Monday, March 11, 2013

"the disinhibited brain"

 PHOTO: Building Tests -Baudelaire Enivrez vous

i confess to loving the title of this slightly dated article on CRPS -- mostly because when i was tutoring local university students (we live in a university mecca; marlinspike hall is the virtual epicenter of an educational glut), i always explained that students over 21 could not learn french without the assistance of a good red (or white, whatever we had brought up from the cellars that day) wine.

holding forth as i poured, always into the appropriate crystal glass, eyes shining in the candlelight (because who needs to see the book, anyway?), i would explain that learning a language after the age of three or four required a high degree of disinhibition. this would always be followed by a grandiloquent recitation of baudelaire {hi, TW!}:


Il faut être toujours ivre, tout est là ; c'est l'unique question. Pour ne pas sentir l'horrible fardeau du temps qui brise vos épaules et vous penche vers la terre, il faut vous enivrer sans trêve.

Mais de quoi? De vin, de poésie, ou de vertu à votre guise, mais enivrez-vous!

Et si quelquefois, sur les marches d'un palais, sur l'herbe verte d'un fossé, vous vous réveillez, l'ivresse déjà diminuée ou disparue, demandez au vent, à la vague, à l'étoile, à l'oiseau, à l'horloge; à tout ce qui fuit, à tout ce qui gémit, à tout ce qui roule, à tout ce qui chante, à tout ce qui parle, demandez quelle heure il est. Et le vent, la vague, l'étoile, l'oiseau, l'horloge, vous répondront, il est l'heure de s'enivrer ; pour ne pas être les esclaves martyrisés du temps, enivrez-vous, enivrez-vous sans cesse de vin, de poésie, de vertu, à votre guise.

(Les petits poèmes en prose)

[i've changed my mind several times, but i think richard howard has the best translation. go find it.]

granted, the students who were in the first week of french 101 guzzled their wine and ran out the door, but the rest usually stayed on for a few months, or until they brought their average up to a C.

adults don't like to make mistakes.  we are uncomfortable, embarrassed.  you cannot learn a language, you cannot USE a language, even the one you've heard and spoken your entire life, even if you are the most educated of the educable.  so, really, have a beer, take a toke, whatever.  remember that the point is to communicate.  you might get a star on your paper for perfection but there are no trophies for the one who sits there, prim, silent.

break eggs, make omelettes.

for a while, i tutored this FBI agent and (kinda) his wife.  she'd "accompany" him and follow the lesson from the other end of the table, even participating in exercises and conversation, and i always felt like billing her, too, but hell, he was an FBI agent.  he was big into disinhibition, though, bless his FBI heart!  chablis was his choice, but he did okay with poésie and, being FBI 'n all, probably vertu, aussi.  brent something.  they had me and fred over for dinner where we got into a weird conversation that always reminds me of the dinner scene in la cage aux folles.

so anyway, these scientists have come up with the notion of CRPS being caused by a brain gone completely wacko, disinhibited as all get out.  it's a brain that will allow you to feel EVERYTHING!

you'd probably like to read the article, huh?  okay!

The 'Disinhibited' Brain: New Findings On CRPS -- A Disease Characterized by Severe Pain

Complex regional pain syndrome (CRPS), also known as Morbus Sudeck, is characterised by "disinhibition" of various sensory and motor areas in the brain. A multidisciplinary Bochum-based research group, led by Prof. Dr. Martin Tegenthoff (Bergmannsheil Neurology Department) and Prof. Dr. Christoph Maier (Bergmannsheil Department of Pain Therapy), has now demonstrated for the first time that with unilateral CRPS excitability increases not only in the brain area processing the sense of touch of the affected hand. In addition, the brain region representing the healthy hand is simultaneously "disinhibited."

The researchers, who have been performing research on and treatment of CRPS for a number of years, are reporting the new findings in the journal Neurology. The study was supported by the Research Funds of the Deutsche Gesetzliche Unfallversicherung (DGUV).

Is there a predisposition for CRPS?

CRPS can develop after even slight injuries and often leads to long-lasting severe pain, impairment of sensation and movement, as well as changes to the skin and the bones of the affected extremity -- in many cases it even causes permanent disability. The precise cause of the syndrome is not known. Alongside inflammatory phenomena, changes in the brain also contribute to the disease becoming chronic. "Although the symptoms are mainly limited to one side of the body, some changes in the brain appear to affect both sides -- a finding which could hint at an individual predisposition for the development of CRPS," says Prof. Martin Tegenthoff.

