David Eagleman talks about the limits of our perception

Our perception if the World is unique to us as our brain filters the incoming information and constructs what we experience. Where our attention goes will depend upon the importance, or salience, of the stimulus.

In pain, something biologically salient is happening, grabbing our attention via the unpleasant feeling that hurts, drawing our focus to a particular body part at any given moment. The salience is determined by the brain’s interpretation of events, the conclusion being that something is potentially dangerous and requires a response. Pain then, motivates an action that maybe to rub the body, move, not move, seek help or take a pain killer — something that reduces the threat and hence the pain.

But, as with all experiences, this is, and can only be our own, unique perception. As you will see from this brief talk, our perception is very limited in comparison to all the other things going on around us and beyond, yet we cannot possibly process the vast array if stimuli and the cues — internal and external. That is why the brain prioritises and biologically creates the best experience and set of multi-system responses. Of course in persisting pain and stress, these responses become easier and easier to evoke and need re-training.

Click here to watch the David Eagleman video

RS — Specialist Pain Physio Clinics, London; treatment & training programmes for persisting pain & injury


Being Real

An excerpt from The Velveteen Rabbit by Margery Williams:

“Real isn’t how you are made,” said the Skin Horse. “It’s a thing that happens to you. When a child loves you for a long, long time, not just to play with, but really loves you, then you become Real.”
“Does it hurt?” asked the Rabbit.
“Sometimes,” said the Skin Horse, for he was always truthful. “When you are Real, you don’t mind being hurt.”
“Does it happen all at once, like being wound up,” he asked, “or bit by bit?”
“It doesn’t happen all at once,” said the Skin Horse. “You become. It takes a long time. That’s why it doesn’t often happen to people who break easily, or have sharp edges, or have to be carefully kept. Generally, by the time you are Real, most of your hair has been loved off, and your eyes drop out, and you get loose in the joints and very shabby. But these things don’t matter at all, because once you are Real, you can’t be ugly, except to people who don’t understand.”

Neurologists as detectives?

sherlock-holmes-glass_550Approaching patients who have possible neurological problems, as well as other complex cases such as chronic pain, with the mindset of a detective, in particular Sherlock Holmes, means that observation and deduction are consistent skills used to derive a meaning from the presentation. The ability to pick out subtle clues via the observation of movement, the way in which the body is postured, the language used and the accompanying gestures will all provide clues, building a picture that is enriched by the narrative, the story that the patient tells.

We must listen in detail to the patient, guide them in telling their tale, that often begins at a point in time that is earlier than would otherwise be thought relevant. How was this person primed by an illness or injury that subsequently manifested in the current condition? How did this problem evolve and what have been the influences?
Only through this detail can we start to understand the nature of the pain or problem, illustrated by changes in movement and function that must be observed with full concentration so as not to miss the most gentle of altered patterns of motion. A mindful approach to detective-based assessment is one way in which this can be achieved.

There is much that can be drawn from great detective work and as elucidators of the body’s responses to pathogen and disease, we can apply the skills with instinct, knowledge and compassion to then become the architects of conditions that allow for change.

RS: Specialist Pain Physio Clinics — the contemporary approach to painful problems 07932 689081

Blame the Amygdala

Here is an entertaining 20 minute discussion of neurologists as detectives (yes, the Sherlock Holmes kind).

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A multitude of phantoms

Mind Hacks

A fascinating paper in the neuroscience journal Brain looks at artistic depictions of phantom limbs – the feeling of the physical presence of a limb after it has been damaged or removed – and gives a wonderful insight how the brain perceives non-functioning or non-existent body parts.

In fact, most people who have a limb amputated will experience a phantom limb, although they often fade over time.

However, the feeling is usually not an exact representation of how the actual limb felt before it was removed, but can involve curious and sometimes painful ‘distortions’ in its perceived physical size, shape or location.

The Brain article looks at the diversity of phantom limb ‘shapes’ through their visual depictions.

The image on the left is from a 1952 case report where an amputation involved a ‘Krukenberg procedure‘.

