
Pain After a delay of Immediate Immediate
Extinction 3 - 5 seconds
Reputation is made in a moment;
character is built in a life time
19. DISCUSSION
Anatomical facts
1. Primary somato sensory area 3b
2. A. Primary somato sensory area 1 & 2
2. B. Second somato sensory cortex and
parietal operculum
In 2a & 2b the receptive fields are larger
bilateral and callosal connection are
abundant
Two is the most gentle of all numbers and represents, diplomacy and tact
20. DISCUSSION Contd…
Contralateral referral of sensations was
not found in normal subjects or in
hemiparetic patients without hemi
sensory loss
Neural mechanisms for perceptual
alteration not clear
“Anger Begins In Folly And Ends In Repentance”
21. DISCUSSION Contd…
It appears that a decrease
in somatosensory input to
one cerebral hemisphere
from the contralateral hand
allows responsiveness of
neurons in this hemisphere
to moderately intense
tactile stimuli on the
ipsilateral hand to exceed
perceptual threshold
(which does not normally
occur).
“By Nature All Men/ Women are alike but
by Education widely different” - Chinese
22. CONCLUSION
Intermanual referral & extinction of pain
occurred immediately in amputation and
brachial plexus lesions and after a delay in
stroke
Intermanual referral of sensation occurred
topographicaly organised manner in
brachial plexus lesions but not in
amputation and stroke
Experience can be defined as
yesterday’s answer to today’s problems
24. My sincere gratitude to my
Teachers, Collegues,Residents,Patients and
Madras Institute of Neurology,
MEDISCAN SYSTEMS & Mr.Thudhimugan for
their computer work
25. We thank
Prof. V.S.Ramachandran, M.D., Ph.D.,
Director
Centre for Brain and Cognitive
Sciences
University of California, San Diego,
USA
26. READ not to contradict or confute
Nor to Believe and Take for Granted
but TO WEIGH AND CONSIDER
THANK YOU
27. Can the mind believe what the eye
sees ?
On vision, visuospatial dysfunction and
body image perception in right
hemispherical dysfunction
Dr.K.Bijoy Menon (Senior Resident)
Dr.Sundar, Dr.Saravanan,
Dr.Ramakrishnan
Dr.Nithyanandan (Asst.Prof) ,
Prof. A.V.Srinivasan
28. Indrani. 50 year old female
Presents with sudden onset of
weakness of left upper and lower limb
O/E.
– Conscious, oriented to time, place
and person
– Mild left UMN facial paresis
– Left hemiplegia
– All peripheral pulses palpable
“Serious, sincere, systematic study surely secures supreme success”
29. CT Brain – P – Shows a (R)
Occipitotemporal infarct
Nine is the most humanitarian of all numbers. It is
effort and sacrifice without the need for reward.
30. Higher mental function evaluation
MMSE : 28/30
She was very attentive and quite clear in her
conversation with us, though she would be
complaining of a vague left sided shoulder pain
On lobar testing, she had
Left visual neglect with (L) hemianopia
No auditory neglect
Absent sensory perception in (L) upper limb and (L)
tactile neglect in the lower limb
“The Truth is fear and immorality are two of the greatest
inhibitors of Performance to progress”
31. Of a burning and unremitting character - F.W.PAVY
32. In any field, find the strangest thing and explore it
33. On cold caloric tests and its
effect on neglect
Discipline Weighs ounces
Regret weighs Tons
35. Video of caloric test and
Nystagmus
A true commitment is a heart felt promise to yourself
from which you will not back down - D.
36. Video of disappearance of
neglect
Every discovery contains an irrational element or 4
creative intuition - Khrl Popper
37. On ‘ Mirror Agnosia’
Mirror Agnosia on the Right
A good teacher is a perpetual learner
38. After caloric test, Mirror
Agnosia on the Left
Three is the most playful of all numbers and also creative, inspirational and motivating
39. ‘Mirror Agnosia’ to front
Five is the most dynamic of all numbers. It is persuasive,
versatile and adaptable
40. On Anosognosia, Body neglect
(Hemisomatognosia) and
somatoparaphrenia
Anosognosia – our patient has it
Body neglect by Bisiach’s test – our
patient does not have it
Somatoparaphrenia – our patient has it
Knowledge without action is useless;
Action without knowledge is foolish
42. On the somatophrenic arm and
mirrors
Number seven is the most spiritual of all numbers.
It is the seeker of truth.
43. On Allesthesia, tactile neglect and ‘blind touch’
‘Touch your left arm’ Bisiach’s test of body
neglect.
Absent proprioception and touch in the left upper
limb
Patient is still able to touch her left arm whatever
position the examiner keeps the arm in.
We learn by thinking and the quality of the learning outcome is
determined by the quality of our thoughts -R.B. Schmeck
45. On visual imagery, neglect and caloric tests
Visual imagery
Bisiach’s test
Our test
Eight is the most result-oriented of all numbers and represents a balanced world
47. Unconscious awareness in a person with
Blind Sight
And
Blind Touch
Conscious mind and unconscious mind
Theories of consciousness and the soul.
NATURE, TIME AND PATIENCE
are the 3 great physicians
48. My sincere gratitude to my
Teachers, Patients and
Madras Institute of Neurology,
MEDISCAN SYSTEMS & Mr.Thudhimugan
for their computer work
