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

Neuro-cognitive effects of degraded visibility on illusory body ownership

Based on visuo-tactile stimulation, the rubber hand illusion induces a sense of ownership for a dummy hand. Manipulating the visibility of the dummy hand during the stimulation influences cognitive aspects of the illusion, suggesting that the related brain activity may be influenced too. To test this, we analyzed brain activity (fMRI), subjective ratings, and skin conductance from 45 neurotypical participants undergoing a modified rubber hand illusion protocol where we manipulated the visibility (high, medium, and low) of a virtual hand, not the brush (virtual hand illusion; VHI). To further investigate the impact of visibility manipulations on VHI-related secondary effects (i.e. vicarious somatosensation), we recorded brain activity and skin conductance during a vicarious pain protocol (observation of painful stimulations of the virtual hand) that occurred after the VHI procedure. Results showed that, during both the VHI and vicarious pain periods, the activity of distinct visual, somatosensory, and motor brain regions was modulated by (i) visibility manipulations, (ii) coherence between visual and tactile stimulation, and (iii) time of visuo-tactile stimulation. Accordingly, embodiment-related subjective ratings of the perceived illusion were specifically influenced by visibility manipulations. These findings suggest that visibility modifications can impact the neural and cognitive effects of illusory body ownership, in that when visibility decreases the illusion is perceived as weaker and the brain activity in visual, motor, and somatosensory regions is overall lower. We interpret this evidence as a sign of the weight of vision on embodiment processes, in that the cortical and subjective aspects of illusory body ownership are weakened by a degradation of visual input during the induction of the illusion.

Visuotactile integration in individuals with fibromyalgia

Our brain constantly integrates afferent information, such as visual and tactile information, to perceive the world around us. According to the maximum-likelihood estimation (MLE) model, imprecise information will be weighted less than precise, making the multisensory percept as precise as possible. Individuals with fibromyalgia (FM), a chronic pain syndrome, show alterations in the integration of tactile information. This could lead to a decrease in their weight in a multisensory percept or a general disruption of multisensory integration, making it less beneficial. To assess multisensory integration, 15 participants with FM and 18 pain-free controls performed a temporal-order judgment task in which they received pairs of sequential visual, tactile (unisensory conditions), or visuotactile (multisensory condition) stimulations on the index and the thumb of the non-dominant hand and had to determine which finger was stimulated first. The task enabled us to measure the precision and accuracy of the percept in each condition. Results indicate an increase in precision in the visuotactile condition compared to the unimodal conditions in controls only, although we found no intergroup differences. The observed visuotactile precision was correlated to the precision predicted by the MLE model in both groups, suggesting an optimal integration. Finally, the weights of the sensory information were not different between the groups; however, in the group with FM, higher pain intensity was associated with smaller tactile weight. This study shows no alterations of the visuotactile integration in individuals with FM, though pain may influence tactile weight in these participants.

Forearm bisection task suggests an alteration in body schema in patients with functional movement disorders (motor conversion disorders)

OBJECTIVES

To explore potential alterations of the Body Schema, the implicit sensorimotor representation of one's own body, in patients with Functional Movement Disorders (FMD, Motor Conversion Disorders), characterized by neurological symptoms of altered voluntary motor function that cannot be explained by typical medical conditions. This investigation is prompted by the potential dissociation from their reportedly intact sense of ownership.

METHODS

10 FMD patients and 11 healthy controls (HC) underwent the Forearm Bisection Task, aimed at assessing perceived body metrics, which consists in asking the subject, blindfolded, to repeatedly point at the perceived middle point of their dominant forearm with the index finger of their contralateral hand, and a psychometric assessment for anxiety, depression, alexithymia, and tendency to dissociation.

RESULTS

FMD patients bisected their forearm more proximally (with an increased shift towards their elbow equal to 7.5%) with respect to HC; average bisection point was positively associated with anxiety levels in the whole sample, and with the tendency to dissociation in the FMD group.

CONCLUSIONS

FMD patients perceive their forearm as shorter than HC, suggesting an alteration of their Body Schema. The Body Schema can go through short- and long-term updates in the life course, mainly related to the use of each body segment; we speculate that, despite FMD being a disorder of functional nature, characterized by variability and fluctuations in symptomatology, the lack of sense of agency over a body part might be interpreted by the nervous system as disuse and hence influence the Body Schema, as deficits of organic etiology do.

Skin temperature changes in response to body ownership modulation vary according to the side of stimulation

A growing body of research has shown that a unilateral alteration in the sense of limb ownership is associated with the cooling of a limb's temperature. However, the recent emergence of contradictory results calls into question the existence of a relationship between this physiological reaction and the sense of body ownership. In the light of evidence that the malleability of the sense of hand ownership differs based on the preferential motor use of the hand to which the illusion is applied, one might observe the same lateralised pattern in the skin temperature cooling. In particular, if skin temperature change is a signature of body ownership, we expected a stronger illusion and reduction in skin temperature when altering ownership alteration of the left hand compared to the right hand in dextral individuals. To test this hypothesis, we selectively perturbated body ownership of the left or right hand in 24 healthy participants in different experimental sessions using the Mirror-Box Illusion (MBI) paradigm. Participants were asked to tap synchronously or asynchronously at a constant rhythm with their left and right index fingers against two parallel mirrors while looking at their reflected right/left hand. Skin temperature was measured before and after each MBI application, and explicit judgments of ownership and proprioceptive drift were collected. The results showed a consistent cooling of the hand's temperature only when the illusion was performed on the left hand. Proprioceptive drift exhibited the same pattern. In contrast, the explicit judgment of ownership of the reflected hand was similar across the two hands. These data provide evidence in favor of a specific laterality effect of the physiological response to an induced alteration of body part ownership. Moreover, they highlight the possibility of a direct link between proprioception and skin temperature.

