The use of temperature biofeedback in the treatment of chronic pain due to causalgia.

A patient with chronic pain due to a reflex sympathetic dystrophy in his hand and arm was successfully treated with temperature biofeedback after several months of conservative standard medical care brought little relief. Over the 18 treatment sessions the patient learned to emit a reliable handwarming response of 1 to 1.5 degrees C. Coincident with his learning, the pain in his hand and arm decreased markedly and remained absent at 1-year follow-up.     

Where the eye looks, the hand follows; limb-dependent magnetic misreaching in optic ataxia

The posterior parietal cortex (PPC) is thought to play an important role in the sensorimotor transformations associated with reaching movements. In humans, damage to the PPC, particularly bilateral lesions, leads to impairments of visually guided reaching movements (optic ataxia). Recent accounts of optic ataxia based upon electrophysiological recordings in monkeys have proposed that this disorder arises because of a breakdown in the tuning fields of parietal neurons responsible for integrating spatially congruent retinal, eye, and hand position signals to produce coordinated eye and hand movements . We present neurological evidence that forces a reconceptualization of this view. We report a detailed case study of a patient with a limb-dependent form of optic ataxia who can accurately reach with either hand to objects that he can foveate (thereby demonstrating coordinated eye-hand movements) but who cannot effectively decouple reach direction from gaze direction for movements executed using his right arm. The demonstration that our patient's misreaching is confined to movements executed using his right limb, and only for movements that are directed to nonfoveal targets, rules out explanations based upon simple perceptual or motor deficits but indicates an impairment in the ability to dissociate the eye and limb visuomotor systems when appropriate.     

Successful Sequential Treatment with Itraconazole and ALA-PDT for Cutaneous Granuloma by <Emphasis Type="Italic">Candida albicans</Emphasis>: A Case Report and Literature Review

Photodynamic therapy (PDT) is a process that combines a photosensitizing drug and light and promotes phototoxic responses in target cells, mainly via oxidative damage. Antifungal photodynamic therapy has been successfully employed against Candida species, dermatophytes, and deep mycoses. We present a case of a cutaneous granuloma caused by C. albicans treated with 5-aminolevulinic acid (ALA)-PDT. A 64-year-old man presented with two plaques on his right hand and wrist for 2 years. The diagnosis was made based on histopathology, mycology, and molecular identification of paraffin-embedded tissues. The patient was treated with itraconazole for 1 month and two sessions of ALA-PDT. After 2 months of follow-up, the patient was cured and has not experienced any recurrence to date. ALA-PDT was well tolerated in this patient with little pain. In general, application of PDT in mycoses is safe and effective in most cases. ALA-PDT is a good choice for inactivation of C. albicans.     

Improvement of pain and regional osteoporotic changes in the foot and ankle by low-dose bisphosphonate therapy for complex regional pain syndrome type I: a case series

Introduction

Complex regional pain syndrome is characterized by pain, allodynia, hyperalgesia, edema, signs of vasomotor instability, movement disorders, joint stiffness, and regional osteopenia. It is recognized to be difficult to treat, despite various methods of treatment, including physiotherapy, calcitonin, corticosteroids, sympathetic blockade, and nonsteroidal anti-inflammatory drugs. Pathophysiologically, complex regional pain syndrome reveals enhanced regional bone resorption and high bone turnover, and so bisphosphonates, which have a potent inhibitory effect on bone resorption, were proposed for the treatment of complex regional pain syndrome.

