51
|
Meeus M, Nijs J. Central sensitization: a biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clin Rheumatol 2006; 26:465-73. [PMID: 17115100 PMCID: PMC1820749 DOI: 10.1007/s10067-006-0433-9] [Citation(s) in RCA: 341] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2006] [Revised: 08/28/2006] [Accepted: 08/31/2006] [Indexed: 12/22/2022]
Abstract
In addition to the debilitating fatigue, the majority of patients with chronic fatigue syndrome (CFS) experience chronic widespread pain. These pain complaints show the greatest overlap between CFS and fibromyalgia (FM). Although the literature provides evidence for central sensitization as cause for the musculoskeletal pain in FM, in CFS this evidence is currently lacking, despite the observed similarities in both diseases. The knowledge concerning the physiological mechanism of central sensitization, the pathophysiology and the pain processing in FM, and the knowledge on the pathophysiology of CFS lead to the hypothesis that central sensitization is also responsible for the sustaining pain complaints in CFS. This hypothesis is based on the hyperalgesia and allodynia reported in CFS, on the elevated concentrations of nitric oxide presented in the blood of CFS patients, on the typical personality styles seen in CFS and on the brain abnormalities shown on brain images. To examine the present hypothesis more research is required. Further investigations could use similar protocols to those already used in studies on pain in FM like, for example, studies on temporal summation, spatial summation, the role of psychosocial aspects in chronic pain, etc.
Collapse
Affiliation(s)
- Mira Meeus
- Department of Human Physiology, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel (VUB), Brussel, Belgium
- Division of Musculoskeletal Physiotherapy, Department of Health Sciences, University College Antwerp, Antwerp, Belgium
| | - Jo Nijs
- Department of Human Physiology, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel (VUB), Brussel, Belgium
- Division of Musculoskeletal Physiotherapy, Department of Health Sciences, University College Antwerp, Antwerp, Belgium
- Department of Health Sciences, Division of Musculoskeletal Physiotherapy, Hogeschool Antwerpen (HA), Van Aertselaerstraat 31, 2170 Merksem, Belgium
| |
Collapse
|
52
|
Montoya P, Sitges C, García-Herrera M, Izquierdo R, Truyols M, Collado D. [Considerations on alterations in brain activity in patients with fibromyalgia]. REUMATOLOGIA CLINICA 2006; 2:251-260. [PMID: 21794338 DOI: 10.1016/s1699-258x(06)73056-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2005] [Accepted: 10/18/2005] [Indexed: 05/31/2023]
Abstract
Fibromyalgia is a chronic musculoskeletal pain disorder of unknown etiology, characterized by widespread pain. Clinical and experimental research has demonstrated that patients with fibromyalgia may have enhanced pain sensitivity at several points of the body, together with neuroendocrine abnormalities, and abnormal activation of pain-related brain regions. Recent data have also shown that affective and cognitive processing of pain-related information could also be disturbed in fibromyalgia. In our opinion, all these findings suggest the existence of abnormal central pain processing, which could be responsible for the persistence of chronic pain in these patients.
Collapse
Affiliation(s)
- Pedro Montoya
- Departamento de Psicología e Instituto Universitario de Investigación en Ciencias de la Salud (IUNICS). Universitat de les Illes Balears. Palma de Mallorca. España
| | | | | | | | | | | |
Collapse
|
53
|
van Vliet PM, Heneghan NR. Motor control and the management of musculoskeletal dysfunction. ACTA ACUST UNITED AC 2006; 11:208-13. [PMID: 16781184 DOI: 10.1016/j.math.2006.03.009] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2005] [Revised: 02/28/2006] [Accepted: 03/30/2006] [Indexed: 11/16/2022]
Abstract
This paper aims to develop understanding of three important motor control issues--feedforward mechanisms, cortical plasticity and task-specificity and assess the implications for musculoskeletal practice. A model of control for the reach-to-grasp movement illustrates how the central nervous system integrates sensorimotor processes to control complex movements. Feedforward mechanisms, an essential element of motor control, are altered in neurologically intact patients with chronic neck pain and low back pain. In healthy subjects, cortical mapping studies using transcranial magnetic stimulation have demonstrated that neural pathways adapt according to what and how much is practised. Neuroplasticity has also been demonstrated in a number of musculoskeletal conditions, where cortical maps are altered compared to normal. Behavioural and neurophysiological studies indicate that environmental and task constraints such as the goal of the task and an object's shape and size, are determinants of the motor schema for reaching and other movements. Consideration of motor control issues as well as signs and symptoms, may facilitate management of musculoskeletal conditions and improve outcome. Practice of entire everyday tasks at an early stage and systematic variation of the task is recommended. Training should be directed with the aim of re-educating feedforward mechanisms where necessary and the amount of practice should be sufficient to cause changes in cortical activity.
