Derangement of body representation in complex regional pain syndrome: report of a case treated with mirror and prisms

Abstract

Perhaps the most intriguing disorders of body representation are those that are not due to primary disease of brain tissue. Strange and sometimes painful phantom limb sensations can result from loss of afference to the brain; and Complex Regional Pain Syndrome (CRPS)—the subject of the current report—can follow limb trauma without pathology of either the central or peripheral nervous system. This enigmatic and vexing condition follows relatively minor trauma, and can result in enduring misery and a useless limb. It manifests as severe pain, autonomic dysfunction, motor disability and ‘neglect-like’ symptoms with distorted body representation. For this special issue on body representation we describe the case of a patient suffering from CRPS, including symptoms suggesting a distorted representation of the affected limb. We report contrasting effects of mirror box therapy, as well as a new treatment—prism adaptation therapy—that provided sustained pain relief and reduced disability. The benefits were contingent upon adapting with the affected limb. Other novel observations suggest that: (1) pain may be a consequence, not the cause, of a disturbance of body representation that gives rise to the syndrome; (2) immobilisation, not pain, may precipitate this reorganisation of somatomotor circuits in susceptible individuals; and (3) limitation of voluntary movement is neither due to pain nor to weakness but, rather, to derangement of body representation which renders certain postures from the repertoire of hand movements inaccessible.

Pain, body, and space: What do patients with complex regional pain syndrome really neglect?

“…Indeed, Sumitani et al [35] have shown that prism adaptation can additionally decrease pain and other CRPS symptoms following two weeks of treatment. These data were replicated by Bultitude and Rafal [2] who confirmed in one patient that daily prism adaptation could alleviate CRPS symptoms such as pain, swelling and hand motricity after ten days. Other techniques based on similar conceptions are also potentially relevant.…”

“…Moseley et al [27] have demonstrated modification of the perception of pain in CRPS by distorting the visual size of the affected hand. Other teams [2,22,37] have tried to cure CRPS patients with mirror rehabilitation [29]. With this technique, synchronous movements of the two limbs are made while the affected limb is hidden behind a mirror that gives to the subject the image of the unaffected limb as it was the affected one.…”

“…With this technique, synchronous movements of the two limbs are made while the affected limb is hidden behind a mirror that gives to the subject the image of the unaffected limb as it was the affected one. The subject sees the reflected image of the unaffected limb in the space occupied by the affected one, giving the illusion of a healthy moving limb, and this change in visual inputs is helpful in alleviating CRPS symptoms after several days of treatment [2,22,37]. …”

Sensing the body in chronic pain: A review of psychophysical studies implicating altered body representation

“…In light of such observations, the associated changes in chronic pain patients regarding proprioception more likely involves upstream disturbances, such as the neural processing of proprioceptive signals (Brumagne et al, 2004;Popa et al, 2007;McCabe and Blake, 2008). Conversely, higher-order alterations in body representation (Bultitude and Rafal, 2010) through cortical reorganisation have also been implicated (Moseley and Gandevia, 2005).…”

Body Integrity Identity Disorder: Deranged Body Processing, Right Fronto-Parietal Dysfunction, and Phenomenological Experience of Body Incongruity

“…Disordered body representation in BIID may also correspond to predisposition towards attentional focus on somatic information, as is seen in conditions such as CRPS1 and fixed dystonia (Bultitude and Rafal 2010;Edwards et al 2011), which are also associated with seeking amputation of the affected limb and disturbed body representation. In these latter conditions, a peripheral injury triggers a series of pathophysiological changes resulting in persistent pain, and there is evidence of disturbed body representation (e.g., impaired mental rotation of body parts; Katschnig et al 2010;Moseley 2004).…”