Assessment of body perception disturbances in complex regional pain syndrome: A systematic review using the COSMIN guideline

OBJECTIVE

To conduct a systematic review to identify which tools are being used to assess body perception disturbances in Complex Regional Pain Syndrome (CRPS) and to provide an evidence-based recommendation in the selection of an assessment tool, based on measurement properties.

DATABASES AND DATA TREATMENT

Five electronic databases (EMBASE, Pubmed, PsycInfo, Science Direct and Web of Science) were searched for English or French written articles, with no time restrictions. All original articles using a body perception assessment tool with adult patients with CRPS were selected, regardless of their design (controlled trials, single case, qualitative study). Two investigators screened abstracts, selected full articles and extracted data independently.

RESULTS

Thirty-eight full-text papers were obtained and three main methods to evaluate body perception disturbances were identified: The Bath Body Perception Disturbance Scale, the Neglect-like Symptoms questionnaire adapted from Galer and the patient's body perception description. No full psychometric assessments were found. The Limb Laterality Recognition Task was also used in conjunction with another method.

CONCLUSIONS

Three main assessment methods for CRPS body perception disturbances are currently used. Full psychometric evaluation has not been completed for any of the assessment methods. As a consequence, we could not fully apply the COSMIN guideline. To date, there is no agreement concerning the use of a specific questionnaire or scale. The results indicate a need for further research such as psychometric properties of these questionnaires.

SIGNIFICANCE

This systematic review identified body perception disturbances assessment methods and their the psychometric properties in order to provide help and guidance to researchers and clinicians to investigate those clinical features.

The sensorimotor theory of pathological pain revisited

Harris (1999) proposed that pain can arise in the absence of tissue damage because changes in the cortical representation of the painful body part lead to incongruences between motor intention and sensory feedback. This idea, subsequently termed the sensorimotor theory of pain, has formed the basis for novel treatments for pathological pain. Here we review the evidence that people with pathological pain have changes to processes contributing to sensorimotor function: motor function, sensory feedback, cognitive representations of the body and its surrounding space, multisensory processing, and sensorimotor integration. Changes to sensorimotor processing are most evident in the form of motor deficits, sensory changes, and body representations distortions, and for Complex Regional Pain Syndrome (CRPS), fibromyalgia, and low back pain. Many sensorimotor changes are related to cortical processing, pain, and other clinical characteristics. However, there is very limited evidence that changes in sensorimotor processing actually lead to pain. We therefore propose that the theory is more appropriate for understanding why pain persists rather than how it arises.

Clinical and Neurophysiological Effects of Progressive Movement Imagery Training for Pathological Pain

Movement limitation is a common characteristic of chronic pain such that pain prevents the very movement and activity that is most likely to promote recovery. This is particularly the case for pathological pain states such as complex regional pain syndrome (CRPS). One clinical approach to CRPS that has growing evidence of efficacy involves progressive movement imagery training. Graded Motor Imagery (GMI) targets clinical and neurophysiological effects through a stepwise progression through implicit and explicit movement imagery training, mirror therapy and then functional tasks. Here we review experiences from over 20 years of clinical and research experience with GMI. We situate GMI in terms of its historical underpinnings, the benefits and outstanding challenges of its implementation, its potential application beyond CRPS. We then review the neuropathological targets of GMI and current thought on its effects on neurophysiological biomarkers. Perspective This article provides an overview of our experiences with graded motor imagery training over the last 20 years focussing on the treatment of CRPS. It does both cover the theoretical underpinnings for this treatment approach, biomarkers which indicate potential changes driven by GMI, and experiences for achieving optimal treatment results.

Where is my arm? Investigating the link between complex regional pain syndrome and poor localisation of the affected limb

Background

Anecdotally, people living with Complex Regional Pain Syndrome (CRPS) often report difficulties in localising their own affected limb when it is out of view. Experimental attempts to investigate this report have used explicit tasks and yielded varied results.

Methods

Here we used a limb localisation task that interrogates implicit mechanisms because we first induce a compelling illusion called the Disappearing Hand Trick (DHT). In the DHT, participants judge their hands to be close together when, in fact, they are far apart. Sixteen volunteers with unilateral upper limb CRPS (mean age 39 ± 12 years, four males), 15 volunteers with non-CRPS persistent hand pain (‘pain controls’; mean age 58 ± 13 years, two males) and 29 pain-free volunteers (‘pain-free controls’; mean age 36 ± 19 years, 10 males) performed a hand-localisation task after each of three conditions: the DHT illusion and two control conditions in which no illusion was performed. The conditions were repeated twice (one for each hand). We hypothesised that (1) participants with CRPS would perform worse at hand self-localisation than both the control samples; (2) participants with non-CRPS persistent hand pain would perform worse than pain-free controls; (3) participants in both persistent pain groups would perform worse with their affected hand than with their unaffected hand.