Case presentation

A 48-year-old Japanese man with complex regional pain syndrome type I had severe right ankle pain with a visual analog scale score of 59 out of 100 regardless of treatment with physiotherapy and nonsteroidal anti-inflammatory drugs for five months. Radiographs showed marked regional osteoporotic changes and bone scintigraphy revealed a marked increase in radioactivity in his ankle. One month after the start of oral administration of risedronate (2.5 mg per day), his bone pain had fallen from a VAS score of 59 out of 100 to 18 out of 100. Bone scintigraphy at 12 months showed a marked reduction in radioactivity to a level comparable to that in his normal, left ankle. On the basis of these results, the treatment was discontinued at 15 months. At 32 months, our patient had almost no pain and radiographic findings revealed that the regional osteoporotic change had returned to normal.A second 48-year-old Japanese man with complex regional pain syndrome type I had severe right foot pain with a visual analog scale score of 83 out of 100 regardless of treatment with physiotherapy and nonsteroidal anti-inflammatory drugs for nine months. Radiographs showed regional osteoporotic change in his phalanges, metatarsals, and tarsals, and bone scintigraphy revealed a marked increase in radioactivity in his foot. One month after the start of oral administration of alendronate (35 mg per week), his bone pain had fallen from a visual analog scale score of 83 out of 100 to 30 out of 100 and, at nine months, was further reduced to 3 out of 100. The treatment was discontinued at 15 months because of successful pain reduction. At 30 months, our patient had no pain and the radiographic findings revealed marked improvement in regional osteoporotic changes.

Conclusions

We believe low-dose oral administration of bisphosphonate is worth considering for the treatment of idiopathic complex regional pain syndrome type I accompanied by regional osteoporotic change.

     

Recovery of the motor function of the arm with the aid of a hand exoskeleton controlled by a brain–computer interface in a patient with an extensive brain lesion

The dynamics of motor function recovery in a patient with an extensive brain lesion has been investigated during a course of neurorehabilitation assisted by a hand exoskeleton controlled by a brain–computer interface. Biomechanical analysis of the movements of the paretic arm recorded during the rehabilitation course was used for an unbiased assessment of motor function. Fifteen procedures involving hand exoskeleton control (one procedure per week) yielded the following results: (a) the velocity profile for targeted movements of the paretic hand became nearly bell-shaped; (b) the patient began to extend and abduct the hand, which was flexed and adducted at the beginning of the course; and (c) the patient started supinating the forearm, which was pronated at the beginning of the rehabilitation course. The first result is interpreted as improvement of the general level of control over the paretic hand, and the two other results are interpreted as a decrease in spasticity of the paretic hand.     

Stroke rehabilitation reaches a threshold

Motor training with the upper limb affected by stroke partially reverses the loss of cortical representation after lesion and has been proposed to increase spontaneous arm use. Moreover, repeated attempts to use the affected hand in daily activities create a form of practice that can potentially lead to further improvement in motor performance. We thus hypothesized that if motor retraining after stroke increases spontaneous arm use sufficiently, then the patient will enter a virtuous circle in which spontaneous arm use and motor performance reinforce each other. In contrast, if the dose of therapy is not sufficient to bring spontaneous use above threshold, then performance will not increase and the patient will further develop compensatory strategies with the less affected hand. To refine this hypothesis, we developed a computational model of bilateral hand use in arm reaching to study the interactions between adaptive decision making and motor relearning after motor cortex lesion. The model contains a left and a right motor cortex, each controlling the opposite arm, and a single action choice module. The action choice module learns, via reinforcement learning, the value of using each arm for reaching in specific directions. Each motor cortex uses a neural population code to specify the initial direction along which the contralateral hand moves towards a target. The motor cortex learns to minimize directional errors and to maximize neuronal activity for each movement. The derived learning rule accounts for the reversal of the loss of cortical representation after rehabilitation and the increase of this loss after stroke with insufficient rehabilitation. Further, our model exhibits nonlinear and bistable behavior: if natural recovery, motor training, or both, brings performance above a certain threshold, then training can be stopped, as the repeated spontaneous arm use provides a form of motor learning that further bootstraps performance and spontaneous use. Below this threshold, motor training is "in vain": there is little spontaneous arm use after training, the model exhibits learned nonuse, and compensatory movements with the less affected hand are reinforced. By exploring the nonlinear dynamics of stroke recovery using a biologically plausible neural model that accounts for reversal of the loss of motor cortex representation following rehabilitation or the lack thereof, respectively, we can explain previously hard to reconcile data on spontaneous arm use in stroke recovery. Further, our threshold prediction could be tested with an adaptive train-wait-train paradigm: if spontaneous arm use has increased in the "wait" period, then the threshold has been reached, and rehabilitation can be stopped. If spontaneous arm use is still low or has decreased, then another bout of rehabilitation is to be provided.     