This operation is rarely performed in the modern world but it involves…

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Lost in translation – Chronic pain


It happens all the time, a new scientific discovery gets over-hyped in a media frenzy (antibiotics for back pain and differences in male and female brains are two recent examples that come to mind) and the stories about the responses to the story become further sensational headlines themselves.

Sometimes its a “new” take on an old problem; a miracle berry from the Amazon rain forest that makes you lose weight no matter what you eat.

At other times it can be outdated information that still gets trotted out and other times still it’s just plain old nonsense and rubbish that needs calling out.

We call these “lost in translation”; stories that appear in popular media that get it wrong (horribly at times) or try to grab attention; try to get your ‘clicks’ and ‘views’ in our electronic age, with fantastic headlines.

Far from being trivial, these are the stories that…

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CRPS Bugle | Update on the latest research on complex regional pain syndrome #CRPS #RSD

ImageHappy New Year! — and now just into 2014 by a few hours, the first CRPS Bugle of the year. I anticipate another 12 months of advancement in the understanding of pain neurobiology, and new ways of thinking about pain so we can tackle the problem with increasing effectiveness. 

Here are some recent studies:

Complex regional pain syndrome type I of the knee: A systematic literature review.

Eur J Pain. 2013 Dec 17. doi: 10.1002/j.1532-2149.2013.00434.x. — van Bussel CM, Stronks DL, Huygen FJ.


In our Center for Pain Medicine, a group of patients reported to have symptoms possibly attributable to complex regional pain syndrome (CRPS) of only the knee(s). Therefore, this study aimed to investigate whether the literature reports on patients with CRPS type I in the knee(s) alone and, if so, to summarize the reported diagnostics, aetiology and treatment strategies of CRPS of the knee(s). Medline, Embase, Cochrane Library, PubMed and Web of Science were searched for articles focusing on a painful disorder of the knee, most likely CRPS type I. Screening on title and abstract was followed by full-text reading and searching of reference lists to determine the final set of relevant articles. Of the 513 articles identified, 31 met the inclusion criteria. These articles reported on a total of 368 patients diagnosed with CRPS of the knee(s) based on the diagnostic criteria used at the time of publication. Knee surgery, especially arthroscopic surgery, was the most common inciting event in developing CRPS of the knee(s). Various treatment strategies were applied with variable outcomes. In conclusion, the scientific literature does report cases of CRPS type I of only the knee(s). This applies when using the diagnostic criteria prevailing at the time of publication and, obviously for a smaller number of cases, also when using the current Budapest criteria set. Arthroscopic knee surgery is described multiple times as the inciting event. We recommend to include CRPS of the knee in future research on the aetiological mechanisms of and optimal treatment for CRPS.

RS — this is a very useful contribution to the literature. I have seen a number of cases of CRPS that involve the knee joint. It is worth noting that the Budapest Criteria should be used for diagnosis. The oft omitted descriptions of the CRPS experience include an altered sense of the knee, and usually beyond the boundaries of the joint, in addition to varying degrees of neglect and denial. Many people with persisting knee pain will also demonstrate aversion, not wishing to look directly, touch or be touched, each of these triggering withdrawal and perhaps a feeling of nausea or a shudder such as that felt in response to a knife screeching across a plate. Restoring a normal body sense is key to recovery, at least due to the brain’s need to integrate senses and the threat value of altered functioning to diminish as both the physical sense of the body changes and the mental processing of what is happening becomes less burdensome. 


Health-related quality of life in 975 patients with Complex Regional Pain Syndrome type 1

Pain. 2013 Dec 13. pii: S0304-3959(13)00665-9. doi: 10.1016/j.pain.2013.12.017 — van Velzen GA, Perez RS, van Gestel MA, Huygen FJ, Kleef MV, Eijs FV, Dahan A, van Hilten JJ, Marinus J.


