Disorders of sensation and perception

10 Disorders of sensation and perception






Introduction


The senses that we possess (sight, hearing, touch, taste, smell and proprioception) are used by us all continuously throughout each day of our life. Their apparently flawless function makes that their essential contribution to our existence is rarely appreciated. Consider the example where, in your university cafeteria, you have made your selection of food and drink and placed this on your tray. Joining the queue at the cash till, you meet one of your lecturers. You engage in a lively debate about the lecture you just had, while balancing your tray on which there is a bowl, filled to the brim, with hot soup. Although the balancing is a seemingly effortless task, the fact that you perform it without conscious awareness does not render this a simple problem. While conducting your conversation your proprioceptors – the sensors in your muscles, tendons and joint capsules that provide information about your posture and movement – as well as various sensors in your skin, continuously detect changes in joint position and orientation, speed, pressure and shear forces in your skin. This afferent information is relayed to the spinal cord, where it feeds into various reflex loops under higher cortical and cerebellar influence (Chapter 6). The resulting motor output is geared towards maintaining a level position of your tray to ensure your soup does not spill over and create a mess, as well as preserve your posture.


People with the – albeit rare – condition of sensory neuropathy would probably not be able to do this; they would be unable to feel the position of themselves – or the tray – in space. With afferent information being corrupted or lacking altogether, the postural reflex mechanisms are unable to produce the required output, and the person would be likely to drop the tray. A fascinating study can be found in Sacks (1985), where he describes the case of a so-called ‘disembodied lady’. Bereft of proprioception due to a rare infection, she does not ‘feel’ her body, and lacks the unconscious control to stabilise her posture. Through the process of rehabilitation, she learns to compensate for the lack of automatic posture control by using vision, and by consciously focusing her attention, e.g. by looking at her tray. But the moment her attention is distracted and she looks elsewhere, her posture collapses. Such profound isolated impairments of proprioception are rare; however, case studies such as this highlight the important role of sensory information in our daily activities and illustrate how senses can compensate for each other to a certain degree.


The aim of this chapter is to compare and contrast ‘sensation’ with ‘perception’, detail the various stages involved in information processing, and explain the impact that a neurological condition, e.g. stroke, may have on this. We will focus on pain perception in particular, as an analysis of this phenomenon demonstrates how sensation, perception, as well as cognition interact in creating this unpleasant experience. Studying the process of ‘central post-stroke pain’ also helps to deepen our understanding of the impact that a lesion of the central nervous system may have on signal processing (Case study 10.1). Finally, interesting work has been carried out in the domain of pain assessment, which highlights some further complications in people with a neurological condition such as stroke.



Case study 10.1 A case of central post-stroke pain


A 68-year-old man suffered a ‘lacunar’ stroke due to a blocked cerebral artery (i.e. infarction) 6 weeks previously. This has caused a left-sided face, arm and leg weakness. He is not yet walking, but has increasing muscle tone in his arm and leg. Since the stroke he has described his left arm as feeling ‘dead’, but for the last week has been complaining that it aches before his therapy sessions. After therapy, however, the pain seems to be better. The medical team have prescribed ibuprofen. The therapist considers whether the pain is due to spasticity, especially as there is some glenohumeral mal alignment (i.e. shoulder subluxation). However, careful passive external rotation of the humerus does not make the pain any worse and the elbow easily straightens with a slow stretch. Palpation of the shoulder does not reveal any tenderness. The patient remarks that the pain is worse when they wear a long sleeved shirt and sometimes there is an uncomfortable tingling feeling between the mid upper arm and forearm. In this area the therapist finds reduced sensitivity to temperature; using a cold teaspoon while lightly touching the skin recreates the paraesthesia. Also, after some careful questioning, it emerges that the increase in pain before therapy may be related to anxiety; when practising transfers (e.g. moving from sit to stand), the patient experiences pain, which is probably caused by the weight placed on the affected arm. The fear associated with anticipating pain causes anxiety, which increases autonomic activation, which in turn aggravates the neuropathic pain prior to treatment sessions – even though other aspects of the intervention reduce the pain.


Based on this information, the medical team decides that this is possibly a case of central post-stroke pain. After discussion with the medical team, amitriptyline is prescribed and a pain record is kept by the nursing staff using a 0–10 rating scale. After 7 days the pain sensations are becoming less intense and less frequent. As the patient’s apprehension about transferring during therapy sessions improves, the association between pain and therapy also disappears.



Sensation


As explained in Chapter 9, attention is a major factor in the processing of information, as it helps us to direct our sensory systems towards relevant information, select appropriate information, allocate energy to process the information and regulate our attention to allow us to complete a task. Sensory information that is not attended to is poorly remembered, and, therefore, attention is a major component in the process of learning.


