The sign wasn’t placed there       By the Big Printer in the sky           Prof. A.V. SRINIVASAN.            Prof. A.V. SR...
Pharmacology Physical and Neurological          Non Pharmacolgical  Affective  Behavioural  Cognitive  Social
Strategies - to be incorporated into a   non-pharmacologic approach.  Education about condition  Patient preference  Mo...
Non-pharmacological therapiesSimple       Physical         Cognitive                              IndividualPacing       M...
Non-pharmacological therapies                            Physical Treatments                 Movement-Simple           bas...
Cognitive TreatmentsIndividual      Group                 Counseling      Pain Management                Programs         ...
Modification of the sensory             aspects of pain   Simple measures - heat, ice, massage, manipulative    therapies...
Modification of the sensory             aspects of pain   Stimulating inhibitory mechanisms in the periphery or    in the...
Modification of the sensory          aspects of pain Alter pain processing at the cortical level , e.g. cognitive therapi...
Neurogenic Pain copious documentation   (I have a list  here…) fixed ideas (“I have been told I have a  crumbling spine”...
Thomas Elbert                   Basic                   PrinciplesCortical representation expands linearly with use.   S...
Sensory modulation in spatial neglect                 Novel Techniques    Peripheral somatosensory- Magnetic    stimulati...
Sensory modulation and Stroke   Rehabilitation aimed to increase use of    paretic hand   Virtual reality   Motor image...
Other techniques   Caloric tests for balance          Brings awareness of illness to patient.    Kinesthetic, visual, a...
INTERMANUAL REFERRAL OFSENSATION AND EXTINCTION OFPAIN IN PERIPHERAL ANDCENTRAL LESIONS OF SOMATOSENSORY SYSTEM
BACKGROUND Allesthesia and extinction of referral  sensation in brachial plexus lesions  A.V. Srinivasan and V.S. Ramacha...
METHODS8 patients (19-51 years) Brachial plexus lesion             – one Amputation                         – two Strok...
CENTRAL LESIONStrokeThalamic stroke     - threeTemparo parietal    - twoThree to four months laterIpsilateral   arm    ...
STROKE Contd… Intense pressure on the normal hand resulted  in extinction of pain in the stroke side Pain returned withi...
AMPUTATION   Both the patients (below    elbow & knee amputation)    showed intermanual referral of    sensation within 1...
CASE VIGNETTE (BRACHIAL PLEXUS                LESION)   21 year old girl, after total    brachial plexus lesion was    ex...
INTERMANUAL REFERAL AND EXTINCTION OF              PAIN SENSATION                    Hemiparesis with                     ...
DISCUSSIONAnatomical facts   1. Primary somato sensory area 3b   2. A. Primary somato sensory area 1 & 2   2. B. Second so...
DISCUSSION Contd… Contralateral referral of sensations was not  found in normal subjects or in hemiparetic  patients with...
DISCUSSION Contd…It appears that a decrease insomatosensory input to onecerebral hemisphere from thecontralateral hand all...
CONCLUSION Intermanual referral & extinction of pain  occurred immediately in amputation and  brachial plexus lesions and...
READ not to contradict or confuteNor to Believe and Take for Grantedbut TO WEIGH AND CONSIDER  THANK  YOU
CASE VIGNETTE (BRACHIAL PLEXUS                LESION)   21 year old girl, after total    brachial plexus lesion was    ex...
INTERMANUAL REFERAL AND EXTINCTION OF              PAIN SENSATION                    Hemiparesis with                     ...