Collapse
Affiliation(s)
- Paulette M van Vliet
- School of Health Sciences, University of Birmingham, 52 Pritchatt's Road, Edgbaston B15 2TT, UK.
| | | |
Collapse
|
54
|
Sundström T, Guez M, Hildingsson C, Toolanen G, Nyberg L, Riklund K. Altered cerebral blood flow in chronic neck pain patients but not in whiplash patients: a 99mTc-HMPAO rCBF study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2006; 15:1189-95. [PMID: 16614854 PMCID: PMC3233957 DOI: 10.1007/s00586-005-0040-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2005] [Accepted: 11/30/2005] [Indexed: 10/24/2022]
Abstract
A cross-sectional study to investigate regional cerebral blood flow (rCBF) in patients with chronic whiplash syndrome and chronic neck pain patients without previous history of trauma along with a healthy control group. Chronic neck pain is a common disorder and a history of cervical spine injury including whiplash trauma constitute a risk factor for persistent neck pain. The aetiology of the late whiplash syndrome is unknown with no specific diagnostic criteria based on imaging, physiological, or psychological examination. Earlier studies indicate a parieto-occipital hypoperfusion but it is unclear if the hypoperfusion represents a response to chronic pain. The rCBF was monitored in 45 patients with chronic neck pain: 27 cases with chronic whiplash syndrome and 18 age and gender matched cases with non-traumatic chronic neck pain. The rCBF was estimated with single-photon emission computed tomography (SPECT) using technetium-99m hexamethylpropylene amine oxime (HMPAO). The non-traumatic patients displayed rCBF changes in comparison with the whiplash group and the healthy control group. These changes included rCBF decreases in a right temporal region close to hippocampus, and increased rCBF in left insula. The whiplash group displayed no significant differences in rCBF in comparison with the healthy controls. The present study suggests different pain mechanisms in patients with chronic neck pain of non-traumatic origin compared to those with chronic neck pain due to a whiplash trauma.
Collapse
Affiliation(s)
- Torbjörn Sundström
- Department of Radiation Sciences, Diagnostic Radiology, Norrlands University Hospital, Umeå University, 901 85, Umea, Sweden.
| | | | | | | | | | | |
Collapse
|
55
|
Jochims A, Ludäscher P, Bohus M, Treede RD, Schmahl C. Schmerzverarbeitung bei Borderline-Persönlichkeitsstörung, Fibromyalgie und Posttraumatischer Belastungsstörung. Schmerz 2006; 20:140-50. [PMID: 15983783 DOI: 10.1007/s00482-005-0405-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The authors review relevant experimental studies on pain perception and processing in psychiatric disorders with traumatic stress as an etiological factor. In borderline personality disorder, post-traumatic stress disorder, and fibromyalgia neurophysiological and neuropsychological patterns of pain processing appear to be different. Experimental studies in borderline patients show a desensitization of pain thresholds whereas patients with fibromyalgia show an opposite pattern, which could be explained by a central augmentation of pain processing. Furthermore, the authors outline methods to assess pain perception (peripheral and central) and describe the neurobiological mechanisms of pain processing, particularly the distinction between the sensory-discriminative lateral system and the affective-motivational medial system. Finally, suggestions for further research and implications for therapy are proposed.
Collapse
Affiliation(s)
- A Jochims
- Klinik für Psychosomatik und Psychotherapeutische Medizin, Zentralinstitut für Seelische Gesundheit Mannheim
| | | | | | | | | |
Collapse
|
56
|
Farrell MJ, Laird AR, Egan GF. Brain activity associated with painfully hot stimuli applied to the upper limb: a meta-analysis. Hum Brain Mapp 2005; 25:129-39. [PMID: 15846813 PMCID: PMC6871740 DOI: 10.1002/hbm.20125] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The capacity of pain to alert against potential injury or focus attention on damaged tissue is enhanced by the intrinsically aversive nature of the experience. Finding methods to relieve pain will ultimately be facilitated by deeper understanding of the processes that contribute to the experience, and functional brain imaging has contributed substantially toward that end. An impressive body of literature has identified a distributed network of pain-related activity in the brain that is subject to considerable modulation by different stimulus parameters, contextual factors, and clinical conditions. The fundamental substrates of the pain network are yet to be distilled from the highly variable results of studies published thus far. Qualitative reviews of the pain-imaging literature have been contributory, but lack the greater surety of quantitative methods. We employ the activation likelihood estimation (ALE) meta-analytic technique to establish the most consistent activations among studies reporting brain responses subsequent to the application of noxious heat. A network of pain-related activity was replicated for stimuli to either upper limb that included two discernible regions of the mid-anterior cingulate cortex, bilateral thalami, insula, and opercula cortices, posterior parietal cortex, premotor cortex, supplementary motor area, and cerebellum. The findings of the meta-analysis resonate with other streams of information that continue to enhance our understanding of pain in the brain. The results also point toward new areas of research that may be fruitful for the exploration of central pain processing.
