The influence of temporal summation on a C-fibre reflex in the rat: effects of lesions in the rostral ventromedial medulla (RVM)

The transition from naïve to primed nociceptive state: A novel wind-up protocol in mice

Wind-up (WU) is a progressive, frequency-dependent facilitation of spinal cord neurons in response to repetitive nociceptive stimulation of constant intensity. We identified a new WU-associated phenomenon in naïve mice (not exposed to noxious stimulation immediately prior to WU stimulation), which were subjected to a novel experimental protocol composed of three consecutive trains of WU stimulation. The 1st train produced a typical linear 'wind-up' curve as expected following a repeating series of stimuli; in addition, this 1st train sensitized ('primed') the nociceptive system so that the responses to two subsequent trains (inter-train interval of 10 min) were significantly amplified compared with the response to the 1st train. We named this augmented response potentiation-of-windup, or "PoW". The PoW phenomenon appears to be centrally mediated, as the augmented response was suppressed by administration of an NMDA receptor antagonist (MK-801) and by cutting the spinal cord. Furthermore, the PoW protocol is accompanied by enhanced pain behavior. The 'priming' effect of the 1st train could be mimicked by exposure to natural noxious stimuli prior to the PoW protocol. Presumably, the PoW phenomenon has not been previously reported due to a procedural reason: typically, WU protocols have been executed in 'primed' rather than naïve animals, i.e., animals exposed to nociceptive stimulation prior to the actual WU recording. Our findings indicate that the PoW paradigm can distinguish between 'naïve' and 'primed' states, suggesting its use as a tool for the assessment of central sensitization.

Slow temporal summation of pain for assessment of central pain sensitivity and clinical pain of fibromyalgia patients

BACKGROUND

In healthy individuals slow temporal summation of pain or wind-up (WU) can be evoked by repetitive heat-pulses at frequencies of ≥.33 Hz. Previous WU studies have used various stimulus frequencies and intensities to characterize central sensitization of human subjects including fibromyalgia (FM) patients. However, many trials demonstrated considerable WU-variability including zero WU or even wind-down (WD) at stimulus intensities sufficient for activating C-nociceptors. Additionally, few WU-protocols have controlled for contributions of individual pain sensitivity to WU-magnitude, which is critical for WU-comparisons. We hypothesized that integration of 3 different WU-trains into a single WU-response function (WU-RF) would not only control for individuals' pain sensitivity but also better characterize their central pain responding including WU and WD.

METHODS

33 normal controls (NC) and 38 FM patients participated in a study of heat-WU. We systematically varied stimulus intensities of.4 Hz heat-pulse trains applied to the hands. Pain summation was calculated as difference scores of 1st and 5th heat-pulse ratings. WU-difference (WU-Δ) scores related to 3 heat-pulse trains (44°C, 46°C, 48°C) were integrated into WU-response functions whose slopes were used to assess group differences in central pain sensitivity. WU-aftersensations (WU-AS) at 15 s and 30 s were used to predict clinical FM pain intensity.

RESULTS

WU-Δ scores linearly accelerated with increasing stimulus intensity (p<.001) in both groups of subjects (FM>NC) from WD to WU. Slope of WU-RF, which is representative of central pain sensitivity, was significantly steeper in FM patients than NC (p<.003). WU-AS predicted clinical FM pain intensity (Pearson's r = .4; p<.04).

CONCLUSIONS

Compared to single WU series, WU-RFs integrate individuals' pain sensitivity as well as WU and WD. Slope of WU-RFs was significantly different between FM patients and NC. Therefore WU-RF may be useful for assessing central sensitization of chronic pain patients in research and clinical practice.

Exploring the central modulation hypothesis: do ancient memory mechanisms underlie the pathophysiology of trigger points?

A myofascial trigger point (TrP) is a point of focal tenderness, associated with a taut band of muscle fibers, that can develop in any skeletal muscle. TrPs are a common source of pain and motor dysfunction in humans and other vertebrates. There is no universally accepted pathophysiology to explain the etiology, symptomatology and treatment of TrPs. This article reviews and extends the author's previously published hypothesis for the pathophysiology of TrPs, "Trigger Points and Central Modulation-A New Hypothesis." The author proposes that central nervous system-maintained global changes in α-motoneuron function, resulting from sustained plateau depolarization, rather than a local dysfunction of the motor endplate, underlie the pathogenesis of TrPs.