Results

Our first two hypotheses were not supported. Our third hypothesis was supported —when visually and proprioceptively encoded positions of the hands were incongruent (i.e. after the DHT), relocalisation performance was worse with the affected hand than it was with the unaffected hand. The similar results in hand localisation in the control and pain groups might suggest that, when implicit processes are required, people with CRPS’ ability to localise their limb is preserved.

Exploring the Interaction Between Handedness and Body Parts Ownership by Means of the Implicit Association Test

The experience of owning a body is built upon the integration of exteroceptive, interoceptive, and proprioceptive signals. Recently, it has been suggested that motor signals could be particularly important in producing the feeling of body part ownership. One thus may hypothesize that the strength of this feeling may not be spatially uniform; rather, it could vary as a function of the degree by which different body parts are involved in motor behavior. Given that our dominant hand plays a leading role in our motor behavior, we hypothesized that it could be more strongly associated with one’s self compared to its non-dominant counterpart. To explore whether this possible asymmetry manifests as a stronger implicit association of the right hand (vs left hand) with the self, we administered the Implicit Association Test to a group of 70 healthy individuals. To control whether this asymmetric association is human-body specific, we further tested whether a similar asymmetry characterizes the association between a right (vs left) animal body part with the concept of self, in an independent sample of subjects (N = 70, 140 subjects total). Our results revealed a linear relationship between the magnitude of the implicit association between the right hand with the self and the subject’s handedness. In detail, the strength of this association increased as a function of hand preference. Critically, the handedness score did not predict the association of the right-animal body part with the self. These findings suggest that, in healthy individuals, the dominant and non-dominant hands are differently perceived at an implicit level as belonging to the self. We argue that such asymmetry may stem from the different roles that the two hands play in our adaptive motor behavior.

Modifications in fMRI Representation of Mental Rotation Following a 6 Week Graded Motor Imagery Training in Chronic CRPS Patients

Complex regional pain syndrome (CRPS) is a neuropathic pain condition that is difficult to treat. For behavioral interventions, graded motor imagery (GMI) showed relevant effects, but underlying neural substrates in patient groups have not been investigated yet. A previous study investigating differences in the representation of a left/right hand judgment task demonstrated less recruitment of subcortical structures, such as the putamen, in CRPS patients than in healthy controls. In healthy volunteers, the putamen activity increased after a hand judgment task training. In order to test for longitudinal effects of GMI training, we investigated 20 CRPS patients in a wait-list crossover design with 3 evaluation time points. Patients underwent a 6 week GMI treatment and a 6 week waiting period in a randomized group assignment and treatment groups were evaluated by a blinded rater. When compared to healthy matched controls at baseline, CRPS patients showed less functional activation in areas processing visual input, left sensorimotor cortex, and right putamen. Only GMI treatment, but not the waiting period showed an effect on movement pain and hand judgment task performance. Regression analyses revealed positive associations of movement pain with left anterior insula activation at baseline. Right intraparietal sulcus activation change during GMI was associated with a gain in performance of the hand judgment task. The design used here is reliable for investigating the functional representation of the hand judgment task in an intervention study. PERSPECTIVE: Twenty chronic CRPS patients underwent a 6 week GMI intervention in a randomized wait-list crossover design. functional MRI was tested pre and post for the hand lateralization task which improved over GMI but not over WAITING. Performance gain was positively related to right parietal functional MRI activation.

Intact tactile anisotropy despite altered hand perception in complex regional pain syndrome: rethinking the role of the primary sensory cortex in tactile and perceptual dysfunction

Complex Regional Pain Syndrome (CRPS) is characterised by pain, autonomic, sensory and motor abnormalities. It is associated with changes in the primary somatosensory cortex (S1 representation), reductions in tactile sensitivity (tested by two-point discrimination), and alterations in perceived hand size or shape (hand perception). The frequent co-occurrence of these three phenomena has led to the assumption that S1 changes underlie tactile sensitivity and perceptual disturbances. However, studies underpinning such a presumed relationship use tactile sensitivity paradigms that involve the processing of both non-spatial and spatial cues. Here, we used a task that evaluates anisotropy (i.e., orientation-dependency; a feature of peripheral and S1 representation) to interrogate spatial processing of tactile input in CRPS and its relation to hand perception. People with upper limb CRPS (n = 14) and controls with (n = 15) or without pain (n = 19) judged tactile distances between stimuli-pairs applied across and along the back of either hand to provide measures of tactile anisotropy. Hand perception was evaluated using a visual scaling task and questionnaires. Data were analysed with generalised estimating equations. Contrary to our hypotheses, tactile anisotropy was bilaterally preserved in CRPS, and the magnitude of anisotropic perception bias was comparable between groups. Hand perception was distorted in CRPS but not related to the magnitude of anisotropy or bias. Our results suggest against impairments in spatial processing of tactile input, and by implication S1 representation, as the cause of distorted hand perception in CRPS. Further work is warranted to elucidate the mechanisms of somatosensory dysfunction and distorted hand perception in CRPS.

