non pharmacological management of neurogenic pain
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The sign wasn't placed thereThe sign wasn't placed thereBy the Big Printer in the skyBy the Big Printer in the sky
1111thth MAY, 2012 MAY, 2012
Prof. A.V. SRINIVASANProf. A.V. SRINIVASAN,,
MD, DM, Ph.D, DSc(hon)MD, DM, Ph.D, DSc(hon) F.R.C.P(LONDON)F.R.C.P(LONDON)
F.A.A.N, F.I.ANF.A.A.N, F.I.AN..
Emeritus Professor - The Tamilnadu DR MGR Emeritus Professor - The Tamilnadu DR MGR Medical UniversitMedical Universityy
Prof. A.V. SRINIVASANProf. A.V. SRINIVASAN,,
MD, DM, Ph.D, DSc(hon)MD, DM, Ph.D, DSc(hon) F.R.C.P(LONDON)F.R.C.P(LONDON)
F.A.A.N, F.I.ANF.A.A.N, F.I.AN..
Emeritus Professor - The Tamilnadu DR MGR Emeritus Professor - The Tamilnadu DR MGR Medical UniversitMedical Universityy
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Thomas Elbert
•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.
Basic PrinciplesBasic Principles
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Sensory modulation in spatial neglect
• Peripheral somatosensory- Magnetic stimulation
• Repetitive optokinetic stimulation
• Neck Vibration training
Drug Treatment is currently unsuccessfulDrug Treatment is currently unsuccessful
Novel TechniquesNovel Techniques
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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
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Other techniques
Caloric tests for balance
• Brings awareness of illness to patient.
Kinesthetic, visual, and auditory cues to improve Parkinsonian gait.
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INTERMANUAL REFERRAL OF SENSATION AND EXTINCTION OF PAIN IN PERIPHERAL AND CENTRAL LESIONS OF SOMATO SENSORY SYSTEM
INTERMANUAL REFERRAL OF SENSATION AND EXTINCTION OF PAIN IN PERIPHERAL AND CENTRAL LESIONS OF SOMATO SENSORY SYSTEM
Whatever the Mind can conceive and Believe, Whatever the Mind can conceive and Believe, the mind can Achievethe mind can Achieve
Napoleon Hill Napoleon Hill
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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 intuitionEvery discovery contains an irrational element or 4 creative intuition Khrl Popper Khrl Popper
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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; Science is below the mind; Spirituality is beyond the mindSpirituality is beyond the mind
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CENTRAL LESION
StrokeThalamic 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 growingWhen they tell you to grow up, they mean stop growing
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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 numbersOne is the most independent, unconventional and individualistic of all numbers
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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 The Truth is Fear & Immorality are two of the greatest inhibitors of Performance to progressPerformance to progress
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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 pathogenicSocial Isolation is in itself a pathogenicFactor for disease production”Factor for disease production”
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DR V S RAMACHANDRAN
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INTERMANUAL REFERAL AND EXTINCTION OF PAIN SENSATION
Hemiparesis with hemisensory
deficitAmputation
Brachial plexus
Spatial organi-sation
Poor Poor Excellent
Localisation Good Poor Excellent
Time of occurance
After 3 to 4 months
Immediate with in 7 days
Immediate with in 7days
PainExtinction
After a delay of
3 - 5 seconds
Immediate Immediate
Reputation is made in a moment;Reputation is made in a moment;
character is built in a life timecharacter is built in a life time
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DISCUSSIONAnatomical facts
1. Primary somato sensory area 3b
2. A. Primary somato sensory area 1 & 22. B. Second somato sensory cortex and
parietal operculum
In 2a & 2b the receptive fields are largerbilateral and callosal connection areabundant
Two is the most gentle of all numbers and represents, diplomacy and tactTwo is the most gentle of all numbers and represents, diplomacy and tact
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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”Anger Begins In Folly And Ends In Repentance”
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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 butBy Nature All Men/ Women are alike butby Education widely different” - Chineseby Education widely different” - Chinese
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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 Experience can be defined as
yesterday’s answer to today’s problemsyesterday’s answer to today’s problems
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Dedicated to my family for
making everything worthwhile
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My sincere gratitude to my
Teachers, Collegues,Residents,Patients and
Madras Institute of Neurology,
MEDISCAN SYSTEMS & Mr.Thudhimugan for
their computer work
My sincere gratitude to my
Teachers, Collegues,Residents,Patients and
Madras Institute of Neurology,
MEDISCAN SYSTEMS & Mr.Thudhimugan for
their computer work
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We thank
Prof. V.S.Ramachandran, M.D., Ph.D., Director
Centre for Brain and Cognitive Sciences
University of California, San Diego, USA
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READ READ not to contradict or confutenot to contradict or confute
Nor to Believe and Take for GrantedNor to Believe and Take for Granted
butbut TOTO WEIGH AND CONSIDERWEIGH AND CONSIDER
THANK YOUTHANK YOU
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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
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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”Serious, sincere, systematic study surely secures supreme success”
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CT Brain – P – Shows a (R) Occipitotemporal infarct
Nine is the most humanitarian of all numbers. It is Nine is the most humanitarian of all numbers. It is effort and sacrifice without the need for reward.effort and sacrifice without the need for reward.
