Wherever is my arm? Impaired upper limb position accuracy in complex regional pain syndrome.
Knowledge of the position of one's limbs is an essential component of daily function and relies on complex interactions of sensorimotor body schema-related information. Those with Complex Regional Pain Syndrome (CRPS) express difficulty in knowing where their affected limb is positioned. The aim of this study was to determine the degree to which experimental data supported the reported difficulty in limb position sense. A controlled experimental design was used to measure upper limb position accuracy amongst those with CRPS of one arm. Position accuracy was individually measured in both arms and compared to a known target position. Video captured each of 36 trials (half with arm in full view and half with vision obscured). The error in degrees between actual and known targets was determined using video analysis software. The Brief Pain Inventory measured pain. A subjective mental image representation of both upper limbs was documented. The CRPS group had moderate pain intensity and were significantly less accurate in positioning both the affected and unaffected limbs compared to controls (p<0.001). Position accuracy of the CRPS affected limb significantly improved with vision (8.3 degrees in view, 10.7 degrees not in view). Subjective mental representations of the affected limb were visualised as distorted. Evidence of bilateral arm positioning impairments in unilateral arm CRPS suggests that central mechanisms are involved. Cortical reorganisation in regions associated with the body schema (i.e. primary somatosensory and parietal cortices) is proposed as an explanation. The exact relationship between pain and limb position deficits requires further exploration.
Lewis
Jennifer S
JS
McGill University, Montreal, Canada The Royal National Hospital for Rheumatic Diseases NHS Foundation Trust, Bath, UK University of Southampton, Southampton, UK Auckland University of Technology, Auckland, New Zealand University of Bath, Bath, UK.
Kersten
Paula
P
McPherson
Kathryn M
KM
Taylor
Gordon J
GJ
Harris
Nigel
N
McCabe
Candida S
CS
Blake
David R
DR
D000328:Adult; D001132:Arm / Q000294:innervation* / Q000503:physiopathology; D020918:Complex Regional Pain Syndromes / Q000150:complications* / Q000503:physiopathology*; D004185:Disability Evaluation; D005121:Extremities / Q000294:innervation* / Q000503:physiopathology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009949:Orientation / Q000502:physiology; D010147:Pain Measurement; D010468:Perceptual Disorders / Q000209:etiology* / Q000503:physiopathology*; D020886:Somatosensory Disorders / Q000209:etiology* / Q000503:physiopathology*
Acerra N, Moseley GL. Dysynchiria: watching the mirror image of the unaffected limb elicits pain on the affected side. Neurology. 2005;65:751-753.
Bearne LM, Coomer AF, Hurley MV. Upper limb sensorimotor function and functional performance in patients with rheumatoid arthritis. Disabil Rehabil. 2007;29:1035-1039.
Bruehl S, Harden RN, Galer BS, Saltz S, Backonja M, Stanton-Hicks M. Complex regional pain syndrome: are there distinct subtypes and sequential stages of the syndrome? Pain. 2002;95:119-124.
Bullock-Saxton JE, Wong WJ, Hogan N. The influence of age on weight-bearing joint reposition sense of the knee. Exp Brain Res. 2001;136:400-406.
Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med. 1994;23:129-138.
Cohen H, McCabe CS, Harris N, Blake DR. Clinical evidence of parietal lobe dysfunction in patients with CRPS Type 1. Rheumatology. 2009;48:i95.
Dielissen P, Claassen AT, Veldman P, Goris R. Amputation for reflex sympathetic dystrophy. J Bone Joint Surg. 1995;77B:270-273.
Dover G, Powers M. Reliability of joint position sense and force reproduction measures during internal and external rotation of the shoulder. J Athl Train. 2003;38:304-310.
Dudzinski D. Amputate my arm please-I don't want it anymore. J Clin Ethics. 2005;16:196-201.
Ferrell WR, Crighton A, Sturrock RD. Position sense at the proximal interphalangeal joint is distorted in patients with rheumatoid-arthritis of finger joints. Exp Physiol. 1992;77:675-680.
Förderreuther S, Sailer U, Straube A. Impaired self-perception of the hand in complex regional pain syndrome (CRPS). Pain. 2004;110:756-761.
Frith CD, Blakemore SJ, Wolpert DM. Abnormalities in the awareness and control of action. Philos Trans R Soc Lond B: Biol Sci. 2000;355:1771-1788.
Galer BS, Butler S, Jensen MP. Case-reports and hypothesis – a neglect-like syndrome may be responsible for the motor disturbance in reflex sympathetic dystrophy (Complex-Regional-Pain-Syndrome-1). J Pain Symptom Manage. 1995;10:385-391.
Galer BS, Jensen M. Neglect-like symptoms in complex regional pain syndrome: results of a self-administered survey. J Pain Symptom Manage. 1999;18:213-217.
Ghez C, Gordon J, Ghilardi M. Impairments of reaching movements in patients without proprioception. II: Effects of visual information on accuracy. J Neurophysiol. 1995;73:361-372.
