Anthony Tsay

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

There is growing evidence that chronic pain conditions can have an associated central pathology, involving both cortical reorganisation and an incongruence between expected and actual sensory-motor feedback. While such findings are primarily driven by the recent proliferation of neuroimaging studies, the psychophysical tasks that complement those investigations have received little attention. In this review, we discuss the literature that involves the subjective appraisal of body representation in patients with chronic pain. We do so by examining three broad sensory systems that form the foundations of the sense of physical self in patients with common chronic pain disorders: (i) reweighting of proprioceptive information; (ii) altered sensitivity to exteroceptive stimuli; and, (iii) disturbed interoceptive awareness of the state of the body. Such findings present compelling evidence for a multisensory and multimodal approach to therapies for chronic pain disorders.

Limb position sense, proprioceptive drift and muscle thixotropy at the human elbow joint

When a blindfolded subject holds his or her arm at a particular angle, its reported position shifts over time; this is known as proprioceptive drift. Here, we show that in relation to position sense at the elbow, the direction of perceived shifts is consistent with adaptation in discharge levels of sensory receptors in elbow muscles. Raising or lowering receptor discharge levels by similar amounts in opposing muscles at the elbow using muscle conditioning abolishes proprioceptive drift, but large position errors may result. The present experiments provide an explanation for proprioceptive drift and indicate that, in a forearm position‐matching task, the brain is not concerned with actual discharge levels from arm muscles, but with their difference.

The sensory origins of human position sense

Position sense at the human forearm can be measured in blindfolded subjects by matching positions of the arms or by a subject pointing to the perceived position of an unseen arm. Effects on position sense tested were: elbow muscle conditioning with a voluntary contraction, muscle vibration, loading the arm and elbow skin stretch. Conditioning contractions and vibration produced errors in a matching task, consistent with the action of muscle spindles as position sensors. Position errors in a pointing task were not consistent with the action of muscle spindles. Loading the arm or skin stretch had no effect in either matching or pointing tasks. It is proposed that there are two kinds of position sense: (i) indicating positions of different body parts relative to one another, using signals from muscle spindles; and (ii) indicating position of the body in extrapersonal space, using signals from exteroceptors, vision, touch and hearing.

Position sense at the human forearm after conditioning elbow muscles with isometric contractions

These experiments were designed to test the idea that, in a forearm position-matching task, it is the difference in afferent signals coming from the antagonist muscles of the forearm that determines the perceived position of the arm. In one experiment, flexor and then extensor muscles of the reference arm were conditioned by isometric voluntary contractions while the arm was held at the test angle, approximately 45° from the horizontal. At the same time, indicator arm flexor muscles were contracted while the arm was flexed, or extensors were contracted while it was extended. After an indicator flexor contraction, during matching, subjects made large errors in the direction of flexion, by 9.3° relative to the reference arm and after an indicator extensor contraction by 7.4° in the direction of extension. In the second experiment, with reference muscles conditioned as before, slack was introduced in indicator muscles by a combination of muscle contraction and stretch. This was expected to lower levels of afferent activity in indicator muscles. The subsequent matching experiment yielded much smaller errors than before, 1.4° in the direction of flexion. In both experiments, signal levels coming from the reference arm remained the same and what changed was the level of indicator signal. The fact that matching errors were small when slack was introduced in indicator muscles supported the view that the signal coming from reference muscles was also small. It was concluded that the brain is concerned with the signal difference from the antagonist pair of each arm and with the total signal difference between the two arms.