There are limited data available on health related quality of life (QoL) of patients with complex regional pain syndrome (CRPS). In the present study we examined QoL in 975 CRPS patients attending six different clinics in the Netherlands. QoL was assessed using the SF-36 with the mental health summary score (MHS) and the physical health summary score (PHS) as dependent variable. Influence of gender, type of affected limb, disease duration, pain scores, CRPS severity and the employed set of diagnostic criteria was investigated. We found the lowest scores of QoL in the physical domains of the SF-36, with lower limb CRPS patients reporting poorer results than patients with an affected upper limb. Influence of gender on QoL was not found and correlations of QoL with disease duration and the CRPS severity score were weak. Pain correlated moderately with QoL. In addition, patients fulfilling stricter diagnostic criteria (i.e., the Budapest criteria) had lower QoL scores than patients fulfilling less strict criteria (i.e., the Orlando criteria). We conclude that loss of QoL in CRPS patients is mainly due to reduced physical health. A comparison with data available from the literature shows that CRPS patients generally report poorer QoL than patients with other chronic pain conditions, particularly in the physical domains. Pain correlated moderately with QoL and therefore deserves on-going attention by physicians. Lastly, patients meeting the diagnostic Budapest criteria have lower QoL scores than patients meeting the Orlando criteria, highlighting the impact of different sets of criteria on population characteristics.


Sensitivity and specificity of 3-phase bone scintigraphy in the diagnosis of complex regional pain syndrome of the upper extremity.

Clin J Pain. 2010 Mar-Apr;26(3):182-9. doi: 10.1097/AJP.0b013e3181c20207 — Wüppenhorst N, Maier C, Frettlöh J, Pennekamp W, Nicolas V.


Joint and bone alterations are seldom mentioned in the diagnostic criteria for complex regional pain syndrome (CRPS) even though they are important for long-term outcome. Altered periarticular bone metabolism can be detected by 3-phase bone scintigraphy (TPBS). Although frequently examining the diagnostic efficacy of TPBS is debatable.

In all, 78 TPBS (45 CRPS/33 control group) were evaluated qualitatively and quantitatively. Sensitivity and specificity of the qualitative blinded reviewer analysis (n=57) compared with quantitative region of interest (ROI)-based analysis over the metacarpophalangeal, proximal, and distal interphalangeal joints (n=74) were evaluated. Patients’ sex, age, duration of CRPS, inciting event, extent of joint alteration, and handedness were included as covariables.

Qualitative blinded reviewer TPBS analysis had a high specificity (83%-100%). However, sensitivity was 31% to 50%. Interrater reliability was moderate (kappa score 0.56). Using the ROI-based evaluation, the highest sensitivity (69%) and specificity (75%) (ROI score > or =1.32) was shown for phase 3, whereas sensitivity of phases 1 and 2 rapidly declined to 50%. Duration of CRPS until TPBS was the only variable with significant impact on ROI scores of phase 3 (F=23.7; P=0.000; R=0.42). ROI scores declined with increasing duration of CRPS.

In conclusion, TPBS is a highly specific tool for diagnosing CRPS of the upper limb. ROI evaluation of phase 3 within the first 5 months after onset of CRPS is an appropriate additional diagnostic tool to confirm or exclude CRPS of the upper extremity.

RS: a slightly older study that looks at the possibility of a diagnostic tool for CRPS beyond the criteria determined by signs and symptoms (Budapest). The next paper (below) suggests that caution is prudent — often in the literature a finding is countered with further data that throws up a different view, nonetheless an important development in the route to understanding the role of BS in diagnosis.


Concordance of qualitative bone scintigraphy results with presence of clinical complex regional pain syndrome 1: meta-analysis of test accuracy studies.

Eur J Pain. 2012 Nov;16(10):1347-56. doi: 10.1002/j.1532-2149.2012.00137.x — Ringer R, Wertli M, Bachmann LM, Buck FM, Brunner F.


To date, no attempt has been made to investigate the agreement between qualitative bone scintigraphy (BS) and the presence of complex regional pain syndrome 1 (CRPS 1) and the agreement between a negative BS in the absence of CRPS 1.

To summarize the existing evidence quantifying the concordance of qualitative BS in the presence or absence of clinical CRPS 1.