Pronociception from the dorsomedial nucleus of the hypothalamus is mediated by the rostral ventromedial medulla in healthy controls but is absent in arthritic animals

The dorsomedial nucleus of the hypothalamus (DMH) has been proposed to participate in stress-induced hyperalgesia through facilitation of pronociceptive cells in the rostroventromedial medulla (RVM). We hypothesized that the DMH participates in hyperalgesia induced by arthritis. The DMH was pharmacologically manipulated while assessing heat-evoked nociceptive behavior or the discharge rates of pronociceptive RVM ON- and antinociceptive RVM OFF-like cells in NAIVE, SHAM and monoarthritic (ARTH) animals. In NAIVE and SHAM animals, the changes in nociceptive behavior induced by activation of the DMH by glutamate and inhibition by lidocaine were in line with earlier evidence indicating that the DMH has a nociceptive facilitating role. However, in ARTH animals, neither activation nor inhibition of the DMH influenced pain-like behavior evoked by stimulation of an uninflamed skin region (paw and tail). In accordance with these behavioral results, activation or inhibition of the DMH induced pronociceptive changes in the discharge rates of RVM cells in NAIVE and SHAM animals, which suggests that the DMH has a pronociceptive role mediated by the RVM in normal animals. However, in ARTH animals, both glutamate and lidocaine in the DMH failed to influence either pain-like behavior or noxious stimulation-evoked responses of RVM cells, while blocking the DMH increased spontaneous activity in the pronociceptive RVM ON cells. Our data indicate that the DMH participates in descending facilitation of cutaneous nociception in healthy controls, but it is not engaged in the regulation of cutaneous nociception in monoarthritic animals, while a minor role in tonic suppression of nociception in arthritis cannot be discarded.

Antinociceptive Effects of Heterotopic Electroacupuncture in Formalin-Induced Pain

This study examined the antinociceptive effect of electroacupuncture (EA) to heterotopic acupoints on formalin-induced pain in rats. EA (2 ms, 10 Hz, and 3 mA) was delivered to heterotopic acupoints HE7 and PE7, or non-acupoints at the right fore limb, for 30 min and was immediately followed by subcutaneous formalin injection into the left hind paw, respectively. The quantified pain score, electromyogram (EMG) response of the C-fiber reflex, and cFos immunoreactivity were assessed, respectively. EA to heterotopic acupoints significantly reduced both early- and late-phase pain-like behaviors and significantly decreased the EMG responses of the C-fiber reflex after formalin injection. By contrast, EA to non-acupoints had no significant effects on pain-like behavior or the EMG response. In addition, EA to heterotopic acupoints decreased cFos immunoreactivity in the lumbar spinal dorsal horn. Therefore, EA induced pre-emptive antinociception via the extra-segmental inhibition of the formalin-induced pain, suggesting that EA to heterotopic acupoints is a useful treatment for inflammatory pain.

Facilitation and inhibition of withdrawal reflexes following repetitive stimulation: electro- and psychophysiological evidence for activation of noxious inhibitory controls in humans

A systematic evaluation of nociceptive withdrawal reflexes and pain rating was undertaken in order to explore the mechanisms underlying temporal summation of repetitive electrocutaneous stimulation in healthy individuals (n=12; age=27.5+/-1.5 years). Five-second subreflex threshold (RT) electrocutaneous stimulation at different frequencies (single stimulus, 5, 10, and 20 Hz) and intensities (0.6RT and 0.8RT) was applied on the dorsum of the foot, and the withdrawal reflex from the ipsilateral biceps femoris muscle was measured. The subjects scored the pain intensity on a visual analogue scale (0-100 mm) for the beginning, the middle and the end phase of the 5 s series of stimulation, and the respective averaged reflex size was calculated. The reflex size increased at stimulus frequencies 10 Hzx0.8RT and 20 Hzx0.8RT as compared with 5 Hzx0.8RT (SNK, P<0.05), and by an increase in current intensity from 0.6RT to 0.8RT (SNK, P<0.05). Pain intensity increased with the increase in the current intensity from 0.6RT to 0.8RT (SNK, P<0.05). Profound activation of inhibition following electrocutaneous pain stimuli was demonstrated by reduction in pain intensity and reflex size during the last second as compared with the first second at 0.6RT current intensity (SNK, P<0.05). The pain intensity peaked between 5 and 10 Hz (P<0.05) and was reduced at 20 Hz for current intensities at 0.8RT (P<0.05). This study provides evidence for both frequency dependent central integration of the repetitive electrocutaneous stimuli and activation of a pain inhibitory system by psychophysical and electrophysiological means, demonstrating the delicate balance between neuronal facilitation and inhibition in the human pain system.