Collapse
Affiliation(s)
- Michael J Farrell
- Howard Florey Institute, University of Melbourne, Melbourne, Australia.
| | | | | |
Collapse
|
57
|
Abstract
Neuropathic pain is defined as a chronic pain condition that occurs or persists after a primary lesion or dysfunction of the peripheral or central nervous system. Traumatic injury of peripheral nerves also increases the excitability of nociceptors in and around nerve trunks and involves components released from nerve terminals (neurogenic inflammation) and immunological and vascular components from cells resident within or recruited into the affected area. Action potentials generated in nociceptors and injured nerve fibers release excitatory neurotransmitters at their synaptic terminals such as L-glutamate and substance P and trigger cellular events in the central nervous system that extend over different time frames. Short-term alterations of neuronal excitability, reflected for example in rapid changes of neuronal discharge activity, are sensitive to conventional analgesics, and do not commonly involve alterations in activity-dependent gene expression. Novel compounds and new regimens for drug treatment to influence activity-dependent long-term changes in pain transducing and suppressive systems (pain matrix) are emerging.
Collapse
Affiliation(s)
- Walter Zieglgänsberger
- Department of Clinical Neuropharmacology, Max Planck Institute of Psychiatry, Kraepelinstrasse 2, 80804 Munich, Germany.
| | | | | |
Collapse
|
58
|
Apkarian AV, Bushnell MC, Treede RD, Zubieta JK. Human brain mechanisms of pain perception and regulation in health and disease. Eur J Pain 2005; 9:463-84. [PMID: 15979027 DOI: 10.1016/j.ejpain.2004.11.001] [Citation(s) in RCA: 2078] [Impact Index Per Article: 109.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2004] [Accepted: 11/02/2004] [Indexed: 12/31/2022]
Abstract
CONTEXT The perception of pain due to an acute injury or in clinical pain states undergoes substantial processing at supraspinal levels. Supraspinal, brain mechanisms are increasingly recognized as playing a major role in the representation and modulation of pain experience. These neural mechanisms may then contribute to interindividual variations and disabilities associated with chronic pain conditions. OBJECTIVE To systematically review the literature regarding how activity in diverse brain regions creates and modulates the experience of acute and chronic pain states, emphasizing the contribution of various imaging techniques to emerging concepts. DATA SOURCES MEDLINE and PRE-MEDLINE searches were performed to identify all English-language articles that examine human brain activity during pain, using hemodynamic (PET, fMRI), neuroelectrical (EEG, MEG) and neurochemical methods (MRS, receptor binding and neurotransmitter modulation), from January 1, 1988 to March 1, 2003. Additional studies were identified through bibliographies. STUDY SELECTION Studies were selected based on consensus across all four authors. The criteria included well-designed experimental procedures, as well as landmark studies that have significantly advanced the field. DATA SYNTHESIS Sixty-eight hemodynamic studies of experimental pain in normal subjects, 30 in clinical pain conditions, and 30 using neuroelectrical methods met selection criteria and were used in a meta-analysis. Another 24 articles were identified where brain neurochemistry of pain was examined. Technical issues that may explain differences between studies across laboratories are expounded. The evidence for and the respective incidences of brain areas constituting the brain network for acute pain are presented. The main components of this network are: primary and secondary somatosensory, insular, anterior cingulate, and prefrontal cortices (S1, S2, IC, ACC, PFC) and thalamus (Th). Evidence for somatotopic organization, based on 10 studies, and psychological modulation, based on 20 studies, is discussed, as well as the temporal sequence of the afferent volley to the cortex, based on neuroelectrical studies. A meta-analysis highlights important methodological differences in identifying the brain network underlying acute pain perception. It also shows that the brain network for acute pain perception in normal subjects is at least partially distinct from that seen in chronic clinical pain conditions and that chronic pain engages brain regions critical for cognitive/emotional assessments, implying that this component of pain may be a distinctive feature between chronic and acute pain. The neurochemical studies highlight the role of opiate and catecholamine transmitters and receptors in pain states, and in the modulation of pain with environmental and genetic influences. CONCLUSIONS The nociceptive system is now recognized as a sensory system in its own right, from primary afferents to multiple brain areas. Pain experience is strongly modulated by interactions of ascending and descending pathways. Understanding these modulatory mechanisms in health and in disease is critical for developing fully effective therapies for the treatment of clinical pain conditions.
Collapse
Affiliation(s)
- A Vania Apkarian
- Department of Physiology, Northwestern University Medical School, 303 E. Chicago Avenue, Ward 5-003, Chicago, IL 60611, USA.
| | | | | | | |
Collapse
|
59
|
Abstract
The purpose of this article is to summarise how functional imaging techniques have changed our understanding of normal and abnormal pain mechanisms, how they inform a change in clinical practice and to speculate on possible future clinical uses.