Ignoring space around a painful limb? No evidence for a body-related visuospatial attention bias in complex regional pain syndrome

BACKGROUND

Complex Regional Pain Syndrome (CRPS) is a disorder of severe chronic pain in one or more limb(s). People with CRPS report unusual perceptions of the painful limb suggesting altered body representations, as well as difficulty attending to their affected limb (i.e., a 'neglect-like' attention bias). Altered body representations and attention in CRPS might be related, however, existing evidence is unclear. We hypothesized that if there were a body-related visuospatial attention bias in CRPS, then any attention bias away from the affected side should be larger for or limited to circumstances when the (impaired) body representation is involved in the task versus when this is not the case.

METHODS

We included 40 people with CRPS, 40 with other limb pain conditions, and 40 pain-free controls. In half of the people with pain, their upper limb was affected, in the other half their lower limb. We administered computerized tasks of spatial attention, including free viewing of images, shape cancellation, temporal order judgement, and dot-probe. The degree to which different versions of each task involved body representation was manipulated by one or more of the following: (1) presenting stimuli nearer versus further away from the body, (2) using body related versus neutral stimuli, and (3) inducing mental rotation of body parts versus no mental rotation. In addition to perceptual judgements, eye movements were recorded as a sensitive index of spatial attention. Bayesian repeated measures analyses were performed.

RESULTS

We found no evidence for a (body-related) visuospatial attention bias in upper limb CRPS. Secondary analyses suggested the presence of a body-related visuospatial attention bias away from the affected side in some participants with lower limb CRPS.

DISCUSSION

Our results add to growing evidence that there might be no general visuospatial attention bias away from the affected side in CRPS.

Intervention Using Body Shadow to Evoke Loading Imagery in a Patient with Complex Regional Pain Syndrome in the Foot: A Case Report

We present the case of a female patient who developed complex regional pain syndrome (CRPS) after a right-foot injury. The patient had pain from the right knee to the toes and showed severe disgust at the appearance of the affected limb. Consequently, the affected limb was not fully loaded, and the patient had difficulty walking. General interventions, such as mirror therapy, were attempted, but the effect was limited. We hypothesized that this was due to the disgust toward the affected limb, and we implemented a body-shadow intervention that we developed. This reduced the disgust for the affected limb and improved pain, but neither changed the anticipated pain of loading the affected limb nor improved the patient’s walking ability. The reason for this was considered to be that the previous interventions using the body shadow utilized the third-person perspective, denoting that the image of the load sensation on the sole of the foot during walking was insufficient; therefore, we attempted a first-person body-shadow intervention. The results showed improvement in the patient’s walking ability. In CRPS of the foot, it is important to use interventions that evoke images of loading without causing anticipatory pain, pointing to the effectiveness of body-shadow interventions.

Altered visuomotor integration in complex regional pain syndrome

During self-guided movements, we optimise performance by combining sensory and self-motion cues optimally, based on their reliability. Discrepancies between such cues and problems in combining them are suggested to underlie some pain conditions. Therefore, we examined whether visuomotor integration is altered in twenty-two participants with upper or lower limb complex regional pain syndrome (CRPS) compared to twenty-four controls. Participants located targets that appeared in the unaffected (CRPS) / dominant (controls) or affected (CRPS) / non-dominant (controls) side of space, using the hand of their unaffected/dominant or affected/non-dominant side of the body. For each side of space and each hand, participants located the target using visual information and no movement (vision only condition), an unseen pointing movement (self-motion only condition), or a visually-guided pointing movement (visuomotor condition). In all four space-by-hand conditions, controls reduced their variability in the visuomotor compared to the vision and self-motion only conditions and in line with a model prediction for optimal integration. Participants with CRPS showed similar evidence of cue combination in two of the four conditions. However, they had better-than-optimal integration for the unaffected hand in the affected space. Furthermore, they did not integrate optimally for the hand of the affected side of the body in unaffected space, but instead relied on the visual information. Our results suggest that people with CRPS can optimally integrate visual and self-motion cues under some conditions, despite lower reliability of self-motion cues, and use different strategies to controls.

Clinical Intervention Using Body Shadows for a Patient with Complex Regional Pain Syndrome Who Reported Severe Pain and Self-Disgust Toward the Affected Site: A Case Report

A woman in her thirties developed complex regional pain syndrome in her left shoulder due to a traffic accident. She demonstrated autonomic nervous symptoms (swelling, sweating, and skin color asymmetry) in her left hand, severe allodynia, neglect-like symptoms (NLS), impaired body image associated with impaired body awareness, and functional impairment of the left shoulder and elbow. She also reported physical self-disgust toward her affected limb, describing it as “reptilian,” as well as aversion to touching others; this body awareness exacerbated her pain and NLS. We therefore conducted stepwise interventions using body shadows. The intervention did not trigger physical self-disgust, enabling formation of body ownership and a body image unaccompanied by pain. Consequently, the patient showed improvements in pain, NLS, and autonomic nervous symptoms.

Explicit and Implicit Own's Body and Space Perception in Painful Musculoskeletal Disorders and Rheumatic Diseases: A Systematic Scoping Review

Background: Pain and body perception are essentially two subjective mutually influencing experiences. However, in the field of musculoskeletal disorders and rheumatic diseases we lack of a comprehensive knowledge about the relationship between body perception dysfunctions and pain or disability. We systematically mapped the literature published about the topics of: (a) somatoperception; (b) body ownership; and (c) perception of space, analysing the relationship with pain and disability. The results were organized around the two main topics of the assessment and treatment of perceptual dysfunctions.

