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Symptoms and Signs Caused by Neural Plasticity Symptoms and signscaused byneural plasticity AageR. Møller Universityof Texas at Dallas, Callier Center for Communication Disorders, Dallas, TX, USA Plasticchanges in thecentral nervous system are associated with hyperactivity,hypersensitivity, and spread of activityincluding activation of brainregions that are not typicallyinvolved. Symptoms and signssuch as neuropathicpain and tinnitusand hyperactivedisorders such as muscle spasm and synkinesismay result from suchchanges in function. Plasticchanges that cause symptoms of diseasescan be initiated by novel stimulations,overstimulation, or deprivationof input and theinduced changesin thefunction of central nervoussystem structures may persist and aggravateafter these events have ceased if the condition isnot reversed.Disorders that are caused by neural plasticity are potentially reversible with treatment.However, theabsence of morphologic abnormalitiesmakes diagnosis of theseconditions difcult and theirtreatment hasbeen hampered by lack of understandingof theirpathophysiology. Here the role of neuralplasticity in thepathophysiology of severaldisorders is reviewed. [NeurolRes 2001; 23: 565–572] Keywords:Neural plasticity, neuropathic pain; muscle spasm; synkinesis; tinnitus INTRODUCTION structuresincluding re-routing of information to regions Ithas been known for manyyears that the developing ofthe brain that are not normallyinvolved in aparticular centralnervous system(CNS) is plastic, causing its function.Allodynia, i.e. pain evoked by somatic functionto change in different ways as a resultof stimulationthat normally does not evokepain, is an externaland internal factors. Only relatively recently has exampleof a symptomcaused by changes in the CNS. itbecome evident that the mature nervous systemis also Allodyniaand phonophobia aresigns of re-routing of plastic1–15.Neuralplasticity is an ability of the nerve informationin the central nervous systemevoked by cellsto change their function or structure.This isusually sensorystimulation. Synkinesis is asignof establishment considerednecessary for thedeveloping organism, and ofnew connections between motoneurons. Other benecial to the mature organism because it canchange symptomssuch ashyperalgesia (increased sensitivity to thefunction of speci c partsof the CNS to suitchanging painfulstimuli) and hyperpathia (exaggerated subjective demandsor compensatefor theeffect of injuries and response topainful stimuli that continue after the diseases.It is neural plasticity that makes it possible for stimulationhas ceased), and muscle spasm that may strokevictims to regain functions after destruction of occurafter peripheral nerve injuries, are signs of plastic neuraltissue. Neural plasticity most likely also plays an changesresulting in hypersensitivity and hyperactivity. importantrole in making it possibleto adaptthe nervous Tinnitusand certain forms ofvertigo are examples of systemto the use of prostheses such ascochlear disorders thatmay be caused by plastic changes in the implantsand auditory brainstem implants. However, functionof speci c CNSstructures resulting in hyper- neuralplasticity can also cause symptoms and signs of activityor re-routingof information. diseases.The symptoms that arise from functional Theplastic changes that occur in themature nervous changesthat are expressions of neural plasticity are systemare different from thosethat occur in the not associatedwith detectable morphologic or chemical developingnervous system.The function of thedevelop- abnormalities.This isin signi cant contrast to the ingnervous systemnormally changes during develop- symptomsand signs of disorders thatare associated mentand the abnormalities that occur are regarded as withtissue injuries and which usually can be identi ed errors inthe normal development. The mature nervous byima gingtec hniques or byelec trophysiologic systemis normally stable, except for changesthat are methods. relatedto aging. Altered excitability of speci c neural Symptomscaused by neural plasticity have been structures,changes in synaptic ef cacy or outgrowth of studiedmost extensively with regard to pain 4 ,15 –2 4, but newconnections (sprouting) are common changes neuralplasticity can also cause other symptoms and attributedto neural plasticity. Expression of neural signsabout which less is known. The symptoms of plasticitymay occur as a resultof external and internal neuralplasticity may be hypersensitivity, hyperactivity eventssuch asdeprivation of sensory input, over- and/or extendedactivation of central nervous system stimulation,or tissueinjury and in ammation. The same eventsmay cause long lasting modi cations or altera- tionsin theexpression of receptors 1 9.Plasticchanges in thenervous systemmay be regarded as a form of