Position sense at the human elbow joint measured by arm matching or pointing

Position sense at the human elbow joint has traditionally been measured in blindfolded subjects using a forearm matching task. Here we compare position errors in a matching task with errors generated when the subject uses a pointer to indicate the position of a hidden arm. Evidence from muscle vibration during forearm matching supports a role for muscle spindles in position sense. We have recently shown using vibration, as well as muscle conditioning, which takes advantage of muscle’s thixotropic property, that position errors generated in a forearm pointing task were not consistent with a role by muscle spindles. In the present study we have used a form of muscle conditioning, where elbow muscles are co-contracted at the test angle, to further explore differences in position sense measured by matching and pointing. For fourteen subjects, in a matching task where the reference arm had elbow flexor and extensor muscles contracted at the test angle and the indicator arm had its flexors conditioned at 90°, matching errors lay in the direction of flexion by 6.2°. After the same conditioning of the reference arm and extension conditioning of the indicator at 0°, matching errors lay in the direction of extension (5.7°). These errors were consistent with predictions based on a role by muscle spindles in determining forearm matching outcomes. In the pointing task subjects moved a pointer to align it with the perceived position of the hidden arm. After conditioning of the reference arm as before, pointing errors all lay in a more extended direction than the actual position of the arm by 2.9°–7.3°, a distribution not consistent with a role by muscle spindles. We propose that in pointing muscle spindles do not play the major role in signalling limb position that they do in matching, but that other sources of sensory input should be given consideration, including afferents from skin and joint.

Position Sense in Chronic Pain: Separating Peripheral and Central Mechanisms in Proprioception in Unilateral Limb Pain

UNLABELLED Awareness of limb position is derived primarily from muscle spindles and higher-order body representations. Although chronic pain appears to be associated with motor and proprioceptive disturbances, it is not clear if this is due to disturbances in position sense, muscle spindle function, or central representations of the body. This study examined position sense errors, as an indicator of spindle function, in participants with unilateral chronic limb pain. The sample included 15 individuals with upper limb pain, 15 with lower limb pain, and 15 sex- and age-matched pain-free control participants. A 2-limb forearm matching task in blindfolded participants, and a single-limb pointer task, with the reference limb hidden from view, was used to assess forearm position sense. Position sense was determined after muscle contraction or stretch, intended to induce a high or low spindle activity in the painful and nonpainful limbs, respectively. Unilateral upper and lower limb chronic pain groups produced position errors comparable with healthy control participants for position matching and pointer tasks. The results indicate that the painful and nonpainful limb are involved in limb-matching. Lateralized pain, whether in the arm or leg, does not influence forearm position sense. PERSPECTIVE Painful and nonpainful limbs are involved in bilateral limb-matching. Muscle spindle function appears to be preserved in the presence of chronic pain.

Muscle damage produced by isometric contractions in human elbow flexors

Isometric exercise is often prescribed during rehabilitation from injury to maintain muscle condition and prevent disuse atrophy. However, such exercise can lead to muscle soreness and damage. Here we investigate which parameters of isometric contractions are responsible for the damage. Bouts of 30 repetitions of maximum voluntary contractions of elbow flexors in 38 subjects were carried out and peak force, soreness, and tenderness were measured before the exercise, immediately afterwards, at 2 h, and at 24 h postexercise. When one arm was held near the optimum angle for force generation (90°), the force it produced was greater by 28% than by the other arm held at a longer length (155°). However, despite the smaller contraction forces of the muscle held at the longer length, after the exercise it exhibited a greater fall in force that persisted out to 24 h (20% fall) and more delayed soreness than the muscle exercised at 90° (7% fall at 24 h). The result indicates a length dependence of the damage process for isometric contractions at maximum effort. In four additional experiments, evidence was provided that the damage occurred during the plateau of the contraction and not the rising or relaxation phases. The damage had a prompt onset and was cumulative, continuing for the duration of the contraction. We interpret our findings in terms of the nonuniform lengthening of sarcomeres during the plateau of the contractions and conclude that muscle damage from isometric exercise is minimized if carried out at lengths below the optimum, using half-maximum or smaller contractions. NEW & NOTEWORTHY Isometric exercise, where muscle contracts while the limb is held fixed, is often possible for individuals rehabilitating from injury and can help maintain muscle condition. Such exercise has been reported to cause some muscle damage and soreness. We confirm this and show that to minimize damage, exercising muscles should be held at shorter than the optimum length for force and carried out at half-maximum effort or less.