Methods: This scoping review followed the six-stage methodology suggested by Arksey and O'Malley. Ten electronic databases and grey literature were systematically searched. The PRISMA Extension for Scoping Reviews was used for reporting results. Two reviewers with different background, independently performed study screening and selection, and one author performed data extraction, that was checked by a second reviewer.

Results: Thirty-seven studies fulfilled the eligibility criteria. The majority of studies (68%) concerned the assessment methodology, and the remaining 32% investigated the effects of therapeutic interventions. Research designs, methodologies adopted, and settings varied considerably across studies. Evidence of distorted body experience were found mainly for explicit somatoperception, especially in studies adopting self-administered questionnaire and subjective measures, highlighting in some cases the presence of sub-groups with different perceptual features. Almost half of the intervention studies (42%) provided therapeutic approaches combining more than one perceptual task, or sensory-motor tasks together with perceptual strategies, thus it was difficult to estimate the relative effectiveness of each single therapeutic component.

Conclusions: To our knowledge, this is the first attempt to systematically map and summarize this research area in the field of musculoskeletal disorders and rheumatic diseases. Although methodological limitations limit the validity of the evidence obtained, some strategies of assessment tested and therapeutic strategies proposed represent useful starting points for future research. This review highlights preliminary evidence, strengths, and limitations of the literature published about the research questions, identifying key points that remain opened to be addressed, and make suggestions for future research studies. Body representation, as well as pain perception and treatment, can be better understood if an enlarged perspective including body and space perception is considered.

Neuropsychological Changes in Complex Regional Pain Syndrome (CRPS)

Complex Regional Pain Syndrome (CRPS) is a poorly understood chronic pain condition of multifactorial origin. CRPS involves sensory, motor, and autonomic symptoms primarily affecting one extremity. Patients can also present with neuropsychological changes such as reduced attention to the CRPS-affected extremity, reminiscent of hemispatial neglect, yet in the absence of any brain lesions. However, this "neglect-like" framework is not sufficient to characterise the range of higher cognitive functions that can be altered in CRPS. This comprehensive literature review synthesises evidence of neuropsychological changes in CRPS in the context of potential central mechanisms of the disorder. The affected neuropsychological functions constitute three distinct but not independent groups: distorted body representation, deficits in lateralised spatial cognition, and impairment of non-spatially-lateralised higher cognitive functions. We suggest that many of these symptoms appear to be consistent with a broader disruption to parietal function beyond merely what could be considered "neglect-like." Moreover, the extent of neuropsychological symptoms might be related to the clinical signs of CRPS, and rehabilitation methods that target the neuropsychological changes can improve clinical outcomes in CRPS and other chronic pain conditions. Based on the limitations and gaps in the reviewed literature, we provide several suggestions to improve further research on neuropsychological changes in chronic pain.

Multisensory mechanisms of body perception in somatoform disorders

OBJECTIVE

According to one of the hypotheses, somatoform disorders (SD) are related to disturbed perception of bodily signals. We suspect that the disturbances and abnormalities of multisensory integration dynamics may be an additional SD mechanism. The objective of the research was to investigate multisensory bodily illusion dynamics in SD patients.

METHODS

A clinical group of SD patients (n = 16) and a control group (n = 17) participated in experiments aimed at eliciting a visual-tactile rubber hand illusion (RHI) and a visual-kinesthetic virtual hand illusion (VHI).

RESULTS

For both illusions studied, the illusion dynamics in SD patients differed from those of healthy subjects. The visual-tactile illusion on the subjective level appeared to be less strong in SD patients, and no proprioceptive drift (PD) was detected. The subjective dynamics of the visual-kinesthetic illusion in patients were similar to those of the control group, but the PD dynamics were different: after the termination of stimuli from the artificial limb, the proprioceptive system did not return to its initial state; on the contrary, PD continued to increase.

CONCLUSION

In comparison with the norm, patients with somatoform disorders display differences in multisensory mechanisms underlying the development of body perception. The results suggest that the disturbance of visual-tactile integration of the stimuli represents one of the mechanisms of body perception distortion in somatoform disorders. It may be assumed that one of the reasons for persistent symptom perception in SD patients is the rigidity of multisensory stimuli perception, at least in the visual-motor domain.

Paradoxes in rehabilitation

Paradoxical enhancement and paradoxical recovery of function after brain injury harmonize well with the concept of "ultrabilitation" and its focus on novel forms of flourishing in rehabilitation settings. I consider three sets of paradoxes which may impact on brain injury rehabilitation. Firstly, I consider post-traumatic growth after brain injury and its key determinants. Secondly, I review the role of illusions in rehabilitation and the paradox that some clinical conditions may be improved by invoking perceptual distortions. Thirdly, I consider paradoxical recovery profiles after brain injury, since knowledge of such paradoxical profiles may help inform attempts at rehabilitation of some patients. Finally, I consider how some of these paradoxes relate to components of ultrabilitation, and in addition to the nascent field of positive neuropsychology and the concept of resilience after brain injury.Implications for rehabilitationIllusions can sometimes be harnessed as a therapeutic tool in rehabilitation.There may be spontaneous, positive outcomes of an injury or illness, in the form of "post-traumatic growth", and these should be considered as part of a holistic therapeutic approach in rehabilitation.Some patients make an exceptional recovery from a severe brain insult, and lessons could be learned from such cases, such as disciplined use of compensatory strategies, which could have broader implications for neurorehabilitation.