Effects of diffuse noxious inhibitory controls on temporal summation of the RIII reflex in humans

The aim of this study was to investigate the effects of diffuse noxious inhibitory controls (DNICs) on the temporal summation of the nociceptive flexion reflex (RIII reflex) in humans. Recordings were obtained from 36 healthy adults (16 M, 20 F), and the area and temporal summation threshold (TST) of the RIII reflex were measured. The subjective intensity of the painful sensation was rated on an 11-point visual analogue scale (VAS). Neurophysiological and VAS measurements were recorded after activation of DNICs by means of the cold pressor test (CPT), which involved immersing the hand in cold water (2-4 degrees C). A slight significant lower TST was found in the females versus the males. In all the subjects, the CPT induced a significant TST increase and RIII area reduction compared with the control session. The VAS results paralleled those of the RIII reflex area and TST. During the CPT, a significant difference in the percentage TST increase emerged between females and males, being lower in the former. Similarly, we found a significantly lower percentage reduction of the RIII area in women than in men during the CPT. To summarize, activation of DNICs through the CPT significantly increased the TST of the RIII reflex in healthy subjects. This inhibitory effect was gender-specific. Whereas other findings are based on psychophysical evaluations, the results of this experimental study provide an objective neurophysiological demonstration that DNICs attenuate temporal summation in humans and confirm the presence of significant differences in pain modulation mechanisms between men and women.

Halothane depresses C-fiber-evoked windup of deep dorsal horn neurons in mice

A progressive increase in the response of a nociceptive spinal neuron to repeated electrical C-fiber stimulation reflects a phenomenon called windup. Second order neurons in the dorsal horn, as well as motoneurons, can develop windup. Inhaled anesthetics act primarily in spinal cord to suppress movement induced by noxious stimulation. We hypothesized that halothane would depress neuronal windup in mice at concentrations that also prevented movement. We measured windup in deep dorsal horn neurons in lumbar spinal cord at 0.75 MAC (the minimum alveolar concentration of anesthetic that prevents movement in 50% of subjects in response to noxious stimulation), 0.9 MAC, and 1.1 MAC. The change from 0.75 to 0.9 MAC did not significantly decrease windup (-11+/-22%), but the change from 0.9 to 1.1 MAC decreased windup (-35+/-7%, P<0.01). We conclude that halothane depresses neuronal windup in the range that prevents movement, and that the effect on windup might play a role in halothane's immobilizing action.

Discharge of raphe magnus ON and OFF cells is predictive of the motor facilitation evoked by repeated laser stimulation

Medullary raphe magnus (RM) on and off cells are thought to modulate spinal nociception by gating withdrawals evoked by noxious stimulation. To test whether withdrawal initiation is the target of RM modulation, we examined the relationship between on and off cell discharge and motor withdrawal evoked by noxious laser heat in halothane-anesthetized rats. The cellular responses of both cell types began during the 50 msec after onset of the tail flick, peaked within 200 msec, and outlasted the duration of the motor reaction. Thus, it is unlikely that the target of on and off cell modulation is withdrawal initiation; instead, on and off cells may modulate reactions to repeated noxious stimulation. We therefore tested whether laser heat-evoked changes in RM cell discharge were predictive of the modulatory effects of one noxious stimulus on the reaction to a subsequent noxious stimulus. Two pulses of laser heat were presented at interpulse intervals of 0.8, 2.0, or 10.0 sec. The motor withdrawal evoked by the second pulse was significantly enhanced relative to that evoked by the first pulse. The observed motor enhancement depended on supraspinal input because it was not present in spinalized rats. Comparison of the relative changes in motor and cellular activity preceding double laser heat stimulation revealed parallel changes between motor facilitation, decreases in off cell discharge, and increases in on cell discharge. This finding suggests a preparatory role for RM on and off cells in enhancing reactions to a noxious stimulus that closely follows another noxious stimulus.

Temporal facilitation of the flexor reflex induced by C-fiber activity: comparison between adult and aged rats

We investigated the wind-up phenomenon of the flexor reflex in adult and aged rats. The sural nerve was stimulated at C-fiber strength and reflex activity was recorded from the semitendinosus muscle. The wind-up rate, the increment rate of the C-fiber response (i.e. activity from 100 to 600 ms after stimulation) by successive stimuli (five train pulses), was decreased exponentially with increasing stimulus intervals from 3 to 20 s. The time constant of the decay for the aged rats was 9.2+/-3.2 s (mean+/-SD), which was significantly longer than for the adult rats (6.4+/-2.9 s). The findings indicate that the effects of C-fiber activation on the spinal nociceptive pathways attenuate more slowly in aged rats as compared with adult rats.

