Some background studies to imagery work for painful conditions | part 1

Brain. 2001 Oct;124(Pt 10):2098-104.

Pain and the body schema: evidence for peripheral effects on mental representations of movement.

Schwoebel J, Friedman R, Duda N, Coslett HB.

Abstract

Some accounts of body representations postulate a real-time representation of the body in space generated by proprioceptive, somatosensory, vestibular and other sensory inputs; this representation has often been termed the ‘body schema’. To examine whether the body schema is influenced by peripheral factors such as pain, we asked patients with chronic unilateral arm pain to determine the laterality of pictured hands presented at different orientations. Previous chronometric findings suggest that performance on this task depends on the body schema, in that it appears to involve mentally rotating one’s hand from its current position until it is aligned with the stimulus hand. We found that, as in previous investigations, participants’ response times (RTs) reflected the degree of simulated movement as well as biomechanical constraints of the arm. Importantly, a significant interaction between the magnitude of mental rotation and limb was observed: RTs were longer for the painful arm than for the unaffected arm for large-amplitude imagined movements; controls exhibited symmetrical RTs. These findings suggest that the body schema is influenced by pain and that this task may provide an objective measure of pain.

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Arch Neurol. 2009 May;66(5):557-60.

The mirror neuron system.

Abstract

Mirror neurons are a class of neurons, originally discovered in the premotor cortex of monkeys, that discharge both when individuals perform a given motor act and when they observe others perform that same motor act. Ample evidence demonstrates the existence of a cortical network with the properties of mirror neurons (mirror system) in humans. The human mirror system is involved in understanding others’ actions and their intentions behind them, and it underlies mechanisms of observational learning. Herein, we will discuss the clinical implications of the mirror system.

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Annu Rev Neurosci. 2004;27:169-92.

The mirror-neuron system.

Rizzolatti G, Craighero L.

Abstract

A category of stimuli of great importance for primates, humans in particular, is that formed by actions done by other individuals. If we want to survive, we must understand the actions of others. Furthermore, without action understanding, social organization is impossible. In the case of humans, there is another faculty that depends on the observation of others’ actions: imitation learning. Unlike most species, we are able to learn by imitation, and this faculty is at the basis of human culture. In this review we present data on a neurophysiological mechanism–the mirror-neuron mechanism–that appears to play a fundamental role in both action understanding and imitation. We describe first the functional properties of mirror neurons in monkeys. We review next the characteristics of the mirror-neuron system in humans. We stress, in particular, those properties specific to the human mirror-neuron system that might explain the human capacity to learn by imitation. We conclude by discussing the relationship between the mirror-neuron system and language.

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Acta Psychol (Amst). 2001 Apr;107(1-3):155-81.

Integrating cognitive psychology, neurology and neuroimaging.

Parsons LM.

Abstract

In the last decade, there has been a dramatic increase in research effectively integrating cognitive psychology, functional neuroimaging, and behavioral neurology. This new work is typically conducting basic research into aspects of the human mind and brain. The present review features as examples of such integrations two series of studies by the author and his colleagues. One series, employing object recognition, mental motor imagery, and mental rotation paradigms, clarifies the nature of a cognitive process, imagined spatial transformations used in shape recognition. Among other implications, it suggests that when recognizing a hand’s handedness, imagining one’s body movement depends on cerebrally lateralized sensory-motor structures and deciding upon handedness depends on exact match shape confirmation. The other series, using cutaneous, tactile, and auditory pitch discrimination paradigms, elucidates the function of a brain structure, the cerebellum. It suggests that the cerebellum has non-motor sensory support functions upon which optimally fine sensory discriminations depend. In addition, six key issues for this integrative approach are reviewed. These include arguments for the value and greater use of: rigorous quantitative meta-analyses of neuroimaging studies; stereotactic coordinate-based data, as opposed to surface landmark-based data; standardized vocabularies capturing the elementary component operations of cognitive and behavioral tasks; functional hypotheses about brain areas that are consistent with underlying microcircuitry; an awareness that not all brain areas implicated by neuroimaging or neurology are necessarily directly involved in the associated cognitive or behavioral task; and systematic approaches to integrations of this kind.

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Behav Brain Res. 1996 May;77(1-2):45-52.

The neurophysiological basis of motor imagery.

Decety J.

