We are used to read: Neuropathic pain and other somatosensory abnormalities (Lindblom & Verillo, 1979; Jänig & Kirillova, 2013). Then if we are reading carefully, authors usually decribed hyperalgesia or mechanical allodynia (Gierthmühlen et al, Nature Reviews Neurology 2014). But where - and how - are you testing the third somaesthetic clinical examination sign: Tactile hypoaesthesia ?
In our study, Long-term pain conditions after a stroke, QST (quantitative sensory testing) was used.
QST is also recommended by DGN guidelines (2012).
I use to test hyaesthesia by touching > 10 times the same areal or writing numbers/ figures (triangle, circle) in this region (dermolexia). But I suppose, the important test "Der pathologische Funktionswandel" (Stein, Weizsäcker) is not very often used anymore.
As clinician, I consider Quantitative Somatosensory Testing (QST) as a good choice to test Dynamic Mechanical Allodynia (DMA) or PinPrick Hyperalgesia (PPH). Our Certified Somatosensory Therapis of Pain (CSTP) may test, in any session, EITHER tactile hypoaesthesia OR Static Mechanical Allodynia (SMA) but NOT other somatosensory disorders. We observed that the ability to detect stimuli is decreasing step by step. After the testing of DMA the patient has difficulties to detect tctile stimuli - or NOT.
The spf A-delta NCS device (Neuralscan, Axon II), is over 95% sensitive to test both dermatomal points and map peripheral neuropathy. We us it daily in our clinic, where we treat, and improve, neuropathic symptoms with our COmbined Electrochemical technique (CET). If anyone is interested in seeing pre- and post tersting, poease email me directly at [email protected], or cell 702-521-95432 (USA pacific coast time). My website is nvpainrelief.com. I have found in data soon to ber puvblished that there is a correlation between Neuralscan results and improvement in neuropathic sy,mptoms. Keep in mind, however, we are only looking at A-delta fibers; efferenbt and afferent c fibers also play a role in neuropathies.
I do agree that C neurofibers also play a role in neuropathic pain. But A-bêta neurofibers lesions induce tactile hypoaesthesia. Through tactile stimulation adaptative neuroplasticity mechanisms can be organized in order to supply nerve injury.
Dear Claude,
This is a very intersting question because of the very important function of aesthesia (not only hypoaesthesia but also hyperaesthesia) in relationship to motor function, more specifially of the hand. In our clinical projects we have tested tactile aesthesia very oft with monofilaments in addition to other test methods, such as QST.
A brief historical sketch of the monofilamenten aesthesia test. The test using monofilamenten was developed at the end of the eighteenth century by Von Frey. Von Frey investigated the tactile sensations with the aid of natural bristles of different thickness and stiffness. He used the force required to bend a hair as a measure of the mechanical stimulus applied to the skin. After the twenties of the last century this method gradually fell into oblivion. In 1960 Semmes and Weinstein published the results of their research into somatosensory function. Their method of research was based on the principle developed by Von Frey but they used nylon wire instead of hairs. Since that time so called Semmes-Weinstein (SW) (mono) filaments. Semmes and Weinstein made use of a set of 20 filaments. The (mono) filaments are the only instrument for the determination of the pressure perception - tactile aesthesia in which the pressure which is exerted on the skin, is not affected by the fact that the examiner holds the instrument in the hand.
We have used the monofilamenten test in patients with, for instance, different peripheral neuropathies of the hand and foot, Complex Regional Pain Syndrome (CRPS) type I, and diabetic peripheral neuropathy.
Nijmegen, the Netherlands, November 6, 2014
Prof. Rob Oostendorp, PhD, PT, MPT.
For interested readers, here are some old references to Von Frey
FREY M VON. Beitrage zur Physiologie des Schermzsinns. Ber Sach Gesell der Wissenschaften 1894;46:185-196.
FREY M VON. Verspatete Schmerzempfindungen. Z Gesamte Neurol Psychiat1922;79;324-333.
FREY M VON. Zur Physiologie der Jückempfindung. Arch Neurol Physiol 1922;7: 142-145.
FREY M VON. Gibt es tief Drückempfindungen. Deutsche Med Wochenschrift 1925;51;423-424.
Dear Rob, I am very happy to realize that we are working on a similar manner. In our Handbook we wrote a whoel chapter about Pressure Perception Threshold (which is NOT the Pain Perception Threshold).
Our reference about Max von Frey is:
Frey von, M. (1896). Untersuchung über die Sinnesfunktion der Menschlichen Haut : Erste Abhandlung : Druckempfindung und Schmerz. Des XXIII Bandes der Abhandlungen der mathematisch – physischen Classe der Königlichen Sächsischen Gesellschaft des Wissenschaften (pp. 175-266). Leipzig : S. Hirzel, III. (traduit en anglais sous : H.O. Handwerker & K. Brune (Eds.) [1987]. Classical German contributions to pain research (pp. 69-131)).
I didn't know your earlier one (Frey von, 1894). Could I, please, get a PDF version?
I used, as well, the administration test of Semmes et al., 1960:
Semmes, J., Weinstein, S., Ghent, L. & Teuber, H.L. (1960). Somatosensory changes after penetrating brain wounds in man. Cambridge, MA : Harvard University Press.
Today, instead of their ADADAD administration test (A=Ascending; D=Descending)with 20 aesthesiometers, we are using the modified version by Malenfant: ADADAD but with 7 aesthesiometers.
Malenfant, A. (1998). Déficits sensoriels et névralgies chroniques aux sites guéris de brûlures. Thèse de médecine : http://www.theses.umontreal.ca/theses/pilote/malenfant/these_back.html (source) (6.11.2014)
Malenfant, A., Forget, R., Amsel, R., Papillon, J., Frigon, J.Y. & Choinière, M. (1998). Tactile, thermal and pain sensibility in burned patients with and without chronic pain and paresthesia problems. Pain, 77, 241-251.
Dear Claude,
it is some months ago that you have asked me a pdf of the original article of Von Frey (1894). The complete reference is:
Von Frey M. Beitrage zur Physiologie des Smerzsinners. Berichte über die Verhandlungen Sächsischen Gesellschaft der Wissenschaften zu Leipzig. Mathematisch-physische Classe. 46: 185-190, 1894.
Attached you will find a pdf of the article. From historial point of view it is very interesting to read the original text of Von Fray. Enjoy reading!
I am very interested in your book Handbook for Somatosensory Rehabilitation. If it is possible, do you have a free copy for me? Thank you in advance.
Kind regards,
Rob Oostendorp.
Dear Rob,
Fantastic. Many thanks for this article by
Max von FREY:
Frey von, M. (1894) Beiträge zur Physiologie des Schmerzsinns. Berichte über die Verhandlungen der mathematisch – physischen Classe der Königlichen Sächsischen Gesellschaft des Wissenschafte (pp. 185-190). Leipzig: S. Hirzel.
We have found with the Neuralscan a good correlation with improvment in Neuropathy symptoms (which we accomplish with our CET protocol...anyone interested in either trewatment or Neuralscan documentation, please call (702-521-9542) or email me ([email protected])
Bob Odell
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