Effect of eccentric strength testing on delayed-onset muscle pain

This investigation was designed to determine the effect of eccentric strength testing on delayed-onset muscle pain in 20 untrained university students. Initially, eccentric strength testing (5-repetition maximum [5RM]) was performed bilaterally. Next, 1 arm completed 3 sets of 10 eccentric repetitions to induce delayed-onset muscle pain. Then, in a subsequent session, whichever arm previously performed only the 5RM test completed the 5RM test a second time and the 3 sets of 10 eccentric repetitions. Statistical analyses supported significantly increased pain intensity and unpleasantness across 48 hours post-5RM test alone. However, pain intensity and unpleasantness after the eccentric training bouts were significantly lower in the arm that performed 2 5RM tests than the arm that performed only 1. Thus, the eccentric strength testing produced delayed-onset muscle pain and protected against future delayed-onset muscle pain. These effects should be considered when such testing is used in baseline strength assessments.     

Psychological Aspects of Headache

Headache is considered as a non-specific syndrome illustrating the concept of pain as an emotion. Viewed in this way, its meaning looms larger than its site.Pain indicates dis-ease of the patient, sometimes with his body, but more often with his life. No pain is “imaginary”, nor can some pain be assigned to physiological and some to psychological pathways. Such a decision is often merely a judgmental one.Just as the “brain” cannot easily be separated from the “mind”, so to believe that some pain is “physical” and some “emotional” is a distortion. All painful syndromes are mixed and the problem is to decipher the meaning of the pain. Only rarely will headache respond to physical measures alone.     

Gaze direction and request gesture in social interactions

One of the most important faculties of humans is to understand the behaviour of other conspecifics. The present study aimed at determining whether, in a social context, request gesture and gaze direction of an individual are enough to infer his/her intention to communicate, by searching for their effects on the kinematics of another individual's arm action. In four experiments participants reached, grasped and lifted a bottle filled of orange juice in presence of an empty glass. In experiment 1, the further presence of a conspecific not producing any request with a hand and gaze did not modify the kinematics of the sequence. Conversely, experiments 2 and 3 showed that the presence of a conspecific producing only a request of pouring by holding the glass with his/her right hand, or only a request of comunicating with the conspecific, by using his/her gaze, affected lifting and grasping of the sequence, respectively. Experiment 4 showed that hand gesture and eye contact simultaneously produced affected the entire sequence. The results suggest that the presence of both request gesture and direct gaze produced by an individual changes the control of a motor sequence executed by another individual. We propose that a social request activates a social affordance that interferes with the control of whatever sequence and that the gaze of the potential receiver who held the glass with her hand modulates the effectiveness of the manual gesture. This paradigm if applied to individuals affected by autism disorder can give new insight on the nature of their impairment in social interaction and communication.     

Muscular metastasis, a rare presentation of non-small-cell lung cancer

A 71-year-old man presented with a 2-week history of pain and swelling of his left arm. Subsequent investigations revealed an intramuscular lesion, suggestive of soft tissue sarcoma. Histologic analysis was surprisingly consistent with metastasis from a primary squamous cell lung cancer. Skeletal muscle metastasis as a mode of presentation of primary lung cancer is an unusual phenomenon. A brief literature review accompanies this report.     

Randomised Phase II Trial (NCT00637975) Evaluating Activity and Toxicity of Two Different Escalating Strategies for Pregabalin and Oxycodone Combination Therapy for Neuropathic Pain in Cancer Patients

Purpose

Neuropathic pain is commonly associated with cancer. Current treatments include combination opioid and adjuvant therapies, but no guidelines are available for dose escalation strategies. This phase II study compared the efficacy and tolerability of two dose escalation strategies for oxycodone and pregabalin combination therapy.