Collapse
Affiliation(s)
- A K P Jones
- Human Pain Research Group, University of Manchester Rheumatic Diseases Centre, Hope Hospital, Salford, UK
| | | | | |
Collapse
|
60
|
Laureys S, Faymonville ME, Peigneux P, Damas P, Lambermont B, Del Fiore G, Degueldre C, Aerts J, Luxen A, Franck G, Lamy M, Moonen G, Maquet P. Cortical processing of noxious somatosensory stimuli in the persistent vegetative state. Neuroimage 2002. [PMID: 12377148 DOI: 10.1006/nimg.2002.1236] [Citation(s) in RCA: 201] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The persistent vegetative state (PVS) is a devastating medical condition characterized by preserved wakefulness contrasting with absent voluntary interaction with the environment. We used positron emission tomography to assess the central processing of noxious somatosensory stimuli in the PVS. Changes in regional cerebral blood flow were measured during high-intensity electrical stimulation of the median nerve compared with rest in 15 nonsedated patients and in 15 healthy controls. Evoked potentials were recorded simultaneously. The stimuli were experienced as highly unpleasant to painful in controls. Brain glucose metabolism was also studied with [(18)F]fluorodeoxyglucose in resting conditions. In PVS patients, overall cerebral metabolism was 40% of normal values. Nevertheless, noxious somatosensory stimulation-activated midbrain, contralateral thalamus, and primary somatosensory cortex in each and every PVS patient, even in the absence of detectable cortical evoked potentials. Secondary somatosensory, bilateral insular, posterior parietal, and anterior cingulate cortices did not show activation in any patient. Moreover, in PVS patients, the activated primary somatosensory cortex was functionally disconnected from secondary somatosensory, bilateral posterior parietal, premotor, polysensory superior temporal, and prefrontal cortices. In conclusion, somatosensory stimulation of PVS patients, at intensities that elicited pain in controls, resulted in increased neuronal activity in primary somatosensory cortex, even if resting brain metabolism was severely impaired. However, this activation of primary cortex seems to be isolated and dissociated from higher-order associative cortices.
Collapse
Affiliation(s)
- S Laureys
- Cyclotron Research Center, University of Liège B30, Department of Neurology, CHU B35, Sart Tilman, 4000 Liège, Belgium.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
61
|
Derbyshire SWG, Jones AKP, Creed F, Starz T, Meltzer CC, Townsend DW, Peterson AM, Firestone L. Cerebral responses to noxious thermal stimulation in chronic low back pain patients and normal controls. Neuroimage 2002; 16:158-68. [PMID: 11969326 DOI: 10.1006/nimg.2002.1066] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Changes in regional cerebral blood flow (rCBF) have previously been demonstrated in a number of cortical and subcortical regions, including the cerebellum, midbrain, thalamus, lentiform nucleus, and the insula, prefrontal, anterior cingulate, and parietal cortices, in response to experimental noxious stimuli. Increased anterior cingulate responses in patients with chronic regional pain and depression to noxious stimulation distant from the site of clinical pain have been observed. We suggested that this may represent a generalized hyperattentional response to noxious stimuli and may apply to other types of chronic regional pain. Here these techniques are extended to a group of patients with nonspecific chronic low back pain. Thirty-two subjects, 16 chronic low back pain patients and 16 controls, were studied using positron emission tomography. Thermal stimuli, corresponding to the experience of hot, mild, and moderate pain, were delivered to the back of the subject's right hand using a thermal probe. Each subject had 12 measurements of rCBF, 4 for each stimulus. Correlation of rCBF with subjective pain experience revealed similar responses across groups in the cerebellum, midbrain (including the PAG), thalamus, insula, lentiform nucleus, and midcingulate (area 24') cortex. These regions represented the majority of activations for this study and those recorded by other imaging studies of pain. Although some small differences were observed between the groups these were not considered sufficient to suggest abnormal nociceptive processing in patients with nonspecific low back pain.
Collapse
Affiliation(s)
- S W G Derbyshire
- Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, 15213, USA
| | | | | | | | | | | | | | | |
Collapse
|
62
|
Gracely RH, Petzke F, Wolf JM, Clauw DJ. Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. ARTHRITIS AND RHEUMATISM 2002; 46:1333-43. [PMID: 12115241 DOI: 10.1002/art.10225] [Citation(s) in RCA: 805] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To use functional magnetic resonance imaging (fMRI) to evaluate the pattern of cerebral activation during the application of painful pressure and determine whether this pattern is augmented in patients with fibromyalgia (FM) compared with controls. METHODS Pressure was applied to the left thumbnail beds of 16 right-handed patients with FM and 16 right-handed matched controls. Each FM patient underwent fMRI while moderately painful pressure was being applied. The functional activation patterns in FM patients were compared with those in controls, who were tested under 2 conditions: the "stimulus pressure control" condition, during which they received an amount of pressure similar to that delivered to patients, and the "subjective pain control" condition, during which the intensity of stimulation was increased to deliver a subjective level of pain similar to that experienced by patients. RESULTS Stimulation with adequate pressure to cause similar pain in both groups resulted in 19 regions of increased regional cerebral blood flow in healthy controls and 12 significant regions in patients. Increased fMRI signal occurred in 7 regions common to both groups, and decreased signal was observed in 1 common region. In contrast, stimulation of controls with the same amount of pressure that caused pain in patients resulted in only 2 regions of increased signal, neither of which coincided with a region of activation in patients. Statistical comparison of the patient and control groups receiving similar stimulus pressures revealed 13 regions of greater activation in the patient group. In contrast, similar stimulus pressures produced only 1 region of greater activation in the control group. CONCLUSION The fact that comparable subjectively painful conditions resulted in activation patterns that were similar in patients and controls, whereas similar pressures resulted in no common regions of activation and greater effects in patients, supports the hypothesis that FM is characterized by cortical or subcortical augmentation of pain processing.