Correspondenceand reprint requests to: Aage R. Møller, PhD, Universityof Texas at Dallas, Callier Center for Communication learning.Since plastic changes in function are not Disorders,1966 Inwood Rd., Dallas, TX 752 35-7298,USA. accompaniedby tissue damage they are potentially ,25–28 [[email protected]]Accepted for publication November 2000. reversible3 . # 2001Forefront Publishing Group NeurologicalResearch, 2001, Volume 2 3, September 565 0161–6412/ 01/060565–08 Neuralplasticity: Aage R. Møller Mostof the knowledge about expression of neural NEURALPLASTICITY RELATED TO SPECIFICSYSTEMS plasticityin the mature nervous systemand how itcan Somatosensorysystem causesymptoms and signs of diseases has been gained Paresthesia,hyperesthesia, neuropathic pain and prur- from researchon pain.The results from painresearch itusare symptoms associated with disorders ofthe havebeen used inattempts to understand how plastic somatosensorynervous system.Disorders ofthe somato- changesmay occur in otherparts of the central nervous sensorysystem are also often associated with dysesthe- systemand which symptoms and signs may result 29 ,30. sia,i.e. an unpleasant sensation from stimulationsthat This reviewarticle provides an overviewof the role of arenormally innocuous. Someof these symptoms can neuralplasticity in causing symptoms and signs that becaused by peripheral neuropathies, hyperventilation resultfrom changesin the function of the nervous or metabolicdisturbances, but theycan also be caused system.Speci cally, the role of neural plasticity in byplastic changes of the CNS. The symptoms that are neuropathicpain, tinnitus, vestibular disorders, and causedby neural plasticity are not causedby neural synkinesisand muscle spasm is discussed. activitythat is generated at the location where the sensationis perceived, but ratherby activity generated intheCNS. Allodynia and hyperalgesia are examples of SIGNSOF CENTRALORIGIN OFSYMPTOMS symptomsthat are caused by changes in the CNS. Phantomsensations and phantom pain are perhaps the Pruritus (itching)is relatedto pain, and it canbe caused clearestdemonstrations of disorders wherethe neural byperipheral as well as central disturbances. Phantom activitythat causes the symptoms does not originateat limbsensations are examples of sensations that are thelocation of the symptoms 2 6,28, 31.Phantompain is generatedin the CNS but referredto a peripheral thereforea pure form ofcentral pain. Tinnitus that location.The plastic changes that cause these symptoms occursdespite a severedauditory nerve is also a clear maybe induced by deprivation or over-stimulation.That signof a centralorigin of the abnormal neural activity phantomlimb syndrome is relatedto over-stimulation is thatcauses the symptoms 30.Ithas been shown inanimal supported bythe ndingthat avoiding over-stimulation experimentsthat the auditory 1,2,8,12,1 3, 32 and somato- during amputationby applying local anesthetics to the sensorysensory cortex 3,7,15 mayreorganize so that peripheralnerve can eliminate the occurrence of regionsthat are adjacent to the areas that are deprived of phantomlimb sensations 28. inputexpand to occupy the deprived cortical areas. Allodynia,where sensory stimulation that normally is innocuous isperceivedas beingpainful, is anindication Pain thatabnormal connections have been establishe d Neuropathicpain is an example of sensations that betweenthe somatosensory nervous systemand the maybe caused by neural activity generated in theCNS paincircuitry 4,1 6–18.Someindividuals with tinnitus after but referredto a peripherallocation. Neuropathic pain injuriesto the auditory nerve perceive sounds from canhave many causes but thecause is lessimportant for rubbing theskin, another example of abnormal connec- managementthan the mechanisms that produce the 2 1 19 tionsbetween sensory systems 30 .Synkinesisafter pain .Woolfand Salter dene three main types of peripheralnerve injuries 2 7 andin connection with pain:physiologic, in ammatory and neuropathic pain. hemifacialspasm 33– 36 isanother example of a condition Physiologicpain is caused by normal activation of thatis caused by establishment of new neural connec- nociceptors.In ammatory pain is caused by various tions.The vertigo and nausea from headmovements that forms ofin ammation and tissue damage. Neuropathic isexperienced by individuals with certain vestibular painis caused by lesions of the nervous system, disorders37 mayalso be caused by reorganization of the includinglesions of peripheral nerves or disorders of centralnervous system. theCNS such asstrokes,but itis not known whylesions 21 Centralneuropathic pain is often accompanied by tothe nervous systemcause pain .Neuropathicpain, depression16,whichindicates that new connections or stimulusindependent pain, may persist long after
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