Abstract

Motor imagery may be defined as a dynamic state during which representations of a given motor act are internally rehearsed in working memory without any overt motor output. What neural processes underlie the generation of motor imagery? This paper reviews physiological evidence from measurements of regional brain activity and from measurements of autonomic responses in normal subjects and behavioral observations from brain damaged patients. It is proposed that motor imagery shares neural mechanisms with processes used in motor control. This review emphasizes the importance of the prefrontal cortex and its connections to the basal ganglia in maintaining dynamic motor representations in working memory. This view fits with the general idea that the prefrontal cortex is responsible for the creation and maintenance of explicit representations that guide thought and action.

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Brain Res Cogn Brain Res. 1996 Mar;3(2):87-93.

Do imagined and executed actions share the same neural substrate?

Decety J.

Abstract

This paper addresses the issue of the functional correlates of motor imagery, using mental chronometry, monitoring the autonomic responses and measuring cerebral blood flow in humans. The timing of mentally simulated actions closely mimic actual movement times. Autonomic responses during motor imagery parallel the autonomic responses to actual exercise. Cerebral blood flow increases are observed in the motor cortices involved in the programming of actual movement (i.e. premotor cortex, anterior cingulate, inferior parietal lobule and cerebellum). These three sources of data provide converging support for the hypothesis that imagined and executed actions share, to some extent, the same central structures.

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CRPS March literature review

Neurology. 2011 Sep 13;77(11):1096-101. Epub 2011 Aug 31.

Bilateral somatosensory cortex disinhibition in complex regional pain syndrome type I.

Department of Neurology, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil GmbH, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany. melanie.lenz@rub.de

Abstract

In a previous study, we found bilateral disinhibition in the motor cortex of patients with complex regional pain syndrome (CRPS). This finding suggests a complex dysfunction of central motor-sensory circuits. The aim of our present study was to assess possible bilateral excitability changes in the somatosensory system of patients with CRPS.

We measured paired-pulse suppression of somatosensory evoked potentials in 21 patients with unilateral CRPS I involving the hand. Eleven patients with upper limb pain of non-neuropathic origin and 21 healthy subjects served as controls. Innocuous paired-pulse stimulation of the median nerve was either performed at the affected and the unaffected hand, or at the dominant hand of healthy controls, respectively.

We found a significant reduction of paired-pulse suppression in both sides of patients with CRPS, compared with control patients and healthy control subjects.

These findings resemble our findings in the motor system and strongly support the hypothesis of a bilateral complex impairment of central motor-sensory circuits in CRPS I.

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Anesthesiology. 2012 Feb 15. [Epub ahead of print]

Substance P Signaling Controls Mast Cell Activation, Degranulation, and Nociceptive Sensitization in a Rat Fracture Model of Complex Regional Pain Syndrome.

Abstract

Patients with complex regional pain syndrome have increased tryptase in the skin of the affected extremity indicating mast cell (MC) accumulation and degranulation, processes known to be mediated by substance P (SP). The dysregulation of SP release from primary afferent neurons is characteristic of complex regional pain syndrome. The authors hypothesized that SP acting through the neurokinin-1 receptor results in mast cell accumulation, degranulation, and nociceptive sensitization in a rat model of complex regional pain syndrome.

Groups of 6-10 rats underwent tibia fracture and hind limb casting for 4 weeks, and the hind paw skin was harvested for histologic and immunohistochemical analysis. The effects of a selective neurokinin-1 receptor antagonist (LY303870) and of direct SP intraplantar injection were measured. Dermal MC degranulation induced by sciatic nerve stimulation and the effects of LY303870 on this process were investigated. Finally, the antinociceptive effects of acute and chronic treatment with a MC degranulator (48/80) were tested.

The authors observed that fracture caused MC accumulation, activation, and degranulation, which were inhibited by LY303870; the percentage of MCs in close proximity to peptidergic nerve fibers increased after fracture; electrical stimulation caused MC activation and degranulation, which was blocked by LY303870; intraplantar SP-induced MC degranulation and acute administration of 48/80 caused MC degranulation and enhanced postfracture nociception, but MC-depleted animals showed less sensitization.

These results indicate that facilitated peptidergic neuron-MC signaling after fracture can cause MC accumulation, activation, and degranulation in the injured limb, resulting in nociceptive sensitization.

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Pain. 2012 Feb 13. [Epub ahead of print]

Motor control in complex regional pain syndrome: A kinematic analysis.

Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.