Collapse
Affiliation(s)
- Richard H Gracely
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, Maryland, USA
| | | | | | | |
Collapse
|
63
|
Brooks JCW, Nurmikko TJ, Bimson WE, Singh KD, Roberts N. fMRI of thermal pain: effects of stimulus laterality and attention. Neuroimage 2002; 15:293-301. [PMID: 11798266 DOI: 10.1006/nimg.2001.0974] [Citation(s) in RCA: 284] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Brain activity was studied by fMRI in 18 healthy subjects during stimulation of the thenar eminence of the hand with either warm (non-painful, 40 degrees C) or hot (painful, 46-49 degrees C) stimuli using a contact thermode. Experiments were performed on the right and left hand independently and with two attentional contexts: subjects either attended to pain or attended to a visual global motion discrimination task (to distract them from pain). Group analysis demonstrated that attended warm stimulation of the right hand did not produce any significantly activated clusters. Painful thermal stimulation of either hand elicited significant activity over a large network of brain regions, including insula, inferior frontal gyrus, cingulate gyrus, secondary somatosensory cortex, cerebellum, and medial frontal gyrus (corrected P < 0.05). Insula activity was distributed along its anterior-posterior axis and depended on the hand stimulated and attentional context. In particular, activity within the posterior insula was contralateral to the site of stimulation, tested using regions of interest (ROI) analysis: significant side x site interaction (P = 0.001). With attention diverted from the painful stimulus bilateral anterior insula activity moved posteriorly to midinsula and decreased in extent (ROI analysis: significant main effect of attention (P = 0.03)). The role of the insula in thermosensation and attention is discussed.
Collapse
Affiliation(s)
- Jonathan C W Brooks
- Pain Research Institute, Clinical Sciences Centre, Lower Lane, Liverpool, L9 7AL, United Kingdom
| | | | | | | | | |
Collapse
|
64
|
Naliboff BD, Derbyshire SW, Munakata J, Berman S, Mandelkern M, Chang L, Mayer EA. Cerebral activation in patients with irritable bowel syndrome and control subjects during rectosigmoid stimulation. Psychosom Med 2001; 63:365-75. [PMID: 11382264 DOI: 10.1097/00006842-200105000-00006] [Citation(s) in RCA: 228] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Patients with irritable bowel syndrome (IBS) show evidence of altered perceptual responses to visceral stimuli, consistent with altered processing of visceral afferent information by the brain. In the current study, brain responses to anticipated and delivered rectal balloon distension were assessed. METHODS Changes in regional cerebral blood flow were measured using H2(15)O-water positron emission tomography in 12 nonconstipated IBS patients and 12 healthy control subjects. Regional cerebral blood flow responses to moderate rectal distension (45 mm Hg) and anticipated but undelivered distension were assessed before and after a series of repetitive noxious (60-mm Hg) sigmoid distensions. RESULTS Brain regions activated by actual and simulated distensions were similar in both groups. Compared with control subjects, patients with IBS showed lateralized activation of right prefrontal cortex; reduced activation of perigenual cortex, temporal lobe, and brain stem; but enhanced activation of rostral anterior cingulate and posterior cingulate cortices. CONCLUSIONS IBS patients show altered brain responses to rectal stimuli, regardless of whether these stimuli are actually delivered or simply anticipated. These alterations are consistent with reported alterations in autonomic and perceptual responses and may be related to altered central noradrenergic modulation.
Collapse
Affiliation(s)
- B D Naliboff
- CURE Digestive Diseases Research Center/Neuroenteric Disease Program, University of California School of Medicine, VA Greater Los Angeles Health Care System, 90073, USA.
| | | | | | | | | | | | | |
Collapse
|
65
|
Abstract
A considerable number of functional imaging studies have demonstrated the involvement of multiple central regions during the experience of pain. These regions process information in circuits that can broadly be assumed to process the affective, sensory, cognitive, motor, inhibitory, and autonomic responses stimulated by a noxious event. The concept of a "neuromatrix" for pain processing is, therefore, well supported. There is, however, scant evidence for any particular regional or circuit dysfunction during clinical pain. To be clinically useful, functional imaging may have to step beyond the generalities of the neuromatrix.
