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It isn’t too hard to identify those with cervical injury (anywhere from C1 to C7) on the central pain survey at this site. They typically include symptoms which traditionally have been discussed under brain damage. High cervical injury apparently tends to injure brain far more frequently than is recognized. Questioned carefully, at least fifty percent of those with cervical injury and central pain also display some of the symptoms of subtle brain injury. The real incidence may be one hundred percent, since working memory loss is virtually universal.

The deep suspicion that brain injury was part of central pain began in earnest when Bogduk’s group showed that those with central pain have loss of working memory. Working memory involves multitasking. The conventional tests are not especially well suited for the memory loss of central pain, which includes distraction from the pain itself. However, as most of you know, memory has never been assigned to the spinal cord; yet, here we are with a group of people with memory loss after spinal cord injury. The spinal area of C1 and C2 is especially turning out to look a lot more like brain than we suspected, with many clear integrating functions. Although the work has mainly focused on visual phenomena, the same seems likely to be true for other sensory modalities.

Brain changes following cord injury either have to be due to:

1) changes in the brain induced by ascending pain signals from cord or from genetic/chemical changes in the cord which are picked up and copied in the brain at the synaptic junctions; or

2) actual injury to the brain itself at the time of whatever caused cord injury.

The problem with the second possibility is that a fair number of central pain subjects with various symptoms of brain injury have no apparent brain trauma. However, given the extreme susceptibility of vasoconstriction of blood vessels in the brain, and the fact that the carotid, basilar, and spinal arteries may easily constrict, one does not know if some abnormal perfusion of blood has done something harmful as a consequence of injury to the structures passing through the neck.

Hence, the mystery remains. What is important is that central pain subjects make known their symptoms so that they can be reported to researchers and appropriate studies be designed.

The terminology of subtle brain injury is not well developed. Neurologists are quite good at spotting something that is completely missing or even fifty percent gone, but they are not particularly good at spotting partial injury. For example, no two neurologists are likely to agree on exactly how much Babinski change you have, your hyperreflexivity. They also are not likely to be able to detect twenty five percent loss of vibratory sense, or twenty five percent weakness. Neurologists simply do not do twenty-five percent well. And they do lesser losses even more poorly. Consequently, if you have twenty five percent loss of memory, twenty five percent loss of position sense (proprioception) or twenty five percent loss of anything, you are the best judge. You will know long before any doctor can pick it up.

If you listen carefully during the next neurologic exam, you will see that as to sensation, it is pretty much a yes or no, black or white type of exam. For example, if the big toe refuses to go upward or downward during the test where a point is drawn up the side of the sole, some neurologists disregard it and some will suspect it indicates a partially positive test, since there is no convention on the matter.

You will hear polar words such as “sharp”, “dull”, “yes”, “no” etc which are at the extremes. You are not likely to hear words such as “partially sharp”–there simply isn’t time during the exam, yet that is precisely the type of loss which CP patients most commonly experience. It is true that some doctors use von Frey filaments to detect “subclinical” sensory diminution, but we don’t know of anyone who is using graded temperature probes to detect subtle changes in susceptibility in thermal sensation, either painful or nonpainful. It is safe to say then, that by ahd large neurologists do not do “partial”; consequently, they miss most of the changes typical in CP patients.

It is true that somatosensory evoked potentials will pick up slowing (latency) of signal moving up through cord, but since the results must be corrected for age, height, and other factors, the nomograms are not all that specific, so it would be possible to sneak in a twenty-five percent loss of function in the anterior part of the posterior columns without anyone being the wiser.

The same is true of course of brain damage. A person who loses twenty five percent of themselves is likely going to be alarmed or even terrified. However, you will be alone in this. As Lily Thomlin said, “The thing to remember is…we’re all in this alone”.

We are readying a supplementary survey to try to quantify the percentage of CP patients with brain injury. If you have already completed the first survey, please be on the lookout for the posting of this second one. It is very important that we get at least three hundred respondents, to make it statistically significant.

A good way to recognize brain injury is to read a book written by someone who has it. We know of no book more helpful in this area than “Over My Head” (Andrews McMeel Publishing) by Claudia L. Osborn, who is on the teaching faculty at a college of osteopathy in Michigan. Based on her book, we can list some of the things which you should look for in yourself. We will oversimplify so you can begin to get an idea, since the terms have no intuitive meaning and it takes time to recognize that certain changes are going on, as Dr. Osborn relates in her own story.