Gordon J, Ghilardi M, Ghez C. Impairments of reaching movements in patients without proprioception. I: Spatial errors. J Neurophysiol. 1995;73:347-360.
Graziano MSA. Where is my arm? The relative role of vision and proprioception in the neuronal representation of limb position. Proc Natl Acad Sci USA. 1999;96:10418-10421.
Haggard P, Taylor-Clarke M, Kennett S. Tactile perception, cortical representation and the bodily self. Curr Biol. 2003;13:R170-R173.
Harden RN, Bruehl S, Galer BS, Saltz S, Bertram M, Backonja M, Gayles R, Rudin N, Bhugra MK, Stanton-Hicks M. Complex regional pain syndrome: are the IASP diagnostic criteria valid and sufficiently comprehensive? Pain. 1999;83:211-219.
Jänig W, Baron R. Complex Regional Pain Syndrome: mystery explained? Lancet Neurol. 2003;30:687-697.
Juottonen K, Gockel M, Silen T, Hurri H, Hari R, Forss N. Altered central sensorimotor processing in patients with complex regional pain syndrome. Pain. 2002;98:315-323.
Lewis JS, Kersten P, McCabe CS, McPherson KM, Blake DR. Body perception disturbance: a contribution to pain in Complex Regional Pain Syndrome. Pain. 2007;133:111-119.
Maihöfner C, Handwerker HO, Neundorfer B, Birklein F. Patterns of cortical reorganization in complex regional pain syndrome. Neurology. 2003;61:1707-1715.
Maihöfner C, Handwerker HO, Neundorfer B, Birklein F. Cortical reorganization during recovery from complex regional pain syndrome. Neurology. 2004;63:693-701.
Maihöfner C, Baron R, Decol R, Binder A, Birklein F, Deuschl G, Handwerker HO, Schattschneider J. The motor system shows adaptive changes in complex regional pain syndrome. Brain. 2007;130:2671-2687.
McCabe CS, Shenker N, Lewis J, Blake DR. Impaired self-perception of the hand in complex regional pain syndrome (CRPS). Pain 2005. [Förderreuther S, Sailer U, Staube A. Pain 2004;110:756–61].
Moseley L. Distorted body image in complex regional pain syndrome. Neurology. 2005;65:773.
Overney L, Michel CM, Harris IM, Pegna AJ. Cerebral processes in mental transformations of body parts: recognition prior to rotation. Cogn Brain Res. 2005;25:722-734.
Pleger B, Tegenthoff M, Ragert P, Forster A, Dinse H, Schwenkreis P, Nicolas V, Maier C. Sensorimotor returning in complex regional pain syndrome parallels pain reduction. Ann Neurol. 2005;57:425-429.
Ribbers GM, Mulder T, Geurts AC, den Otter RA. Reflex sympathetic dystrophy of the left hand and motor impairments of the unaffected right hand: impaired central motor processing? Arch Phys Med Rehabil. 2002;83:81-85.
Sandroni P, Benrud-Larson L, McClelland R, Low P. Complex regional pain syndrome type I: incidence and prevalence in Olmsted county, a population-based study. Pain. 2003;103:199-207.
Schwartzman RJ, Kerrigan J. The movement disorder of reflex sympathetic dystrophy. Neurology. 1990;40:57-61.
Schwoebel J, Coslett HB. Evidence for multiple, distinct representations of the human body. J Cogn Neurosci. 2005;17:543-553.
Sirigu A, Daprati E, Ciancia S, Giraux P, Nighoghossian N, Posada A, Haggard P. Altered awareness of voluntary action after damage to the parietal cortex. Nat Neurosci. 2004;7:80-84.
Stanton-Hicks M, Jänig W, Hassenbusch S, Haddox JD, Boas R, Wilson P. Reflex sympathetic dystrophy: changing concepts and taxonomy. Pain. 1995;63:127-133.
Sumitani M, Rossetti Y, Shibata M, Matsuda Y, Sakaue G, Inoue T, Mashimo T, Miyauchi S. Prism adaptation to optical deviation alleviates pathologic pain. Neurology. 2007;68:128-133.
van Hilten JJ, Van de Beek WJT, Vein AA, van Dijk JG, Middelkoop HAM. Clinical aspects of multifocal or generalized tonic dystonia in reflex sympathetic dystrophy. Neurology. 2001;56:1762-1765.
van Rijn MA, Marinus J, Putter H, van Hilten JJ. Onset and progression of dystonia in Complex Regional Pain Syndrome. Pain. 2007;130:287-293.
Veldman P, Reynen H, Arntz I, Goris R. Signs and symptoms of reflex sympathetic dystrophy: prospective study of 829 patients. Lancet. 1993;342:1012-1016.
Wasner G, Schattschneider J, Binder A, Baron R. Complex regional pain syndrome – diagnostic, mechanisms, CNS involvement and therapy. Spinal Cord. 2003;41:61-75.