Actual and Illusory Perception in Parkinson's Disease and Dystonia: A Narrative Review

Sensory information is continuously processed so as to allow behavior to be adjusted according to environmental changes. Before sensory information reaches the cortex, a number of subcortical neural structures select the relevant information to send to be consciously processed. In recent decades, several studies have shown that the pathophysiological mechanisms underlying movement disorders such as Parkinson's disease (PD) and dystonia involve sensory processing abnormalities related to proprioceptive and tactile information. These abnormalities emerge from psychophysical testing, mainly temporal discrimination, as well as from experimental paradigms based on bodily illusions. Although the link between proprioception and movement may be unequivocal, how temporal tactile information abnormalities and bodily illusions relate to motor disturbances in PD and dystonia is still a matter of debate. This review considers the role of altered sensory processing in the pathophysiology of movement disorders, focusing on how sensory alteration patterns differ between PD and dystonia. We also discuss the evidence available and the potential for developing new therapeutic strategies based on the manipulation of multi-sensory information and bodily illusions in patients with these movement disorders.

Heartbeat-enhanced immersive virtual reality to treat complex regional pain syndrome

Objectives

To develop and test a new immersive digital technology for complex regional pain syndrome (CRPS) that combines principles from mirror therapy and immersive virtual reality and the latest research from multisensory body processing.

Methods

In this crossover double-blind study, 24 patients with CRPS and 24 age- and sex-matched healthy controls were immersed in a virtual environment and shown a virtual depiction of their affected limb that was flashing in synchrony (or in asynchrony in the control condition) with their own online detected heartbeat (heartbeat-enhanced virtual reality [HEVR]). The primary outcome measures for pain reduction were subjective pain ratings, force strength, and heart rate variability (HRV).

Results

HEVR reduced pain ratings, improved motor limb function, and modulated a physiologic pain marker (HRV). These significant improvements were reliable and highly selective, absent in control HEVR conditions, not observed in healthy controls, and obtained without the application of tactile stimulation (or movement) of the painful limb, using a readily available biological signal (the heartbeat) that is most often not consciously perceived (thus preventing placebo effects).

Conclusions

Next to these specific and well-controlled analgesic effects, immersive HEVR allows the application of prolonged and repeated doses of digital therapy, enables the automatized integration with existing pain treatments, and avoids application of painful bodily cues while minimizing the active involvement of the patient and therapist.

Classification of evidence

This study provides Class III evidence that HEVR reduces pain and increases force strength in patients with CRPS.

Embodied pain in fibromyalgia: Disturbed somatorepresentations and increased plasticity of the body schema

Fibromyalgia syndrome (FMS) is a highly prevalent, chronic musculoskeletal condition characterized by widespread pain and evoked pain at tender points. This study evaluated various aspects of body awareness in a sample of 14 women with FMS and 13 healthy controls, such as plasticity of the body schema, body esteem, and interoceptive awareness. To this end, the Rubber Hand Illusion (RHI), the Body Esteem Scale (BES), and the Body Perception Questionnaire (BPQ) were used, respectively. Consistent with increased plasticity of the body schema, FMS patients scored higher, with large or very large effect sizes, across all three domains evaluated in the RHI paradigm, namely proprioceptive drift and perceived ownership and motor control over the rubber hand. Scores on all items addressed by the BES were consistently lower among FMS subjects (2.52, SEM .19 vs 3.89, SEM .16, respectively, p < .01, Cohen’s d = .38-.66). In the FMS sample, BES scores assigned to most painful regions also were lower than those assigned to the remaining body sites (1.58, SEM .19 vs 2.87, SEM .18, respectively, p < .01). Significantly higher scores (p < .01, Cohen’s d = .51-.87) were found in the FMS sample across awareness (3.57 SEM .15 vs 1.87 SEM .11), stress response (3.76 SEM .11 vs 1.78 SEM .11), autonomic nervous system reactivity (2.59 SEM .17 vs 1.35 SEM .07), and stress style 2 (2.73 SEM .27 vs 1.13 SEM .04) subscales of the BPQ. Intensity of ongoing clinical pain was found to be strongly correlated with interoceptive awareness (r = .75, p = .002). The results suggest a disturbed embodiment in FMS, characterized by instability of the body schema, negatively biased cognitions regarding one’s own body, and increased vigilance to internal bodily cues. These manifestations may be interpreted as related with the inability of incoming sensory inputs to adequately update negatively biased off-line somatorepresentations stored as long-term memory.

Association of Neglect-Like Symptoms with Anxiety, Somatization, and Depersonalization in Complex Regional Pain Syndrome

Background

Many patients with complex regional pain syndrome (CRPS) report some foreignness of the affected limb, which is referred to as "neglect-like symptoms" (NLS). Despite similarities of the NLS reports to symptoms of body image disturbances in mental disorders, no study has been conducted to examine such associations.

