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