Methods

Patients (N = 75) with oncological neuropathic pain, previously untreated with pregabalin, were recruited in 5 Italian institutions between 2007 and 2010. Patients were randomised to two different dose escalation strategies (arm A; N = 38) oxycodone at a fixed dose with increasing pregabalin doses; (arm B; N = 37) pregabalin at a fixed dose with increasing oxycodone doses. Patients were evaluated from daily diaries and follow-ups at 3, 7, 10, and 14 days after beginning treatment with a numerical rating scale (NRS), neuropathic pain scale (SDN), and well-being scale (ESAS). The primary endpoint was a ≥1/3 reduction in pain (NRS); secondary endpoints included the time to analgesia and adverse effects. The study had a 90% probability of detecting the best strategy for a true difference of at least 15%.

Results

More patients in arm A (76%) than arm B (64%) achieved ≥1/3 overall pain reduction even after controlling for baseline factors (gender, baseline pain). Group A reported fewer side effects than group B; constipation 52.8% vs. 66.7%; nausea: 27.8% vs. 44.4%; drowsiness: 44.4% vs. 55.6%; confusion: 16.7% vs. 27.8%; itching: 8.3% vs. 19.4%.

Conclusions

Both strategies effectively controlled neuropathic pain, but according to the adopted selection design arm A is preferable to arm B for pain control.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00637975","term_id":"NCT00637975"}}NCT00637975     

Jerk-cost modulations during the practice of rapid arm movements

We examined how hand-trajectory smoothness changed during the practice of a motor task where smoothness was quantified by jerk-cost. Four human subjects each moved his nondominant arm between an upper target and a lower target, while circumnavigating a barrier that extended outward from the vertical plane of the targets. The two targets and the barrier placed boundary constraints on hand trajectories, but the motion was not restrained in any other way. Arm movements were recorded on high-speed ciné film, and linear and angular kinematical data were obtained for all arm segments. In each of 100 practice trials, subjects attempted to minimize movement time. After the practice trials, subjects repeated the same motor task but at movement times corresponding to the slowest, mid-range and fastest motion that had occurred during practice. Thus, jerk-cost could be compared for movements of different speeds during practice and after practice. Because the movement task contained several changes in hand-path direction, the changes in the vector characteristics of the hand accelerations were expected to be important for explaining the modulations in jerk-cost with practice. Total jerk-cost, therefore, was calculated as well as the separate magnitudinal and directional jerk-cost components. During practice, total movement time decreased, hand paths became more parabolic in shape, and significant changes occurred in hand acceleration magnitude, direction, and timing. Total jerk-cost and the magnitudinal and directional jerk-cost components were significantly less when slowest hand movements were compared after practice versus during practice. The decrease in jerk-cost indicated an increased smoothness of the practiced movements.K. Schneider was supported by the German Research Association (Deutsche Forschungsgemeinschaft)     

Comparison of transthecal digital block and traditional digital block for anesthesia of the finger

A randomized, double-blind study was performed in 50 patients to compare the transthecal and traditional subcutaneous infiltration techniques of digital block anesthesia regarding the onset of time to achieve anesthesia and pain during the infiltration. All the patients had sustained injury involving two or four fingers of the hand. Each patient served as his or her own control, having one finger infiltrated with the transthecal technique and the other with the subcutaneous infiltration technique. Time to loss of pinprick sensation and pain (at the time of the infiltration and 24 hours postoperatively) were assessed using a visual analogue scale and verbal response score. A total of 104 blocks (52 transthecal and 52 subcutaneous infiltration) were performed. All of these blocks were successful. Mean time to achieve anesthesia with the transthecal block was 165 seconds, compared with 100 seconds for the subcutaneous infiltration block. The mean analogue pain score was higher for transthecal blocks than for subcutaneous infiltration blocks (3.2 +/- 0.19 versus 1.6 +/- 0.14). Twenty-four hours postoperatively, 24 patients who had the transthecal block experienced pain at the injection site of the digit. However, none of the patients who received the subcutaneous infiltration block complained of pain at the digit. The technique of anesthesia preferred by patients for their finger was the subcutaneous infiltration block, because it causes less pain. Our results confirm the efficacy of the transthecal block for achieving anesthesia of the finger; however, because it is a more painful procedure, it is not recommended.     