Collapse
Affiliation(s)
- S W Derbyshire
- University of Pittsburgh Medical Center, PET Facility, B-938 PUH, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
| |
Collapse
|
66
|
Apkarian AV, Krauss BR, Fredrickson BE, Szeverenyi NM. Imaging the pain of low back pain: functional magnetic resonance imaging in combination with monitoring subjective pain perception allows the study of clinical pain states. Neurosci Lett 2001; 299:57-60. [PMID: 11166937 DOI: 10.1016/s0304-3940(01)01504-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Most brain imaging studies of pain are done using a two-state subtraction design (state-related design). More recently event-related functional magnetic reasonance imaging (fMRI) has also been used for studying pain. Both designs severely limit the application of the technology to clinical pain states. Recently we demonstrated that monitoring time fluctuations of perceived pain could be used with fMRI to identify brain regions involved in conscious, subjective perception of pain. Here we extend the methodology to demonstrate that the same approach can be used to study clinical pain states. Subjects are equipped with a finger-spanning device to continuously rate and log their perceived pain during fMRI data collection. These ratings are convolved with a canonical hemodynamic response function to generate predictor waveforms with which related brain activity can be identified. Chronic low back pain patients and a normal volunteer were used. In one series of fMRI scans the patient simply lies in the scanner and indicates spontaneous fluctuations of the subjective pain. In other fMRI scans, a straight-leg raising procedure is performed to exacerbate the back pain. In the normal volunteer, fMRI scans were done during painful and non-painful straight-leg raisings. The results indicate the feasibility of differentiating between different pain states. We argue that the approach can be generalized to identify brain circuitry underlying diverse clinical pain conditions.
Collapse
Affiliation(s)
- A V Apkarian
- Department of Physiology, Northwestern University Medical School, 303 East Chicago Avenue, Chicago, IL 60611, USA.
| | | | | | | |
Collapse
|
67
|
Peyron R, Laurent B, García-Larrea L. Functional imaging of brain responses to pain. A review and meta-analysis (2000). Neurophysiol Clin 2000; 30:263-88. [PMID: 11126640 DOI: 10.1016/s0987-7053(00)00227-6] [Citation(s) in RCA: 1530] [Impact Index Per Article: 63.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Brain responses to pain, assessed through positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) are reviewed. Functional activation of brain regions are thought to be reflected by increases in the regional cerebral blood flow (rCBF) in PET studies, and in the blood oxygen level dependent (BOLD) signal in fMRI. rCBF increases to noxious stimuli are almost constantly observed in second somatic (SII) and insular regions, and in the anterior cingulate cortex (ACC), and with slightly less consistency in the contralateral thalamus and the primary somatic area (SI). Activation of the lateral thalamus, SI, SII and insula are thought to be related to the sensory-discriminative aspects of pain processing. SI is activated in roughly half of the studies, and the probability of obtaining SI activation appears related to the total amount of body surface stimulated (spatial summation) and probably also by temporal summation and attention to the stimulus. In a number of studies, the thalamic response was bilateral, probably reflecting generalised arousal in reaction to pain. ACC does not seem to be involved in coding stimulus intensity or location but appears to participate in both the affective and attentional concomitants of pain sensation, as well as in response selection. ACC subdivisions activated by painful stimuli partially overlap those activated in orienting and target detection tasks, but are distinct from those activated in tests involving sustained attention (Stroop, etc.). In addition to ACC, increased blood flow in the posterior parietal and prefrontal cortices is thought to reflect attentional and memory networks activated by noxious stimulation. Less noted but frequent activation concerns motor-related areas such as the striatum, cerebellum and supplementary motor area, as well as regions involved in pain control such as the periaqueductal grey. In patients, chronic spontaneous pain is associated with decreased resting rCBF in contralateral thalamus, which may be reverted by analgesic procedures. Abnormal pain evoked by innocuous stimuli (allodynia) has been associated with amplification of the thalamic, insular and SII responses, concomitant to a paradoxical CBF decrease in ACC. It is argued that imaging studies of allodynia should be encouraged in order to understand central reorganisations leading to abnormal cortical pain processing. A number of brain areas activated by acute pain, particularly the thalamus and anterior cingulate, also show increases in rCBF during analgesic procedures. Taken together, these data suggest that hemodynamic responses to pain reflect simultaneously the sensory, cognitive and affective dimensions of pain, and that the same structure may both respond to pain and participate in pain control. The precise biochemical nature of these mechanisms remains to be investigated.
Collapse
Affiliation(s)
- R Peyron
- Département de neurologie, hôpital de Bellevue, boulevard Pasteur, 42055 Saint-Etienne, France
| | | | | |
Collapse
|
68
|
Abstract
Functional imaging of the brain is a current reality using positron emission tomography and functional magnetic imaging. This article reviews many of the reports that have emerged in the past several years using these techniques in the analysis of pain experience. The areas of the brain that appear to be functioning during the experience of pain are discussed, and the variances in findings between studies are described. The implications of the findings are noted. Although much has been learned through these techniques, it is clear that further research is needed before clinicians can use these diagnostic studies for therapeutic purposes.
Collapse
|
69
|
Derbyshire SW. Meta-Analysis of Thirty-Four Independent Samples Studied Using PET Reveals a Significantly Attenuated Central Response to Noxious Stimulation in Clinical Pain Patients. CURRENT REVIEW OF PAIN 2000; 3:265-280. [PMID: 10998682 DOI: 10.1007/s11916-999-0044-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Chronic pain disorder is widely understood as a "biopsychosocial" phenomenon, meaning that it is influenced by psychology and certain life events. This broad understanding of chronic pain suggests that central responses during pain experience should be altered in patients compared with pain-free volunteers. A total of 34 studies are reviewed, revealing a widespread "neuromatrix" of activated regions. These regions include the brain stem, thalamus, and lentiform nucleus, and the insula, prefrontal, parietal, and anterior cingulate cortices. Meta-analysis of these studies does not reveal any single region or pattern of activity to be of particular influence during chronic pain but does reveal a generally reduced response to noxious stimulation in patients with concomitant clinical pain. The relevance of this finding remains unclear with the most parsimonious explanation being increased response variability in patients. More specific findings can be revealed when using a hypothesis-generated approach; further investigation of genetic and developmental predisposition is suggested.
