Wednesday, December 19, 2012

CRPS: Spatial Perception (Where are my hand?)

Spatially defined modulation of skin temperature and hand ownership of both hands in patients with unilateral complex regional pain syndrome

  1. Gian Domenico Iannetti4
+Author Affiliations
  1. 1 The Sansom Institute for Health Research, University of South Australia, Adelaide 5000, Australia
  2. 2 Neuroscience Research Australia, Sydney, Australia
  3. 3 Faculty of Psychology, University of Milano-Bicocca, Milan 20126, Italy
  4. 4 Department of Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, UK
  1. Correspondence to: Lorimer Moseley, Sansom Institute for Health Research, University of South Australia, GPO Box 2471, Adelaide 5001, Australia E-mail:

Received March 21, 2012.
Revision received August 16, 2012.
Accepted September 19, 2012.


Numerous clinical conditions, including complex regional pain syndrome, are characterized by autonomic dysfunctions (e.g. altered thermoregulation, sometimes confined to a single limb), and disrupted cortical representation of the body and the surrounding space. The presence, in patients with complex regional pain syndrome, of a disruption in spatial perception, bodily ownership and thermoregulation led us to hypothesize that impaired spatial perception might result in a spatial-dependent modulation of thermoregulation and bodily ownership over the affected limb. In five experiments involving a total of 23 patients with complex regional pain syndrome of one arm and 10 healthy control subjects, we measured skin temperature of the hand with infrared thermal imaging, before and after experimental periods of either 9 or 10 min each, during which the hand was held on one or the other side of the body midline. Tactile processing was assessed by temporal order judgements of pairs of vibrotactile stimuli, delivered one to each hand. Pain and sense of ownership over the hand were assessed by self-report scales. Across experiments, when kept on its usual side of the body midline, the affected hand was 0.5 ± 0.3°C cooler than the healthy hand (P < 0.02 for all, a common finding in cold-type complex regional pain syndrome), and tactile stimuli delivered to the healthy hand were prioritized over those delivered to the affected hand. Simply crossing both hands over the midline resulted in (i) warming of the affected hand (the affected hand became 0.4 ± 0.3°C warmer than when it was in the uncrossed position; P = 0.01); (ii) cooling of the healthy hand (by 0.3 ± 0.3°C; P = 0.02); and (iii) reversal of the prioritization of tactile processing. When only the affected hand was crossed over the midline, it became warmer (by 0.5 ± 0.3°C; P = 0.01). When only the healthy hand was crossed over the midline, it became cooler (by 0.3 ± 0.3°C; P = 0.01). The temperature change of either hand was positively related to its distance from the body midline (pooled data: r = 0.76, P < 0.001). Crossing the affected hand over the body midline had small but significant effects on both spontaneous pain (which was reduced) and the sense of ownership over the hand (which was increased) (P < 0.04 for both). We conclude that impaired spatial perception modulated temperature of the limbs, tactile processing, spontaneous pain and the sense of ownership over the hands. These results show that complex regional pain syndrome involves more complex neurological dysfunction than has previously been considered.*

*over-used punchline!

Graphic from CRPS UK


Useful adjunct article published in same journal, September 14, 2009, available in entirety (pdf)

Space-based, but not arm-based, shift in tactile
processing in complex regional pain syndrome
and its relationship to cooling of the affected limb

G. Lorimer Moseley [1]

Alberto Gallace [2,3]

and Charles Spence [3]

1 PaiN Group & Department of Physiology, Anatomy & Genetics, University of Oxford, UK and Prince of Wales Medical Research Institute &
School of Medical Sciences, University of New South Wales, Sydney, Australia
2 Department of Psychology, University of Milano-Bicocca, P.zza dell’Ateneo Nuovo 1, 20126 Milano, Italy
3 Department of Experimental Psychology, Oxford University, South Parks Road, Oxford OX1 3UD, UK

Correspondence to: G. Lorimer Moseley,
Prince of Wales Medical Research Institute,
Cnr Easy & Barker Streets,
Randwick, 2031,

Complex regional pain syndrome (CRPS) occurs after stroke, but most cases develop after peripheral trauma and without evidence of brain trauma. However, CRPS is associated with symptoms that appear similar to those observed in patients suffering from hemispatial neglect. Ten participants (four males) with CRPS of one arm performed temporal order judgements
of pairs of vibrotactile stimuli, one delivered to each hand, at one of 10 possible stimulus onset asynchronies, under two conditions: arms held each side of the midline and arms crossed over the midline. Participants released a foot switch to indicate which hand had been stimulated first. The order of conditions was randomized and the foot under which the switch was
positioned was counterbalanced. There were two blocks of 150 trials in each condition. The stimulus onset asynchronicity at which the participants were equally likely to select either hand, the point of subjective simultaneity (PSS), was compared between conditions and between those with left or right-sided symptoms. When arms were not crossed, the participants prioritized stimuli from the unaffected limb over those from the affected limb (mean SD PSS = 25 7.5 ms) and the magnitude of the PSS strongly related to the degree to which the affected hand was cooler than the unaffected hand (r = 0.942, P50.001). When the arms were crossed, the effect was reversed: the participants prioritized stimuli from the affected limb over those from the unaffected limb [PSS = –18 13 ms; main effect of condition F (1, 9) = 98.6, P50.001]. There was no effect of the side of
symptoms. These results show that CRPS is associated with a deficit in tactile processing that is defined by the space in which the affected limb normally resides, not by the affected limb itself, and which relates to the relative cooling of the affected limb. This pattern is consistent with data from those with hemispatial neglect after stroke and raises the possibility that chronic CRPS
involves a type of spatial neglect.

Abbreviations: CRPS = complex regional pain syndrome; JND = just noticeable difference; PSS = point of subjective simultan

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