Faulty programming in the brain

As yet, the origins of the disease remain largely unclear. Pain researchers assume that not only inflammatory factors, but also changes in the central nervous system may be a possible cause. For example, in a number of studies researchers found the representation of the affected hand on the brain's "body map" to have shrunk, a phenomenon closely associated with the patients' pain intensity and tactile discrimination abilities.

Excitability changes on both sides

In a previous study, the Bochum group already made an astonishing discovery in the motor system of CRPS patients: the excitability of their motor hand area in the brain is increased -- not only in the half of the brain controlling the affected side, but also in the half correlating to the healthy side. Following these findings hinting at a systemic disorder of the central nervous system, in the current study the group examined whether bilateral disinhibition can also be found in the brain area processing the sense of touch (somatosensory cortex). CRPS patients with unilateral symptoms of the hand were examined. After an electrical stimulation, the researchers measured the brain waves in the somatosensory brain area of the affected and the unaffected hand. Results show: the reduction of inhibition which is found on both sides in CRPS is not limited to motor areas. Those areas of the brain that process sensory perception of the hands exhibit distinct changes too.
"Disinhibition": typical of neuropathic pain

The scientists validated these findings by comparing CRPS patients with healthy volunteers and with patients suffering from pain that -- in contrast to CRPS -- was not caused by a disease of the nerves (so-called non-neuropathic pain). Here too, the researchers found an amazing result: the control patients showed no altered inhibition whatsoever in the hand area, they did not differ from the healthy volunteers. "This shows that the disinhibition of the brain in CRPS patients appears to be specific for neuropathic pain," says Prof. Tegenthoff. [...]


okay, i didn't say it was earth-shattering work.  and really, since i'm cursed with CRPS bilaterally in both arms and legs, well, i just kept sipping wine while you worked at the reading.  the excitability of my motor hand area was increased...

moving on then... it is heartening to see that Medscape's Emergency Medicine section on CRPS has been updated, hooray and hallelujah, as a good ED doc could easily be the medico in the best position to spot burgeoning CRPS or someone at risk for it.  a big pat on the back to Medscape.  for instance, this is the new pathophysiology section (i mean they've got Drexel Dude as their first citation!) and if that isn't progress, well...

No single hypothesis explains all features of reflex sympathetic dystrophy syndrome (RSDS). Schwartzman stated that a common mechanism may be injury to central or peripheral neural tissue.[1] Roberts proposed that sympathetic pain results from tonic activity in myelinated mechanoreceptor afferents. Input causes tonic firing in neurons that are part of a nociceptive pathway. Campbell et al propose a hypothesis that places the primary abnormality in the peripheral nervous system.[2] More recent articles agree that the cause is still unknown.[3] Recent interest has focused on an immune-mediated mechanism.[4] 
Most authors now agree that complex regional pain syndrome (CRPS) is a neurologic disorder affecting central and peripheral nervous systems.[5, 6] Mechanisms include peripheral and central sensitization, inflammation, altered sympathetic and catecholaminergic function, altered somatosensory representation in the brain, genetic factors, and psychophysiologic interactions.[6, 7] 
Other etiologic possibilities have been suggested. German research has noted the association between elevated levels of soluble tumor necrosis factor receptor 1 (sTNF-R1) and enhanced tumor necrosis factor-alpha activity in patients with polyneuropathy with allodynia.[8] Other German researchers have described autoantibodies in patients with CRPS, especially CRPS type 2.[9] 
Harvard researchers Oaklander and Fields have proposed that distal degeneration of small-diameter peripheral axons may be responsible for the pain, vasomotor instability, edema, osteopenia, and skin hypersensitivity of CRPS-1.[10] 
The recent association between the use of ACE inhibitors and CRPS has caused some to consider a neuroinflammatory pathogenesis.[11] 
Recent research has demonstrated cortical changes, suggesting a possible role in pathophysiology.[12] 
All agree that, regardless of the mechanism, the patient experiences intense, burning pain in one or more extremities.

and if *that* didn't perk you up as a significant correction of the basics, check out the epidemiology section!  okay, let's! no... i'll leave you in peace.  or drunk, depending on how you've gone about reading this post.  remember now, an aspirin between your knees tonight will keep you from feeling legitimately raped in the morning.  no, wait.  that's not it...

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