Collapse
Affiliation(s)
- SW Derbyshire
- UCLA/CURE Neuroenteric Disease Program, WLA VAMC, Building 115, Room 223, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA
| |
Collapse
|
70
|
Ladabaum U, Minoshima S, Owyang C. Pathobiology of visceral pain: molecular mechanisms and therapeutic implications V. Central nervous system processing of somatic and visceral sensory signals. Am J Physiol Gastrointest Liver Physiol 2000; 279:G1-6. [PMID: 10898740 DOI: 10.1152/ajpgi.2000.279.1.g1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Somatic and visceral sensation, including pain perception, can be studied noninvasively in humans with functional brain imaging techniques. Positron emission tomography and functional magnetic resonance imaging have identified a series of cerebral regions involved in the processing of somatic pain, including the anterior cingulate, insular, prefrontal, inferior parietal, primary and secondary somatosensory, and primary motor and premotor cortices, the thalamus, hypothalamus, brain stem, and cerebellum. Experimental evidence supports possible specific roles for individual structures in processing the various dimensions of pain, such as encoding of affect in the anterior cingulate cortex. Visceral sensation has been examined in the setting of myocardial ischemia, distension of hollow viscera, and esophageal acidification. Although knowledge regarding somatic sensation is more extensive than the information available for visceral sensation, important similarities have emerged between cerebral representations of somatic and visceral pain.
Collapse
Affiliation(s)
- U Ladabaum
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco 94143-0538, USA
| | | | | |
Collapse
|
71
|
Bradley LA, McKendree-Smith NL, Alberts KR, Alarcón GS, Mountz JM, Deutsch G. Use of neuroimaging to understand abnormal pain sensitivity in fibromyalgia. Curr Rheumatol Rep 2000; 2:141-8. [PMID: 11123051 DOI: 10.1007/s11926-000-0054-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This paper examines the use of neuroimaging to measure change in regional cerebral blood flow (rCBF) produced by pain in patients with fibromyalgia and in healthy individuals. Fibromyalgia patients differ from healthy persons in rCBF distribution in several brain structures involved in pain processing and pain modulation both at rest and during experimental pain induction. These abnormalities may contribute to abnormal pain sensitivity as well as the maladaptive pain behaviors that characterize many patients with fibromyalgia. We anticipate that future neuroimaging studies will enhance our understanding of abnormal pain sensitivity and of pain management interventions aimed at altering central nervous system function in patients with fibromyalgia.
Collapse
Affiliation(s)
- L A Bradley
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, BDB 475, 1808 7th Ave S, Birmingham, Alabama 35294-0012.
| | | | | | | | | | | |
Collapse
|
72
|
Neto FL, Schadrack J, Ableitner A, Castro-Lopes JM, Bartenstein P, Zieglgänsberger W, Tölle TR. Supraspinal metabolic activity changes in the rat during adjuvant monoarthritis. Neuroscience 1999; 94:607-21. [PMID: 10579221 DOI: 10.1016/s0306-4522(99)00185-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Pain is a multi-dimensional experience including sensory-discriminative and affective-motivational components. The attribution of such components to a corresponding cerebral neuronal substrate in the brain refers to conclusions drawn from electrical brain stimulation, lesion studies, topographic mappings and metabolic imaging. Increases in neuronal metabolic activity in supraspinal brain regions, suggested to be involved in the central processing of pain, have previously been shown in various animal studies. The present investigation is the first to describe supraspinal structures which show increased metabolic activity during ongoing monoarthritic pain at multiple time-points. Experimental chronic monoarthritis of a hindlimb induced by complete Freund's adjuvant is one of the most used models in studies of neuronal plasticity associated with chronic pain. Such animals show typical symptoms of hyperalgesia and allodynia for a prolonged period. Metabolic activity changes in supraspinal brain regions during monoarthritis were assessed using the quantitative [14C]-2deoxyglucose technique at two, four, 14 days of the disease and, furthermore, in a group of 14-day monoarthritic rats which were mechanically stimulated by repeated extensions of the inflamed joint. Local glucose utilization was determined ipsi- and contralateral to the arthritic hindpaw in more than 50 brain regions at various supraspinal levels, and compared with saline-injected controls. At two and 14 days of monoarthritis significant bilateral increases in glucose utilization were seen in many brain structures, including brainstem, thalamic, limbic and cortical regions. Within the brainstem, animals with 14-day monoarthritis showed a higher number of regions with increased metabolic activity compared with two days. No differences between ipsi- and contralateral sides were detected in any of the experimental groups. Average increases ranged from 20 to 40% compared with controls and maximum values were detected in specific brain regions, such as the anterior pretectal nucleus, the anterior cingulate cortex and the nucleus accumbens. Interestingly, at four days of monoarthritis, the glucose utilization values were in the control range in almost all regions studied. Moreover, in monoarthritic rats receiving an additional noxious mechanical stimulation, the rates of glucose utilization were also comparable to controls in all brain areas investigated. Such patterns of brain metabolic activity agreed with concomitant changes in the lumbar spinal cord, described in the accompanying report. The present data show that a large array of supraspinal structures displays elevated metabolic activity during painful monoarthritis, with a non-linear profile for the time-points investigated. This observation most probably reflects mechanisms of transmission and modulation of nociceptive input arising from the monoarthritis and accompanying its development.