Methods

We investigated 50 patients with CRPS and 45 pain control patients (N = 27, chronic limb pain; N = 18, migraine headache). NLS, anxiety, depression, depersonalization, and somatization were assessed using validated questionnaires.

Results

Seventy-two percent of the CRPS patients reported at least one NLS vs 29.6% and 33.3% in the two patient control groups. In limb pain controls, NLS correlated with pain intensity. In CRPS patients, NLS correlated with anxiety (rho = 0.658, P  < 0.001), somatization (rho = 0.616, P  < 0.001), depersonalization (rho = 0.634, P  < 0.001), and pain catastrophizing (rho = 0.456, P  < 0.01), but not with intensity of pain, duration of pain, or pain disability.

Conclusions

In CRPS patients, NLS could be a result of somatization, depression, anxiety, and depersonalization, but probably not of pain. Whether these associations are causative must be clarified in longitudinal psychological studies.

Pain and somatic sensation are transiently normalized by illusory body ownership in a patient with spinal cord injury

PURPOSE

Spinal cord injury (SCI), a profound impairment of sensorimotor functions, is often associated with pain related phenomena, including mechanical allodynia, a condition in which non-painful tactile sensation is perceived as pain. Pain and somatic sensation are undeniable markers of normal bodily awareness. However, the mechanism by which they are integrated into a coherent sense of the bodily self remains largely unclear. In this study, we investigated the effect of high-level multisensory manipulation on subjective experiences of pain, touch, and body-ownership.

METHODS

We administered visuo-tactile stimulation based on the rubber hand illusion. In a longitudinal study, we compared the strength of the illusion in a male with SCI, who initially had lost somatosensation in all his fingers, but a few months later reported signs of tactile allodynia restricted to the left C6-dermatome.

RESULTS

After the restoration of some somatosensation, even if it were painful, synchronous but not asynchronous visuo-tactile stimulation induced body illusion. Previously painful stimuli were temporarily perceived as less painful, and the patient further regained tactile sensations in adjacent numb areas.

CONCLUSIONS

The sensations of touch and pain are mutually influenced and inextricably linked to a coherent representation of one's own body. Multisensory manipulations affecting the perception and representation of the body might thus offer a powerful opportunity to mitigate nociceptive and somatic abnormalities.

Feeling stiffness in the back: a protective perceptual inference in chronic back pain

Does feeling back stiffness actually reflect having a stiff back? This research interrogates the long-held question of what informs our subjective experiences of bodily state. We propose a new hypothesis: feelings of back stiffness are a protective perceptual construct, rather than reflecting biomechanical properties of the back. This has far-reaching implications for treatment of pain/stiffness but also for our understanding of bodily feelings. Over three experiments, we challenge the prevailing view by showing that feeling stiff does not relate to objective spinal measures of stiffness and objective back stiffness does not differ between those who report feeling stiff and those who do not. Rather, those who report feeling stiff exhibit self-protective responses: they significantly overestimate force applied to their spine, yet are better at detecting changes in this force than those who do not report feeling stiff. This perceptual error can be manipulated: providing auditory input in synchrony to forces applied to the spine modulates prediction accuracy in both groups, without altering actual stiffness, demonstrating that feeling stiff is a multisensory perceptual inference consistent with protection. Together, this presents a compelling argument against the prevailing view that feeling stiff is an isomorphic marker of the biomechanical characteristics of the back.

The effect of bodily illusions on clinical pain: a systematic review and meta-analysis

This systematic review and meta-analysis critically examined the evidence for bodily illusions to modulate pain. Six databases were searched; 2 independent reviewers completed study inclusion, risk of bias assessment, and data extraction. Included studies evaluated the effect of a bodily illusion on pain, comparing results with a control group/condition. Of the 2213 studies identified, 20 studies (21 experiments) were included. Risk of bias was high due to selection bias and lack of blinding. Consistent evidence of pain decrease was found for illusions of the existence of a body part (myoelectric/Sauerbruch prosthesis vs cosmetic/no prosthesis; standardized mean differences = -1.84, 95% CI = -2.67 to -1.00) and 4 to 6 weeks of mirror therapy (standardized mean differences = -1.11, 95% CI = -1.66 to -0.56). Bodily resizing illusions had consistent evidence of pain modulation (in the direction hypothesized). Pooled data found no effect on pain for 1 session of mirror therapy or for incongruent movement illusions (except for comparisons with congruent mirrored movements: incongruent movement illusion significantly increased the odds of experiencing pain). Conflicting results were found for virtual walking illusions (both active and inactive control comparisons). Single studies suggest no effect of resizing illusions on pain evoked by noxious stimuli, no effect of embodiment illusions, but a significant pain decrease with synchronous mirrored stroking in nonresponders to traditional mirror therapy. There is limited evidence to suggest that bodily illusions can alter pain, but some illusions, namely mirror therapy, bodily resizing, and use of functional prostheses show therapeutic promise.