When we talk about sensation, what we are really referring to is the process of information coming in from the environment (internal or external) through the sense organs and being relayed to the central nervous system. The various sense organs (eyes, ears, nose, tongue, skin and proprioceptors) possess dedicated mechanisms that allow them to receive a specific form of energy from the environment (e.g. electromagnetic wavelengths of a specific range) and transduce this into nerve impulses. Transduction is the key component of sensation, as it is only after this has taken place that the nervous system can begin to process information in the form of action potentials. It is important to remember that sensory information, when it is first encountered, is in its rawest form and inherently meaningless. Assigning meaning to information requires the process of perception, which will be outlined in the next section. To be able to appreciate the complexity of sensation, we will take one example by going through the processes involved in vision. Although readers are referred to other texts (e.g. Kindlen 2003) for a description of the anatomy of the various other sense organs, and the sensory processes involved in each of these, what you should aim to remember from the section on vision are the generic principles involved in information processing.



Vision


Sight is the sense through which we are able to perceive electromagnetic radiation in the form of light waves. The light waves pass into the eye through the cornea (see Fig. 10.1), which starts to curve the light waves before they pass through the lens of the eye, where further curvature results in the light being focused onto the surface of the retina.




Retina


The retina can be considered to be the major structure within the eye since it is the location of the key process of transduction. Transduction is the process by which light energy gets converted into electrical energy (in the form of action potentials), thereby allowing the signal to be processed up through the various levels of the brain.


The retina (see Fig. 10.2) is a thin film of tissue lining most of the inside of the eyeball and contains blood vessels, nerve cells, photoreceptors and pigment cells. It is orangey-red in colour when viewed through an ophthalmoscope because of its blood supply and pigments. In one part of the retina a whitish patch (optic disc) can be seen, which consists of the axons of the optic nerve, i.e. the site where these axons leave the eyeball. The disc appears white because the axons here are myelinated.




Photoreceptors


Two types of photoreceptors can be found in the retina – the rods and the cones – both of which are responsible for the conversion of wave energy into electrical energy. There are approximately one hundred million rods per retina and they are responsible for ‘shades of grey’ vision. The rods exhibit high sensitivity and low acuity, are more numerous in the periphery and are utilised primarily for night vision.


The cones on the other hand, of which there are only three million per retina, are responsible for colour vision and exhibit a low sensitivity and high acuity. The cones are utilised for day vision and can be found concentrated in the fovea.


The photopigments found in the pigment cells of the retina consist of retinal, a vitamin-A derivative, coupled to one of several lipoproteins (opsins). In the human eye there are four different lipoproteins creating four different photopigments: rhodopsin in the rods, and erythrolabe, chlorolabe, and cyanolabe in the cones. Only one type of photopigment is present in each cone and each pigment is best at absorbing light rays of a particular range of wavelengths. These ranges overlap and, as a result, the rays of one wavelength are absorbed by more than one photopigment, but to differing extents, e.g. 580 nm rays are absorbed by both erythrolabe and chlorolabe, but not by cyanolabe. The sensation of colour is created by the blend of signals generated by the three different types of cone. If one or more types of cone are absent from the retina, or lack photopigment, then our perception of colour changes (colour blindness), e.g. some colours may not be seen at all, while others are confused. Stacked, flattened membrane discs contain large amounts of the photopigment molecules. Each rod cell contains about 2 000 stacked discs, studded with 100 million molecules of the photopigment rhodopsin. Rhodopsin consists of an opsin protein and retinal, a light-absorbing vitamin A derivative existing as isomers.


If we take rhodopsin as an example, we can look in some detail at the biochemical cascade of events that takes place when light strikes the retina and stimulates a photoreceptor (see Fig. 10.3).



The whole process occurs within 0.2 s of the photon reaching the rod cell and similar processes occur within the cones. In the cones, the variation in pigment is produced by different forms of opsin each with their own specific interaction with 11-cis-retinal. As a result of this there are different absorption sensitivities in the cone system:




Visual pathways


The optic nerves from each eye meet up at the optic chiasma (see Fig. 10.4) where the nerve fibres carrying signals from the nasal half of the retina cross over to the other side so that information about objects on the right-hand side of the scene we are looking at (right visual field) is carried over to the left side of the brain and vice versa. If injury occurs to the visual pathway on one side of the brain after the chiasma, there will be loss of vision in one half of the visual field of both eyes, which is known as a homonymous hemianopia (see Chapter 5).



From the chiasma, impulses are transmitted to the midbrain (to evoke several visual reflexes) and to the thalamus and the visual cortex in the cerebral hemispheres, to give rise to the sensations of light, colour and movement. After the optic chiasma, some fibres branch off the optic tract to go to parts of the pretectal region and to the superior colliculi. These areas are concerned with several visual reflexes including the pupillary light reflex and reflex eye and head movements.


May 25, 2016 | Posted by in NEUROLOGY | Comments Off on Disorders of sensation and perception

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