Voiss D V
ACCESS Consulting Systems Incorporated, Portland, Oregon, USA.
Neurol Clin. 1995 May;13(2):431-46.
The preceding describes some of the confusion which abounds in practically all areas of clinical medicine and particularly in occupational injuries. In essence, this confusion devolves to a primary failure on our part as clinicians; the failure to differentiate fact from fantasy. In the clinical arena, this is the failure to differentiate between that which is clinical pathology in the peripheral neuromusculoskeletal system and that which is no less real for the patient, a fantasy arising from image-driven, adaptively-initiated activation of specific neuronal groups in the somatosensory or somatomotor cortex, descriptively referred to as "hysterical" or "psychogenic." A common experience of neurologists and other clinicians conducting a sensory examination of the extremities is the presence of nondermatomal or glovelike sensory changes of the feet or hands. Nondermatomal sensory changes are known to engage any part of the body surface. These have often been referred to as hysterical; however, in the clinical sensory examination for touch, vibration, and pinprick, the patient has no control over the area or boundaries of the activated receptive fields in the somatosensory cortex. Fantasies of the patient, provoked by the context of examination, initiate an adaptive response which can expand or contract the boundaries of the somatosensory receptive fields. These sensory changes are unconscious and represent alteration of receptive fields in the somatosensory cortex. The brain is re-entrantly connected. Activation in one area promotes activation in adjacent and associated areas remote from the primary receptive field. The brain organizes its own activity. "Perception thus is not imposed on the brain; rather the brain selects the perceptual mode.... stimulus energy, according to numerous studies from brain-activation, is only a weak determinant of the magnitude of response in primary sensory areas. . . ." The most intense brain activation in the somatosensory cortex is provoked, not by peripheral stimulation, but by adaptive preparation referred to as somatotopical tuning, probably due to an increase in excitatory post-synaptic potentials (EPSPs). Many patients present to neurologists and other clinicians with complaints of numbness and tingling in the fingers, hands, arms, or face and occasionally, as in one of my patients, the entire body.(ABSTRACT TRUNCATED AT 400 WORDS)
上述内容描述了几乎在临床医学的所有领域，尤其是职业损伤领域中普遍存在的一些混乱情况。从本质上讲，这种混乱主要是由于我们临床医生的基本失误造成的；即未能区分事实与幻想。在临床领域，这表现为未能区分周围神经肌肉骨骼系统中的临床病理学情况与对患者来说同样真实的、由体感或躯体运动皮层中图像驱动的、适应性启动的特定神经元群激活所产生的幻想，这种幻想在描述上被称为“癔症性”或“心因性”。神经科医生和其他进行肢体感觉检查的临床医生的常见经历是，足部或手部存在非皮节性或手套样感觉改变。已知非皮节性感觉改变可累及身体表面的任何部位。这些改变常被称为癔症性的；然而，在针对触觉、振动觉和针刺觉的临床感觉检查中，患者无法控制体感皮层中被激活的感受野的区域或边界。由检查情境引发的患者幻想会引发一种适应性反应，这种反应可扩大或缩小体感感受野的边界。这些感觉改变是无意识的，代表着体感皮层中感受野的改变。大脑具有折返连接。一个区域的激活会促进远离初级感受野的相邻及相关区域的激活。大脑组织自身的活动。“因此，感知并非强加于大脑；相反，大脑选择感知模式……根据众多大脑激活研究，刺激能量只是初级感觉区域反应强度的一个弱决定因素……”体感皮层中最强烈的大脑激活并非由外周刺激引发，而是由称为躯体定位调整的适应性准备引发，这可能是由于兴奋性突触后电位（EPSP）增加所致。许多患者向神经科医生和其他临床医生诉说手指、手部、手臂或面部有麻木和刺痛感，偶尔，就像我的一位患者那样，会诉说全身有这种感觉。（摘要截选至400词）