Progressive changes in cutaneous trigger zones for sensation referred to a phantom hand: a case report and review with implications for cortical reorganization

The dominant model of cortical plasticity induced by peripheral denervation suggests that a physiologically-reorganized cortical area can acquire new perceptual meaning, including a change in the peripheral referral of sensation. An alternative view is that such an area may retain its former perceptual significance, even though it becomes responsive to new peripheral inputs. To examine evidence related to this issue, a clinical case is presented documenting the time course of changes in phantom limb sensation in a patient with accidental amputation of a hand. About 24 h after injury, a vivid phantom hand was present; tactile stimulation revealed cutaneous trigger zones on the arm, stimulation of which elicited sensation referred to specific fingers of the phantom. While the phantom hand percept remained fairly stable over time, the trigger zones expanded progressively in size during the next 1-8 weeks but had contracted and changed location considerably about one year later. At all times studied, the trigger zones were topographically related to specific fingers and other parts of the phantom hand. The implications of these and other recent clinical findings for cortical reorganization are discussed, and the following tentative conclusions are drawn. (1) A phantom percept is mediated by central neural networks which remain functionally intact after amputation. (2) Cutaneous trigger zones mapped in humans correspond to novel receptive fields of cortical neurons mapped in animals following peripheral denervation. (3) Cortical reorganization induced by denervation does not produce a major change in perceptual meaning or peripheral reference. In the present case, stimulation of new trigger zones (receptive fields) on the patient's arm presumably activated a reorganized cortical hand area but evoked sensation still referred to the (now missing) hand. Hence, physiological cortical remapping is not necessarily accompanied by functional respecification.     

Body Site Variation of Heat Pain Sensitivity

Thirty-two healthy human subjects provided thresholds for the perception of slight and moderate heat pain. Four body sites were tested bilaterally: thenar eminence of the hand, plantar surface of the foot, dorsolateral forearm, and lateral calf. Thresholds for the glabrous skin of the hand and foot were significantly greater than thresholds for the hairy skin of the arm and leg, the average difference being 1.3°c. Laterality was not a statistically significant factor. Thresholds increased progressively over 2–4 weeks of repeated testing, resulting in values averaging 0.6°c higher in the later sessions. The difference between moderate and slight pain thresholds averaged 1.1°c, and was consistent across body sites and with repeated testing.

The threshold values were normally distributed across subjects. Considerable intersubject variability was observed for both slight and moderate pain thresholds, more so on glabrous than on hairy skin sites. In comparison, the distribution of right-left difference values was narrower, demonstrating less intrasubject versus intersubject variability.

The highly significant difference in thresholds between glabrous and hairy skin sites demonstrates the importance of skin type for heat pain sensitivity. In contrast, there was no significant difference in heat pain sensitivity between comparable sites on the upper versus lower extremities, or between left and right sides.     

Myasis due to Cordylobia anthrophaga (Diptera: Calliphoirdae): description of a clinical case and review of the literature]

A case of myiasis due to Cordylobia anthropophaga is reported. The patient, an Italian man 44 years old, had come back from Nigeria and Ghana. He presented two nodular erythematous lesions of about 1 cm in diameter, on his back and right arm. From the lesions two third larval stage of C. anthropophaga were extracted. The authors report a short review about myiasis cases described in the scientific literature in Italy.     