Abstract

This study evaluated movement velocity, frequency, and amplitude, as well as the number of arrests in three different subject groups, by kinematic analysis of repetitive movements during a finger tapping (FT) task. The most affected hands of 80 patients with complex regional pain syndrome (CRPS) were compared with the most affected hands of 60 patients with Parkinson disease (PD) as well as the nondominant hands of 75 healthy control (HC) subjects. Fifteen seconds of FT with thumb and index finger were recorded by a 60-Hz camera, which allowed the whole movement cycle to be evaluated and the above mentioned movement parameters to be calculated. We found that CRPS patients were slower and tapped with more arrests than the two other groups. Moreover, in comparison with the hands of the HC subjects, the unaffected hands of the CRPS patients were also impaired in these domains. Impairment was not related to pain. Dystonic CRPS patients performed less well than CRPS patients without dystonia. In conclusion, this study shows that voluntary motor control in CRPS patients is impaired at both the affected as well as the unaffected side, pointing at involvement of central motor processing circuits.

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Neuromodulation. 2012 Feb 13. doi: 10.1111/j.1525-1403.2011.00424.x. [Epub ahead of print]

Spinal Cord Stimulation in Complex Regional Pain Syndrome Type I of Less Than 12-Month Duration.

Department of Anesthesiology and Pain Therapy, St Elisabeth Hospital, Tilburg, The Netherlands; Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Anesthesiology and Multidisciplinary Pain Centre, Hospital Oost-Limburg, Genk, Belgium; Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands; and Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands.

Abstract

Introduction:  Complex regional pain syndrome type 1 (CRPS-1) has a 31% probability of becoming chronic. The early use of spinal cord stimulation (SCS) has been recommended as a strategy to prevent chronicity and functional impairment. Methods:  In a prospective study, we treated 74 CRPS-1 patients with a mean disease duration of 17 weeks with standard therapy consisting of physical therapy, topical dimethyl sulfoxide, analgesics, transcutaneous stimulation, and sympathetic blockade. Patients who did not respond to standard therapy were offered a treatment with SCS. In these patients, we investigated the impact on pain, quality of life, and function. Results:  Out of these 74 patients treated with standard therapy, six patients were included for early SCS treatment. The overall mean pain relief after one year was 35%. The mental component of the Short Form 36 improved; however, there was no effect on the physical component. None of the SCS treated patients showed a clear improvement in functional outcome. Discussion:  We conclude that the feasibility of performing a randomized controlled trial on early SCS therapy in CRPS-1 is low because of the good disease improvement with standard therapy in the first year after onset. This study raises questions about the need to use SCS early in the course of CRPS-1 because of the probable lack of additional benefit compared with SCS in chronic CRPS-1.

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Eur J Pain. 2012 Feb;16(2):182-95. doi: 10.1016/j.ejpain.2011.06.016.

Enhanced pain and autonomic responses to ambiguous visual stimuli in chronic Complex Regional Pain Syndrome (CRPS) type I.

Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK; University of Bath, Bath, BA2 7AY, UK; Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK.

Abstract

Cortical reorganisation of sensory, motor and autonomic systems can lead to dysfunctional central integrative control. This may contribute to signs and symptoms of Complex Regional Pain Syndrome (CRPS), including pain. It has been hypothesised that central neuroplastic changes may cause afferent sensory feedback conflicts and produce pain. We investigated autonomic responses produced by ambiguous visual stimuli (AVS) in CRPS, and their relationship to pain. Thirty CRPS patients with upper limb involvement and 30 age and sex matched healthy controls had sympathetic autonomic function assessed using laser Doppler flowmetry of the finger pulp at baseline and while viewing a control figure or AVS. Compared to controls, there were diminished vasoconstrictor responses and a significant difference in the ratio of response between affected and unaffected limbs (symmetry ratio) to a deep breath and viewing AVS. While viewing visual stimuli, 33.5% of patients had asymmetric vasomotor responses and all healthy controls had a homologous symmetric pattern of response. Nineteen (61%) CRPS patients had enhanced pain within seconds of viewing the AVS. All the asymmetric vasomotor responses were in this group, and were not predictable from baseline autonomic function. Ten patients had accompanying dystonic reactions in their affected limb: 50% were in the asymmetric sub-group. In conclusion, there is a group of CRPS patients that demonstrate abnormal pain networks interacting with central somatomotor and autonomic integrational pathways.

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J Hand Ther. 2011 Apr-Jun;24(2):164-8; quiz 169. Epub 2011 Feb 9.

Graded motor imagery.

Hand Therapy Consultation Services, Richmond, Vermont 05477, USA. victoria@htcsllc.com

Abstract

New information regarding cortical changes in patients with chronic pain has prompted a reevaluation of the typical “bottom up” treatment for pain, which focuses on peripheral nociceptive stimuli. More recently, increasing considerations for chronic pain are focused from the “top down” cortical central processing perspective. Graded motor imagery (GMI) is one treatment technique from the “top down” paradigm designed to treat chronic pain. This technique attempts to sequentially normalize central processing to remediate chronic pain. This article briefly summarizes the basic components of GMI, targeting complex regional pain in the upper limb, and describes a case where this method was successfully integrated. The initial research and clinical experience is promising and indicates that patients with chronic pain may benefit from using GMI to “retrain the brain.”