Crossmodal illusions in neurorehabilitation

In everyday life, many diverse bits of information, simultaneously derived from the different sensory channels, converge into discrete brain areas, and are ultimately synthetized into unified percepts. Such multisensory integration can dramatically alter the phenomenal experience of both environmental events and our own body. Crossmodal illusions are one intriguing product of multisensory integration. This review describes and discusses the main clinical applications of the most known crossmodal illusions in rehabilitation settings. We consider evidence highlighting the contribution of crossmodal illusions to restore, at least in part, defective mechanisms underlying a number of disorders of body representation related to pain, sensory, and motor impairments in neuropsychological and neurological diseases, and their use for improving neuroprosthetics. This line of research is enriching our understanding of the relationships between multisensory functions and the pathophysiological mechanisms at the basis of a number of brain disorders. The review illustrates the potential of crossmodal illusions for restoring disarranged spatial and body representations, and, in turn, different pathological symptoms.

Complex regional pain syndrome: From diagnosis to rehabilitation

Complex regional pain syndrome (CRPS) is a debilitating pathology characterised by intense chronic pain associated with vasomotor, sensory and motor dysfunction of the affected limb. Although the pathophysiology of CRPS is not fully understood, it is recognised that inflammatory processes and autonomic dysfunction are involved. These processes are associated with peripheral and central sensitisation as well as changes in brain structure and function, and are reflected in the clinical presentation of CRPS. CRPS management requires an interdisciplinary team and requires the therapeutic approach to be individualised. With regard to pharmacological treatment, bisphosphonates, corticosteroids, ketamine and anticonvulsants have been demonstrated to be effective for CRPS management. Psychotherapy, including cognitive-behavioural therapy, has produced promising results but more studies are needed to confirm its efficacy. Among rehabilitation interventions, there is evidence of the efficacy of physiotherapy and occupational therapy in diminishing CRPS symptoms and achieving a higher level of functioning. In this regard, the rehabilitation modality that seems the most promising according to the actual literature is graded motor imagery, which can help to reverse the maladaptive neuroplasticity occurring in CRPS.

In (or outside of) your neck of the woods: laterality in spatial body representation

Beside language, space is to date the most widely recognized lateralized systems. For example, it has been shown that even mental representations of space and the spatial representation of abstract concepts display lateralized characteristics. For the most part, this body of literature describes space as distal or something outside of the observer or actor. What has been strangely absent in the literature on the whole and specifically in the spatial literature until recently is the most proximal space imaginable – the body. In this review, we will summarize three strands of literature showing laterality in body representations. First, evidence of hemispheric asymmetries in body space in health and, second in body space in disease will be examined. Third, studies pointing to differential contributions of the right and left hemisphere to illusory body (space) will be summarized. Together these studies show hemispheric asymmetries to be evident in body representations at the level of simple somatosensory and proprioceptive representations. We propose a novel working hypothesis, whereby neural systems dedicated to processing action-oriented information about one’s own body space may ontogenetically serve as a template for the perception of the external world.

Complex regional pain syndrome type I affects brain structure in prefrontal and motor cortex

The complex regional pain syndrome (CRPS) is a rare but debilitating pain disorder that mostly occurs after injuries to the upper limb. A number of studies indicated altered brain function in CRPS, whereas possible influences on brain structure remain poorly investigated. We acquired structural magnetic resonance imaging data from CRPS type I patients and applied voxel-by-voxel statistics to compare white and gray matter brain segments of CRPS patients with matched controls. Patients and controls were statistically compared in two different ways: First, we applied a 2-sample ttest to compare whole brain white and gray matter structure between patients and controls. Second, we aimed to assess structural alterations specifically of the primary somatosensory (S1) and motor cortex (M1) contralateral to the CRPS affected side. To this end, MRI scans of patients with left-sided CRPS (and matched controls) were horizontally flipped before preprocessing and region-of-interest-based group comparison. The unpaired ttest of the "non-flipped" data revealed that CRPS patients presented increased gray matter density in the dorsomedial prefrontal cortex. The same test applied to the "flipped" data showed further increases in gray matter density, not in the S1, but in the M1 contralateral to the CRPS-affected limb which were inversely related to decreased white matter density of the internal capsule within the ipsilateral brain hemisphere. The gray-white matter interaction between motor cortex and internal capsule suggests compensatory mechanisms within the central motor system possibly due to motor dysfunction. Altered gray matter structure in dorsomedial prefrontal cortex may occur in response to emotional processes such as pain-related suffering or elevated analgesic top-down control.

[The rubber hand illusion in patients with complex regional pain syndrome. Successful illusion induction shows multisensory integration]

Next to neurogenic inflammation and pathological sympathetic-afferent coupling, functional imaging studies have shown the crucial role of maladaptive cortical reorgansation in the pathophysiology of CRPS. Bilateral neuroplastic alterations in the somatosensory cortex seem to play a substantial role in the dysfunctional sensory processing of stimuli. The aim was to investigate the multimodal integration of sensory and visual stimuli into the body scheme and the influence of higher cognitive body representation in the integration of multimodal schema, body relevant stimuli in patients with CRPS. The investigated sample included 24 patients suffering from CRPS of the upper extremities, 21 patients with chronic hand pain of other origins and 24 healthy probands. The rubber hand illusion was carried out for the first time in patients with complex regional pain syndrome (CRPS). The reprentations show that the patients can integrate a rubber hand in their body representation to the same degree as healthy patients. The intact experience of the rubber hand illusion by CRPS patients indicates that the integration of congruent visual and tactile stimuli in CRPS is intact.