Anchitrema sanguineum (Digenea: Anchitrematidae) Accidentally Found during Colonoscopy of a Patient with Chronic Abdominal Pain: A Case Report

In November 2007, a 46-year-old male Thai patient presented with chronic abdominal pain for over 3 years. Colonoscopy revealed a small parasite of about 2 × 1 mm in size attached to the cecum mucosa. The worm was removed endoscopically, fixed, and stained for morphological observations. The specimen was identified as Anchitrema sanguineum (Digenea: Anchitrematidae), a trematode first reported in a reptile, Chamaeleo vulgaris, from Egypt, and then sporadically found in the intestines of insectivorous bats and other mammals. The patient was treated with praziquantel but no more worms were found in his stool. His symptoms improved slightly but not cured completely. It remains unclear whether the chronic abdominal pain of the patient was caused by this trematode infection. Whatever is the pathogenicity of this trematode, this is the first human case of A. sanguineum infection in the literature.     

Patient-specific computational modeling of upper extremity arteriovenous fistula creation: its feasibility to support clinical decision-making

Introduction

Inadequate flow enhancement on the one hand, and excessive flow enhancement on the other hand, remain frequent complications of arteriovenous fistula (AVF) creation, and hamper hemodialysis therapy in patients with end-stage renal disease. In an effort to reduce these, a patient-specific computational model, capable of predicting postoperative flow, has been developed. The purpose of this study was to determine the accuracy of the patient-specific model and to investigate its feasibility to support decision-making in AVF surgery.

Methods

Patient-specific pulse wave propagation models were created for 25 patients awaiting AVF creation. Model input parameters were obtained from clinical measurements and literature. For every patient, a radiocephalic AVF, a brachiocephalic AVF, and a brachiobasilic AVF configuration were simulated and analyzed for their postoperative flow. The most distal configuration with a predicted flow between 400 and 1500 ml/min was considered the preferred location for AVF surgery. The suggestion of the model was compared to the choice of an experienced vascular surgeon. Furthermore, predicted flows were compared to measured postoperative flows.

Results

Taken into account the confidence interval (25^th and 75^th percentile interval), overlap between predicted and measured postoperative flows was observed in 70% of the patients. Differentiation between upper and lower arm configuration was similar in 76% of the patients, whereas discrimination between two upper arm AVF configurations was more difficult. In 3 patients the surgeon created an upper arm AVF, while model based predictions allowed for lower arm AVF creation, thereby preserving proximal vessels. In one patient early thrombosis in a radiocephalic AVF was observed which might have been indicated by the low predicted postoperative flow.

Conclusions

Postoperative flow can be predicted relatively accurately for multiple AVF configurations by using computational modeling. This model may therefore be considered a valuable additional tool in the preoperative work-up of patients awaiting AVF creation.     

Normalized patellofemoral joint reaction force is greater in individuals with patellofemoral pain

Patellofemoral pain is a disabling, highly prevalent pathology. Altered patellofemoral contact forces are theorized to contribute to this pain. Musculoskeletal modeling has been employed to better understand the etiology of patellofemoral pain. Currently, there are no data on the effective quadriceps moment arm for individuals with patellofemoral pain, forcing researchers to apply normative values when modeling such individuals. In addition, the ratio of patellofemoral reaction force to quadriceps force is often used as a surrogate for patellofemoral joint contact force, ignoring the fact that the quadriceps efficiency can vary with pathology and intervention. Thus, the purposes of this study were to: (1) quantify the effective quadriceps moment arm in individuals with patellofemoral pain and compare this value to a control cohort and (2) develop a novel methodology for quantifying the normalized patellofemoral joint reaction force in vivo during dynamic activities. Dynamic MR data were captured as subjects with patellofemoral pain (30F/3M) cyclically flexed their knee from 10° to 40°. Data for control subjects (29F/9M) were taken from a previous study. The moment arm data acquired across a large cohort of individuals with patellofemoral pain should help advance musculoskeletal modeling. The primary finding of this study was an increased mean normalized patellofemoral reaction force of 14.9% (maximum values at a knee angle of 10°) in individuals with patellofemoral pain. Understanding changes in the normalized patellofemoral reaction force with pathology may lead to improvements in clinical decision making, and consequently treatments, by providing a more direct measure of altered patellofemoral joint forces.