Adynamia

“We were in the car together, riding along. Marcia turned and asked, “What are you thinking?” My answer is always the same, ‘Nothing’ “.–from Dr. Osborn’s notebook. Adynamia is a lack of the energy and force with which one faces, embraces and engages life. It is a lack of being “active or energetic or forceful in personality…lethargy…depletion of psychic energy and action”.

“We all have pieces of ourselves that we secretly cherish, that afford us great pleasure. For me, it was the creative aspect of my analytic mind. It was a source of immeasurable joy. As I became aware that it had stopped inventing solutions…that it could not shift perspective or GRAPPLE WITH MORE THAN ONE THOUGHT AT A TIME, I became frightened.” —Claudia Osborn (Capitals ours)

(Regarding adynamia, see “Emotional Death” at this website)

Inability to multitask, to grapple with mroe than one thought at a time, is the single most frequently mentioned mental problem accompanying central pain, with memory loss being second most common.

Flooding

“Flooding” is basically being so overcome with a multitude of things that everything more or less stops. It is not uncommon for central pain subjects to require notepads for making lists of what they must do or where they are going. Movement by someone near may blank out the ability to do a motor task. (”If I am spreading peanut butter on a cracker and someone moves toward me or speaks out, I am likely to break the cracker”)

Flooding also has the odd characteristic of letting words block out your grasp of words. If you focus more on the idea, and think in the zone of what is being discussed, you are less likely to have your mind wander off and become lost. As you focus on the word presently being spoken to you, it tends to destroy your ability to remember the words which were spoken just moments ago. Rehab specialists looking for this may speak emphatically or interrupt to see if they can deliberately “throw a monkey wrench” in your “attention-concentration” (unable to keep something in your conscious mind).

Memory Loss

“Working memory loss”. One way to test for this is to compare addition and subtraction. The brain can perform addition by simply recalling the sums memorized in grade school, which only involve about ten numberals. Subtraction is different and requires actual analysis and reasoning. With loss of working memory, one can usually perform addition without much loss of function, although the speed may drop. However, if you begin at one hundred, and try to count backward by threes, as in 100…97…94 (keep going), the brain is required to keep in the place the last number in order to process the subtraction. This keeping in place one idea while you work on forming another is hard to do with loss of working memory. Some brain damaged people are actually performing subtraction by using addition. For example, if they want to know what 100 minus 3 is, they will say 97 PLUS 3 is one hundred, so the answer must be 97. This slows them down a little. If your substraction suffers more than your addition, you probably have the loss of working memory seen in CP.

Maximalistic Thinking

This term, although used by Osborn is not in common use. It actually may have more than one meaning. It can mean focusing so much on the thought of the instant that you forget the thought of the prior instant or the overall goal.

As used by Osborn’s therapists, it means not paying close enough attention to the present task and place, such that you forget the task you are engaged in, or cannot remember why you are going somewhere or are at some place.

“Maximalistic thinking” can also mean a heavy focus on something which has no focus, (wandering thought or speech) such as getting into a “loud digressive pointless anecdote”.

Relaxing supervisory functions of the brain

One also sees not being able to put brakes on one’s behavior, with talking too much, remaining silent out of mental exhaustion, not disciplining sexual behavior appropriately and putting it in balance, or generally overdoing productive living or underdoing productive living. Indecision alternating with more or less compulsive behavior might be an example.

Those with such brain injury do not fully recover. They slowly learn to deal with it.

These problems have been neglected for too long in central pain. There are precious few trained to identify subtle brain damage and central pain subjects almost never get to see these people as the cord injury tends to trump or eliminate concerns over the possibility that the brain has also been injured to some degree.

Once again, we will soon be posting a second CP survey and hope that those of you to whom any of the above applies will complete the survey or submit comments to this article relating your experience.

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P.S. If you don’t use a little notebook already, perhaps you would benefit from using one. That thought may be gone before you know it.

With brain injury AND Central Pain, you may want to sleep a lot, but the burning pain won’t allow it for touching the sheets, or other mechanical pain which has become hyperpathic interferes with sleep. This catches the CP subject “between the devil and the deep blue sea”.