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Pain. 2010 May;149(2):296-304. Epub 2010 Mar 31.

Mirrored, imagined and executed movements differentially activate sensorimotor cortex in amputees with and without phantom limb pain.

Department of Clinical and Cognitive Neuroscience, Central Institute of Mental Health, University of Heidelberg, D-68159 Mannheim, Germany. martin.diers@zi-mannheim.de

Abstract

Extended viewing of movements of the intact hand in a mirror as well as motor imagery has been shown to decrease pain in phantom pain patients. We used functional magnetic resonance imaging to assess the neural correlates of mirrored, imagined and executed hand movements in 14 upper extremity amputees – 7 with phantom limb pain (PLP) and 7 without phantom limb pain (non-PLP) and 9 healthy controls (HC). Executed movement activated the contralateral sensorimotor area in all three groups but ipsilateral cortex was only activated in the non-PLP and HC group. Mirrored movements activated the sensorimotor cortex contralateral to the hand seen in the mirror in the non-PLP and the HC but not in the PLP. Imagined movement activated the supplementary motor area in all groups and the contralateral primary sensorimotor cortex in the non-PLP and HC but not in the PLP. Mirror- and movement-related activation in the bilateral sensorimotor cortex in the mirror movement condition and activation in the sensorimotor cortex ipsilateral to the moved hand in the executed movement condition were significantly negatively correlated with the magnitude of phantom limb pain in the amputee group. Further research must identify the causal mechanisms related to mirror treatment, imagined movements or movements of the other hand and associated changes in pain perception.

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Curr Opin Anaesthesiol. 2011 Oct;24(5):524-31.

Phantom limb pain and bodily awareness: current concepts and future directions.

Experimental Neuropsychology Research Unit, Monash University, Clayton, Victoria, Australia. melita.giummarra@monash.edu

Abstract

Phantom pain is a frequent consequence of amputation or deafferentation. There are many possible contributing mechanisms, including stump-related pathology, spinal and cortical changes. Phantom limb pain is notoriously difficult to treat. Continued consideration of the factors associated with phantom pain and its treatment is of utmost importance, not only to advance the scientific knowledge about the experience of the body and neuropathic pain, but also fundamentally to promote efficacious pain management.

This review first discusses the mechanisms associated with phantom pain and summarizes the current treatments. The mechanisms underlying phantom pain primarily relate to peripheral/spinal dysfunction, and supraspinal and central plasticity in sensorimotor body representations. The most promising methods for managing phantom pain address the maladaptive changes at multiple levels of the neuraxis, for example, complementing pharmacological administration with physical, psychological or behavioural intervention. These supplementary techniques are even efficacious in isolation, perhaps by replacing the absent afferent signals from the amputated limb, thereby restoring disrupted bodily representations.

Ultimately, for optimal patient outcomes, treatments should be both symptom and mechanism targeted.

Imagery & mirrors

Many readers will know about mirror box therapy for CRPS and other painful conditions. The Graded Motor Imagery Programme that we use at Specialist Pain Physio is sequential training that starts with laterality, progressing to imagined movements and then to mirror therapy. There is some really good data for the programme and CRPS but it can also be effective with other chronic pains. Interestingly we are now seeing components of GMI being used and written about in the popular press, most recently for Parkinson’s disease and arthritis.

Brain training for pain

A brief article in New Scientist describes the Parkinson’s research by David Linden at Cardiff University. 10 subjects were asked to think about movement for 45 minutes whilst they were having brain scans. Five of the subjects were given feedback that showed them how they were activating the brain and all were asked to practice the imagery at home. Two months later rigidity and tremor had reduced some 37% in the feedback group. The thinking is that there is cortical change underpinning this improved function that is feasible.

Mirror therapy for pain

At The Society for Neuroscience annual meeting 2011 a small study was performed with arthritis (OA & RA) patients used mirror therapy. Subjects observed the moving reflection of the researcher’s hand in the mirror whilst producing the same movement themselves with their hidden hand. After 1 minute it was noted that the subjects pain improved. This was reported in The Guardian today.

For details on our treatment programmes including imagery, mirror therapy, graded motor imagery and other neuroscience-based techniques, come and see our website at http://www.specialistpainphysio.com or call 07518 445491. Our clinics are based in London and Surrey http://www.specialistpainphysio.com/clinics