Collapse
Affiliation(s)
- F L Neto
- Institute of Histology and Embryology and IBMC, Faculty of Medicine of Oporto, Porto, Portugal
| | | | | | | | | | | | | |
Collapse
|
73
|
Jones AK, Kitchen ND, Watabe H, Cunningham VJ, Jones T, Luthra SK, Thomas DG. Measurement of changes in opioid receptor binding in vivo during trigeminal neuralgic pain using [11C] diprenorphine and positron emission tomography. J Cereb Blood Flow Metab 1999; 19:803-8. [PMID: 10413036 DOI: 10.1097/00004647-199907000-00011] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The binding of [11C]diprenorphine to mu, kappa, and delta subsites in cortical and subcortical structures was measured by positron emission tomography in vivo in six patients before and after surgical relief of trigeminal neuralgia pain. The volume of distribution of [11C]diprenorphine binding was significantly increased after thermocoagulation of the relevant trigeminal division in the following areas: prefrontal, insular, perigenual, mid-cingulate and inferior parietal cortices, basal ganglia, and thalamus bilaterally. In addition to the pain relief associated with the surgical procedure, there also was an improvement in anxiety and depression scores. In the context of other studies, these changes in binding most likely resulted from the change in the pain state. The results suggest an increased occupancy by endogenous opioid peptides during trigeminal pain but cannot exclude coexistent down-regulation of binding sites.
Collapse
Affiliation(s)
- A K Jones
- Human Physiology and Pain Research Laboratory, University of Manchester Rheumatic Diseases Centre, Hope Hospital, Salford, United Kingdom
| | | | | | | | | | | | | |
Collapse
|
74
|
Cerebral responses to pain in patients suffering acute post-dental extraction pain measured by positron emission tomography (PET). Eur J Pain 1999; 3:103-113. [PMID: 10700340 DOI: 10.1053/eujp.1998.0102] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Previous studies with normal volunteers have demonstrated distributed cortical responses to experimental heat pain within a network of structures. The network includes the insula, anterior cingulate, prefrontal, inferior parietal and somatosensory cortices. Patients suffering from chronic nociceptive pain following rheumatoid arthritis (RA) have shown damped central responses to experimental heat pain applied to the back of the right hand. In this study of patients with acute, left-sided, post-molar-extraction (surgical) pain, we assessed the cortical responses to experimental heat pain, applied to the back of the right hand, using positron emission tomography (PET), and compared the responses with a previously reported control group and the RA group. In response to the experimental heat pain, the surgical group indicated significantly increased regional cerebral blood flow in the prefrontal cortex [Brodman's area (BA) 44] ipsilateral to the heat stimulus. Contralateral increases were detected in the putamen and transverse temporal gyrus (BA 40/41/42) with bilateral increases in the insular cortex. Compared to the control and RA group, there were significantly reduced responses in the anterior cingulate (BA 24), pre-frontal medial, and orbito-frontal (BA 9/10/32/47) cortices. These results suggest that relatively discrete regions of the cerebral cortex are responsible for acute nociceptive processing during an acute inflammatory episode. The reduced frontal and anterior cingulate responses to the experimental heat pain (applied to the right hand) during acute inflammatory pain (left jaw) illustrates cortical modulation of nociceptive processing that may be related to non-somatotopic, bilateral, nociceptive inputs to these areas. Copyright 1999 European Federation of Chapters of the International Association for the Study of Pain.
Collapse
|
75
|
Jones AK. The contribution of functional imaging techniques to our understanding of rheumatic pain. Rheum Dis Clin North Am 1999; 25:123-52. [PMID: 10083962 DOI: 10.1016/s0889-857x(05)70058-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The main cerebral components of the human pain matrix have been defined using functional imaging techniques. The experience of pain is likely to be elaborated as a result of parallel processing within this matrix. There is not, therefore, a single pain center. The determinants of pain are as likely to be determined by top-down as by bottom-up processes. The precise function of the different components of the matrix are just beginning to be defined. There appear to be important adaptive responses in the forebrain components of the matrix during arthritic pain. Endogenous opioid peptides are strong candidates for the modulation of some of these responses. More extensive and sequential behavioral and functional imaging studies are required to establish the contribution these adaptive responses make to the perception of pain.
Collapse
Affiliation(s)
- A K Jones
- Human Physiology and Pain Research Laboratory, University of Manchester Rheumatic Diseases Centre, Hope Hospital, Salford, United Kingdom
| |
Collapse
|