#CRPS Bugle | 30th May

Pain. 2013 Apr 6. CRPS Bugle

The rubber hand illusion in complex regional pain syndrome: Preserved ability to integrate a rubber hand indicates intact multisensory integration.

Reinersmann A, Landwehrt J, Krumova EK, Peterburs J, Ocklenburg S, Güntürkün O, Maier C.


Department of Pain Medicine, Ruhr-University Bochum, BG Universitätsklinikum Bergmannsheil GmbH, Germany. Electronic address: Annika.Reinersmann@rub.de.


In patients with complex regional pain syndrome (CRPS) type 1, processing of static tactile stimuli is impaired, whereas more complex sensory integration functions appear preserved. This study investigated higher order multisensory integration of body-relevant stimuli using the rubber hand illusion in CRPS patients. Subjective self-reports and skin conductance responses to watching the rubber hand being harmed were compared among CRPS patients (N=24), patients with upper limb pain of other origin (N=21, clinical control group), and healthy subjects (N=24). Additionally, the influence of body representation (body plasticity [Trinity Assessment of Body Plasticity], neglect-like severity symptoms), and clinical signs of illusion strength were investigated. For statistical analysis, 1-way analysis of variance, t test, Pearson correlation, with α=0.05 were used. CRPS patients did not differ from healthy subjects and the control group with regard to their illusion strength as assessed by subjective reports or skin conductance response values. Stronger left-sided rubber hand illusions were reported by healthy subjects and left-side-affected CRPS patients. Moreover, for this subgroup, illness duration and illusion strength were negatively correlated. Overall, severity of neglect-like symptoms and clinical signs were not related to illusion strength. However, patients with CRPS of the right hand reported significantly stronger neglect-like symptoms and significantly lower illusion strength of the affected hand than patients with CRPS of the left hand. The weaker illusion of CRPS patients with strong neglect-like symptoms on the affected hand supports the role of top-down processes modulating body ownership. Moreover, the intact ability to perceive illusory ownership confirms the notion that, despite impaired processing of proprioceptive or tactile input, higher order multisensory integration is unaffected in CRPS.

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Pain. 2012 Nov;153(11):2174-81.

Impaired spatial body representation in complex regional pain syndrome type 1 (CRPS I).

Reinersmann A, Landwehrt J, Krumova EK, Ocklenburg S, Güntürkün O, Maier C.


Department of Pain Management, Ruhr-University Bochum, BG Universitätsklinikum Bergmannsheil GmbH, Bochum, Germany. Annika.reinersmann@rub.de


Recently, a shift of the visual subjective body midline (vSM), a correlate of the egocentric reference frame, towards the affected side was reported in patients with complex regional pain syndrome (CRPS). However, the specificity of this finding is as yet unclear. This study compares 24 CRPS patients to 21 patients with upper limb pain of other origin (pain control) and to 24 healthy subjects using a comprehensive test battery, including assessment of the vSM in light and dark, line bisection, hand laterality recognition, neglect-like severity symptoms, and motor impairment (disability of the arm, shoulder, and hand). Statistics: 1-way analysis of variance, t-tests, significance level: 0.05. In the dark, CRPS patients displayed a significantly larger leftward spatial bias when estimating their vSM, compared to pain controls and healthy subjects, and also reported lower motor function than pain controls. For right-affected CRPS patients only, the deviation of the vSM correlated significantly with the severity of distorted body perception. Results confirm previous findings of impaired visuospatial perception in CRPS patients, which might be the result of the involvement of supraspinal mechanisms in this pain syndrome. These mechanisms might accentuate the leftward bias that results from a right-hemispheric dominance in visuospatial processing and is known as pseudoneglect. Pseudoneglect reveals itself in the tendency to perceive the midpoint of horizontal lines or the subjective body midline left of the centre. It was observable in all 3 groups, but most pronounced in CRPS patients, which might be due to the cortical reorganisation processes associated with this syndrome.

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Pain. 2012 Jul;153(7):1484-94.

Intact 2D-form recognition despite impaired tactile spatial acuity in complex regional pain syndrome type I.

Reiswich J, Krumova EK, David M, Stude P, Tegenthoff M, Maier C.


Department of Pain Management, BG Universitätsklinikum Bergmannsheil GmbH, Ruhr University Bochum, Bochum, Germany.


Tactile acuity measured by 2-point discrimination performance is impaired in patients with complex regional pain syndrome type I (CRPS-I). This is mirrored by pain-associated shrinkage of the cortical representation of the affected limb. We investigated whether, also, more complex tactile performance assessed by a dynamic 2D-form perception task is disturbed in CRPS-I patients. Therefore, we developed a Braille-like recognition task (BT) for geometrical dot pattern identification by dynamic touch. We studied 47 healthy volunteers (Study I) and compared them to 16 CRPS-I patients (Study II). Besides recognition time and error quote of the BT, we assessed static 2-point discrimination thresholds (TPDT). In healthy subjects, the performance in the BT correlated significantly with age and TPDT. In CRPS patients, TPDT was significantly increased on the affected side compared to sex- and age-matched controls from study I (2.98 ± 0.84 mm vs 2.05 ± 0.82 mm, P<0.01). The performance in the BT was not impaired in CRPS-I patients (compared to sex- and age-matched controls from study I) and was not correlated to the TPDT. The intact 2D-form recognition ability in CRPS-I patients might be explained by intact dynamic tactile and proprioceptive functions, which appear to be uncompromised by the impaired static tactile perception, provided that the spacing of the dot pattern is above the individual tactile acuity. These intact 2D-form perception capacities may also be related to higher sensory integration functions like the visual system and intact semantic understanding, which may be spared by the cortical reorganization phenomena in CRPS-I.

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J Clin Neurosci. 2011 Dec;18(12):1596-601.

The rubber hand illusion and its application to clinical neuroscience.

Ramakonar H, Franz EA, Lind CR.


Department of Neurosurgery, Neurosurgical Service of Western Australia, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia 6009, Australia.


The rubber hand illusion (RHI) is a perceptual experience which often occurs when an administered tactile stimulation of a person’s real hand hidden from view, occurs synchronously with a corresponding visual stimulation of an observed rubber hand placed in full vision of the person in a position corresponding to where their real hand might normally be. The perceptual illusion is that the person feels a sense of “ownership” of the rubber hand which they are looking at. Most studies have focused on the underlying neural properties of the illusion and the experimental manipulations that lead to it. The illusion could also be used for exploring the sense of limb and prosthetic ownership for people after amputation. Cortical electrodes such as those used in sensorimotor stimulation surgery for pain may provide an opportunity to further understand the cortical representation of the illusion and possibly provide an opportunity to modulate the individual’s sense of body ownership. Thus, the RHI might also be a critical tool for development of neurorehabilitative interventions that will be of great interest to the neurosurgical and rehabilitation communities.


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