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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 The Truth is fear and immorality are two of the greatest inhibitors of Performance to progress”inhibitors of Performance to progress”
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Of a burning and unremitting character - F.W.PAVYOf a burning and unremitting character - F.W.PAVY
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In any field, find the strangest thing and explore itIn any field, find the strangest thing and explore it
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On cold caloric tests and its effect on neglect
Discipline Weighs ounces Discipline Weighs ounces Regret weighs TonsRegret weighs Tons
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Video of Neglect
““You have got to be before you can You have got to be before you can do and do before you can have”do and do before you can have”
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Video of caloric test and Nystagmus
A true commitment is a heart felt promise to A true commitment is a heart felt promise to yourself from which you will not back down - yourself from which you will not back down -
D. Mcnally D. Mcnally
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Video of disappearance of neglect
Every discovery contains an irrational element or 4 Every discovery contains an irrational element or 4 creative intuition creative intuition - Khrl Popper - Khrl Popper
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On ‘ Mirror Agnosia’Mirror Agnosia on the Right
A good teacher is a perpetual learnerA good teacher is a perpetual learner
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After caloric test, Mirror Agnosia on the Left
Three is the most playful of all numbers and also creative, inspirational and motivatingThree is the most playful of all numbers and also creative, inspirational and motivating
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‘Mirror Agnosia’ to front
Five is the most dynamic of all numbers. It is persuasive, Five is the most dynamic of all numbers. It is persuasive, versatile and adaptableversatile and adaptable
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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;Knowledge without action is useless;Action without knowledge is foolishAction without knowledge is foolish
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Somatoparaphrenia
Number sixth is the most loving of all numbers and is Number sixth is the most loving of all numbers and is harmonious with all other numberharmonious with all other number
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On the somatophrenic arm and mirrors
Number seven is the most spiritual of all numbers. Number seven is the most spiritual of all numbers. It is the seeker of truth.It is the seeker of truth.
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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 We learn by thinking and the quality of the learning outcome is determined by the quality of our thoughts -R.B. Schmeckdetermined by the quality of our thoughts -R.B. Schmeck
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Blind Sight Vs Blind Touch
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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 worldEight is the most result-oriented of all numbers and represents a balanced world
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Results
The True Art of Memory is The Art of Attention The True Art of Memory is The Art of Attention - S.Johnson - S.Johnson
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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 NATURE, TIME AND PATIENCE
are the 3 great physiciansare the 3 great physicians
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My sincere gratitude to my
Teachers, Patients and
Madras Institute of Neurology,
MEDISCAN SYSTEMS & Mr.Thudhimugan
for their computer work
My sincere gratitude to my
Teachers, Patients and
Madras Institute of Neurology,
MEDISCAN SYSTEMS & Mr.Thudhimugan
for their computer work
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Dedicated to my family for
making everything worthwhile
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READ READ not to contradict or confutenot to contradict or confute
Nor to Believe and Take for GrantedNor to Believe and Take for Granted
butbut TOTO WEIGH AND CONSIDERWEIGH AND CONSIDER
THANK YOUTHANK YOU