Athens meeting
Athens meeting
Athens meeting
Athens meeting
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Athens meeting

  1. 1. The sign wasn’t placed there By the Big Printer in the sky Prof. A.V. SRINIVASAN. Prof. A.V. SRINIVASAN. ,, MD, DM, PhD, DSc, FRCP (Lond), FAAN, FIAN EMERITUS PROFESSOR OF NEUROLOGY EMERITUS PROFESSOR OF NEUROLOGYFORMER HEAD AND PROFESSOR OF NEUROLOGYFORMER HEAD AND PROFESSOR OF NEUROLOGY Institute of Neurology Chennai Chennai
  2. 2. Pharmacology Physical and Neurological Non Pharmacolgical Affective Behavioural Cognitive Social
  3. 3. Strategies - to be incorporated into a non-pharmacologic approach.  Education about condition  Patient preference  Modification of sensory aspects of pain  Modification of cognitive/emotional aspects of pain  Built-in assessment and reassessment
  4. 4. Non-pharmacological therapiesSimple Physical Cognitive IndividualPacing Movement workGoal-setting Manipulation Group workRelaxational Interventional
  5. 5. Non-pharmacological therapies Physical Treatments Movement-Simple based Interventional     Spinal    Ice/Heat Manipulation Peripheral Central    Splinting Physiotherapy Acupuncture Injections StimulationCorset/support Exercise TENS “Pulsing” Psychosurgery    Injections Neurolysis      Cryotherapy Stimulation
  6. 6. Cognitive TreatmentsIndividual Group   Counseling Pain Management  Programs  Transpersonal Recovery Modeltherapy (peer-to-peer) CBT/CAT/ACT Peer Support Hypnosis
  7. 7. Modification of the sensory aspects of pain Simple measures - heat, ice, massage, manipulative therapies (e.g. chiropractic, osteopathy), physiotherapy Treating the primary cause - e.g. improve diabetic control; supplement thiamine; reduce/stop alcohol consumption. Treating the primary cause includes interventional techniques such as surgery for disc prolapses or spinal stenosis; or nerve translocation surgery (e.g. carpal tunnel release)
  8. 8. Modification of the sensory aspects of pain Stimulating inhibitory mechanisms in the periphery or in the spinal cord: e.g. acupuncture /TENS; electrical peripheral nerve or dorsal column or central (deep-brain) stimulation Inhibition or prevention of ascending nerve transmission in the peripheral nervous system, in the dorsal root ganglion or spinal cord: e.g. nerve blocks, neurolysis or rhyzolysis
  9. 9. Modification of the sensory aspects of pain Alter pain processing at the cortical level , e.g. cognitive therapies, biofeedback, hypnosis, meditation. It is currently unclear the exact way in which these therapies alter sensation, but is assumed to involved both descending inhibition and alteration of sensitivity to ascending stimulus
  10. 10. Neurogenic Pain copious documentation (I have a list here…) fixed ideas (“I have been told I have a crumbling spine”) frustration (“I just want it sorted!”) hopelessness/helplessness (“you won’t be able to help me, no one can”)
  11. 11. 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.
  12. 12. Sensory modulation in spatial neglect Novel Techniques Peripheral somatosensory- Magnetic stimulation Repetitive optokinetic stimulation Neck Vibration training Drug Treatment is currently unsuccessful
  13. 13. 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
  14. 14. Other techniques Caloric tests for balance  Brings awareness of illness to patient. Kinesthetic, visual, and auditory cues to improve Parkinsonian gait.
  15. 15. INTERMANUAL REFERRAL OFSENSATION AND EXTINCTION OFPAIN IN PERIPHERAL ANDCENTRAL LESIONS OF SOMATOSENSORY SYSTEM
  16. 16. 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)
  17. 17. METHODS8 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
  18. 18. CENTRAL LESIONStrokeThalamic stroke - threeTemparo parietal - twoThree to four months laterIpsilateral arm - no referral to leg
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. INTERMANUAL REFERAL AND EXTINCTION OF PAIN SENSATION Hemiparesis with Brachial hemisensory deficit Amputation plexus Spatial organi- Poor Poor Excellent sation Localisation Good Poor ExcellentTime of occurance After 3 to 4 months Immediate Immediate with in 7 days with in 7days Pain After a delay of Immediate Immediate Extinction 3 - 5 seconds
  23. 23. DISCUSSIONAnatomical facts 1. Primary somato sensory area 3b 2. A. Primary somato sensory area 1 & 2 2. B. Second somato sensory cortex and parietal operculumIn 2a & 2b the receptive fields are largerbilateral and callosal connection areabundant
  24. 24. 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
  25. 25. DISCUSSION Contd…It appears that a decrease insomatosensory input to onecerebral hemisphere from thecontralateral hand allowsresponsiveness of neurons inthis hemisphere tomoderately intense tactilestimuli on the ipsilateral handto exceed perceptualthreshold (which does notnormally occur).
  26. 26. 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
  27. 27. READ not to contradict or confuteNor to Believe and Take for Grantedbut TO WEIGH AND CONSIDER THANK YOU
  28. 28. 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
  29. 29. INTERMANUAL REFERAL AND EXTINCTION OF PAIN SENSATION Hemiparesis with Brachial hemisensory deficit Amputation plexus Spatial organi- Poor Poor Excellent sation Localisation Good Poor ExcellentTime of occurance After 3 to 4 months Immediate Immediate with in 7 days with in 7days Pain After a delay of Immediate Immediate Extinction 3 - 5 seconds
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