Adaptive changes in withdrawal reflexes after noxious stimulation at the heel and the toes in the decerebrated rabbit

In decerebrated rabbits, reflexes evoked by electrical stimulation of the toes in the ankle flexor tibialis anterior were enhanced for > 30 min after application of 20% mustard oil to the base of the toes, whereas responses of the ankle extensor medial gastrocnemius to stimulation of the heel were depressed for > 20 min by the same stimulus. Applied to the heel, mustard oil had inconsistent effects on the flexor reflex but potentiated the extensor response for approximately 1 h. Intrathecal co-administration of naloxone (25 microg) with the selective alpha(2)-adrenoceptor antagonist RX 821002 (200 microg) enhanced both reflexes to more than twice pre-drug values and reduced or abolished all effects of mustard oil. These data confirm that the location of a noxious stimulus is an important determinant of the subsequent adaptive changes in reflexes, and indicate roles for endogenous opioids and noradrenaline in these processes.

Temporal summation and a C-fibre reflex in the rat: effects of morphine on facilitatory and inhibitory mechanisms

In intact rats, an inhibitory mechanism counteracts the increase in excitability of a flexor reflex, which is seen in spinal animals following temporal summation of C-fibre inputs; the Rostral Ventromedial Medulla is involved in this inhibitory mechanism. Electromyographic responses elicited by electrical stimulation of the sural nerve were recorded from the biceps femoris in four types of preparations, namely intact, sham-operated, Rostral Ventromedial Medulla-lesioned and decerebrate-spinal rats. The excitability of the C-fibre reflex was tested during and following high intensity homotopic electrical conditioning stimuli. Morphine (2 mg/kg) did not significantly change the basal test response but increased the excitability of the spinal cord during conditioning. This effect was triggered by the strength of inputs, involved the Rostral Ventromedial Medulla and was probably related to some forms of motor stimulation through dopaminergic transmission. While wind-up was not reduced, the inhibition related to Diffuse Noxious Inhibitory Controls, which occurred following the conditioning period, did. In spinal animals where inhibitory mechanisms disappear, the depressive effects of morphine were unmasked for both wind-up and post-conditioning facilitations. All effects of morphine were completely reversed by naloxone.

The effects of ketamine on the temporal summation (wind-up) of the R(III) nociceptive flexion reflex and pain in humans

Animal studies have suggested that the temporal summation of nociceptive inputs might play a significant role in the development of central sensitization (i.e., hyperexcitability of central nociceptive neurons) and hyperalgesia via the activation of N-methyl-D-aspartate receptors. To further analyze these processes in humans, we evaluated the effects of small systemic doses of ketamine on the temporal summation (i.e., wind-up) of both the nociceptive flexion (R(III)) reflex and sensations of pain in six healthy volunteers. The R(III) reflex was recorded from the biceps femoris and was elicited by electrical stimulation of the sural nerve. First, the recruitment (stimulus/response) curve for the reflex was built using stimuli up to the pain tolerance threshold (applied once every 6 s). A series of 15 stimuli was then applied once a second at an intensity of 1.2 times the reflex threshold. These procedures were performed both before and after the randomized IV injection of either 0.15 mg/kg ketamine or a placebo. The R(III) reflex threshold and its recruitment curve were not significantly altered after the injection of ketamine or placebo. By contrast, the significant increases (i.e., wind-up) in both the reflex responses and the sensations of pain observed during the higher frequency stimulation were significantly reduced after the administration of ketamine, but not placebo. This method might be useful for quantifying and analyzing the wind-up phenomenon and, thus, for studying the neurophysiological and pharmacological mechanisms underlying hyperalgesia in humans.

IMPLICATIONS

The wind-up phenomenon (i.e., the progressive increase of the responses induced by repetitive nociceptive stimuli) was characterized in humans by using electrophysiological recordings of the nociceptive flexion reflex. We showed that, as in animals, this phenomenon, which might represent an elementary form of the central sensitization involved in various painful syndromes, depends on the activation of N-methyl-D-aspartate receptors, because it was selectively reduced after the administration of ketamine.