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°C. Coincident with his learning, the pain in his hand and arm decreased markedly and remained absent at 1-year follow-up.The author wishes to acknowledge the assistance of Dr. Kit S. Mays and the staff of the Pain Clinic of the University of Tennessee Center for the Health Sciences.     

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.     

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.     

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.     

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.     

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.     

Retrocardiac mass causing collapse

A 78-year-old man with a history of hypertension presented to the emergency room after the sudden onset of near-collapse, dyspnoea, dizziness, and nausea. Symptoms had started while the patient was stooped over in an attempt to reach for an item underneath his bed. The patient reported upper abdominal pain, radiating to his back. Prior to his presenting symptoms he had no complaints, nor had he suffered from trauma.     

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.

     

Study on pottical type, palmar and plantar digital formulae, hand clasping, arm folding, handedness, leg folding and stride type in the Daur population, China

The pottical type, palmar and plantar digital formulae, hand clasping, arm folding, handedness, leg folding and stride type have been investigated on a sample of 143 male and 160 female students of the Daur population of Molidawa Banner, Inner Mongolia. The results of this study are the following: 1. the frequency of the hyperextensive pottical type is 49.17%, the relative length of index over annularis 12.21%, right hand clasping 45.87%, right arm folding 49.50%, right handedness 94.39%, right leg folding 72.28% and right stride type 44.88%, 2. pottical type, hand clasping, handedness, leg folding and stride type do not show significant sex differences, 3. there are some relations between hand clasping and arm folding as well as between arm folding and stride type, 4. compared with other population groups, the Daur population shows a low frequency of right hand clasping, a moderate frequency of right arm folding and a low frequency of left handedness.     

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.     

Rehabilitation of an electrical burn patient through thermal biofeedback

A 22-year-old male subject, with high-voltage electrical burns to one wrist, utilized differential relaxation and visual biofeedback to increase skin temperature in the damaged hand. Through 14 thermal biofeedback and passive relaxation sessions, the subject was able to produce temperature increases in his damaged hand of up to 21 degrees F, which considerably diminished the pain. Healing, feeling, and movement control seemed to progress with extreme rapidity, suggesting that axoplasmic transport was greatly enhanced.     

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.     

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)     

A variant of Cenani-Lenz type syndactyly

Cenani-Lenz syndrome is a form of complete syndactyly resembling the spoon hand in Apert syndrome. It is often associated with disorganization of phalanges, the fusion of metacarpals and mesomelic shortness of the arm. We describe an additional case of Cenani-Lenz type of syndactylism in a 16 month-old girl who also has rib and vertebral abnormalities and mixed type hearing loss, that have not been seen before in a single patient.     

Effects of Modulations of the Visual Conditions on Subjects’ Perception of Their Own and Another Person’s Hand

According to current concepts, the execution of expedient actions well-coordinated in space becomes possible owing to the creation of a system for internal representation, which includes a body coordinate system, in the central nervous system. The goal of this study was to assess the effects induced by the exclusion of vision and a left-right inversion in visual space on the accuracy in the internal representation of hands and on aimed arm movements. The study cohort included 16 participants aged from 18 to 25 years. The experiment consisted of two test series. In the first series, a subject placed his/her left hand under a transparent plexiglass screen. Upon the experimenter’s command, the subject had to indicate the position of his/her left wrist and the terminal phalanges of the thumb, middle and little fingers with his/her right index finger on the plexiglass, which was accompanied by the corresponding marks displayed on the screen. The positional accuracy in the subject’s perception of his/her own hand position was recorded in the conditions of a leftright inversion of visual space, which were created by wearing prismatic spectacles and the exclusion of visual control. In the second case, the subject’s left hand was replaced on the table under the transparent screen by a similarly shaped left hand belonging to another person. It has been shown that the positions of the middle fingertip and the wrist were sufficiently precisely perceived by the subject through prismatic spectacles. However, the position of the tips of the thumb and little finger relative to the axis connecting the wrist and the terminal phalanx of the middle finger (the hand axis) was perceptually inverted. The accuracy of the indication was reduced for all fingers when the eyes were closed. In testing another person’s hand, a left–right inversion in the visual space created an illusory 90° turn of the hand’s axis and an illusory bias relative to the wrist towards elongation in the marker points corresponding to another person’s fingers. We can suggest that when the alien hand replaced the subject’s own hand, in accordance with the modulations in the motor task conditions, the egocentric system of coordinates was replaced by the allocentric system. The role of vision in the execution of spatially oriented and accurate hand movements increased in this case.     

PSYCHOLOGICAL ASPECTS OF PAIN IN PATIENTS WITH TERMINAL CANCER

The dying patient reacts emotionally to the problems encountered in the terminal period according to his established pattern of response to stress. The nature of this pattern will play a part in his experience of pain. Some of the types of reaction include the bizarre misinterpretation of bodily sensation of the psychotic, the development of conversion symptoms, the increase in pain through muscle tension in the anxious but overcontrolled person, and the stoical acceptance by guilt-ridden patients. Physicians are sometimes reluctant to devote full attention to the care of the terminally ill for a number of reasons, including the attitude that "curing" is the only worthwhile activity of a doctor of medicine. Observers have found that the physician's attention to the day to day anxieties of the patient in a terminal stage may contribute substantially to his comfort.