We searched Medline, Embase, Dare and the Cochrane Library and screened bibliographies of all included studies.

We selected diagnostic studies investigating the association between qualitative BS results and the clinical diagnosis of CRPS 1. The minimum requirement for inclusion was enough information to fill the two-by-two tables.

Twelve studies met our inclusion criteria and were included in the meta-analysis. The pooled mean sensitivity of 12 two-by-two tables was 0.87 (95% CI, 0.68-0.97) and specificity was 0.69 (95% CI, 0.47-0.85). The pooled mean sensitivity for the subgroup with clearly defined diagnostic criteria (seven two-by-two tables) was 0.80 (95% CI, 0.44-0.95) and specificity was 0.73 (95% CI, 0.40-0.91).

Based on this study, clinicians must be advised that a positive BS is not necessarily concordant with presence of absence or CRPS 1. Given the moderate level of concordance between a positive BS in the absence of clinical CRPS 1, discordant results potentially impede the diagnosis of CRPS 1.


Objective sensory evaluation of the spread of complex regional pain syndrome.

Pain Physician. 2013 Nov-Dec;16(6):581-91 — Edinger L, Schwartzman RJ, Ahmad A, Erwin K, Alexander GM.

The spread of complex regional pain syndrome (CRPS) has been well documented. Many severe refractory long-standing patients have total body pain (TBP) that evolved from a single extremity injury.

The purpose of this study was to document by objective sensory threshold testing the extent of body area involvement in 20 long-standing patients with CRPS who have TBP.

A comparison of sensory threshold testing parameters between 20 long-standing refractory patients with CRPS who have TBP versus 10 healthy participants.

Twenty patients with CRPS who stated that they suffered from total body pain were chosen from the Drexel University College of Medicine CRPS database. They were compared to 10 healthy participants that were age and gender matched to the patients with CRPS. The sensory parameters tested were: skin temperature; static and mechanical allodynia; thermal allodynia; mechanical hyperalgesia; after sensations following all sensory tests. The sites chosen for testing in the patients with CRPS were the most painful area in each of 8 body regions that comprised the total body area.

Five patients with CRPS had signs of CRPS over 100% of their body (20%). One patient had pain over 87% and another had pain over 90% of their body area. The average percentage of body involvement was 62% (range 37% – 100%). All patients with CRPS had at least one sensory parameter abnormality in all body regions. All patients with CRPS had lower pain thresholds for static allodynia in all body areas, while 50% demonstrated a lower threshold for dynamic allodynia in all body regions compared to the healthy participants. Cold allodynia had a higher median pain rating on the Likert pain scale in all body areas versus healthy participants except for the chest, abdomen, and back. Eighty-five percent of the patients with CRPS had a significantly lower pain threshold for mechanical hyperalgesia in all body areas compared to the healthy participants. After sensations occurred after all sensory parameters in the extremities in patients with CRPS.

The primary limitations of this study would be the variability of self-reported data (each subject’s assessment of pain/ discomfort to a tested parameter) and the challenge to uniformly administer each parameter’s assessment since simple tools and not precision instruments were used (with the exception of skin temperature).

TBP and objective sensory loss occur in 20% of patients with refractory long-standing CRPS.

RS: In CRPS and other chronically painful conditions it is common to find other sensitivities including the functional pain syndromes, more-so in women, including irritable bowel syndrome, pelvic pain, migraines and persisting aches and pains with a varying degree of impact and suffering. 



A conversation on compassion | Thich Nhat Hanh

The Center for Compassion and Altruism Research and Education (CCARE) is honored to host a discussion with Thich Nhat Hanh about his life experiences and the role compassion has played throughout them. Thich Nhat Hanh is an internationally renowned Zen master, prolific author, and teacher on the subjects of peace, mindfulness, and meditation. He became a monk at the age of sixteen and went on to help found the “engaged Buddhism” movement. His life’s work has been dedicated to “inner transformation for the benefit of individuals and society” and he was nominated by Nobel Laureate Martin Luther King, Jr. for the Nobel Peace Prize in 1967.