A multisensory investigation of the functional significance of the "pain matrix"

Painful legs and moving toes syndrome evaluated through brain single photon emission computed tomography: a case series

Painful legs and moving toes (PLMT) syndrome is a clinical entity characterized by persistent pain in the feet or legs and involuntary movements of one or more toes. The precise patho-mechanisms of PLMT still remain unknown. Herein, we examined ten patients clinically identified with PLMT syndrome. All patients first presented persistent pain prior to the onset of motor symptoms. Each patient was examined by neurological investigation, neuro-imaging methods including brain magnetic resonance imaging (MRI) and electrophysiological methods. The brain single photon emission computed tomography (SPECT) images of eight patients indicated hypoperfusion of frontal lobes and cerebellum. The conjunction analysis of brain SPECT imaging data of all eight patients, using the 3D-SSP program, compared to 34 controls indicated significant hypoperfusion in the prefrontal cortical, occipital cortical, and cerebellar surfaces, and thalamus, and hyperperfusion in the surface of the anterior cingulate gyrus and parietal cortices including primary and secondary somatosensory cortices, bilaterally. These areas reflected on a part of the pain matrix. Other electrophysiological examinations did not indicate specific abnormalities to explain the patients' symptoms. On treatment with clonazepam, four out of nine patients could resolve their foot-related motor symptoms, but not the sensory symptoms. Overall, their pain was an intractable and persistent symptom throughout their clinical course. Our study infers that PLMT syndrome is fundamentally a chronic pain disorder, possibly relating to the central sensitization, involving the region of a part of pain matrix. Further studies need to confirm our results by adding more patients.

Neural indicators of perceptual variability of pain across species

While several features of brain activity can be used to predict the variability of painful percepts within a given individual, it is much more difficult to predict pain variability across individuals. Here, we used electrophysiology to sample brain activity of humans and rodents, and demonstrated that laser-induced gamma oscillations sampled by central electrodes predict pain sensitivity across individuals both reliably and selectively: reliably, because they consistently predict between-subject pain intensity in both humans and rodents; selectively, because they do not track the between-subject reported intensity of nonpainful but equally salient auditory, visual, and nonnociceptive somatosensory stimuli. This discovery indicates that variability in an individual’s pain sensitivity is, at least partly, explained by variability in the amplitude of gamma oscillations of that individual.

Individuals exhibit considerable and unpredictable variability in painful percepts in response to the same nociceptive stimulus. Previous work has found neural responses that, while not necessarily responsible for the painful percepts themselves, can still correlate well with intensity of pain perception within a given individual. However, there is no reliable neural response reflecting the variability in pain perception across individuals. Here, we use an electrophysiological approach in humans and rodents to demonstrate that brain oscillations in the gamma band [gamma-band event-related synchronization (γ-ERS)] sampled by central electrodes reliably predict pain sensitivity across individuals. We observed a clear dissociation between the large number of neural measures that reflected subjective pain ratings at within-subject level but not across individuals, and γ-ERS, which reliably distinguished subjective ratings within the same individual but also coded pain sensitivity across different individuals. Importantly, the ability of γ-ERS to track pain sensitivity across individuals was selective because it did not track the between-subject reported intensity of nonpainful but equally salient auditory, visual, and nonnociceptive somatosensory stimuli. These results also demonstrate that graded neural activity related to within-subject variability should be minimized to accurately investigate the relationship between nociceptive-evoked neural activities and pain sensitivity across individuals.

Tinnitus and neuropathic pain share a common neural substrate in the form of specific brain connectivity and microstate profiles

Tinnitus and neuropathic pain share similar pathophysiological, clinical, and treatment characteristics. In this EEG study, a group of tinnitus (n = 100) and neuropathic pain (n = 100) patients are compared to each other and to a healthy control group (n = 100). Spectral analysis demonstrates gamma band activity within the primary auditory and somatosensory cortices in patients with tinnitus and neuropathic pain, respectively. A conjunction analysis further demonstrates an overlap of tinnitus and pain related activity in the anterior and posterior cingulate cortex as well as in the dorsolateral prefrontal cortex in comparison to healthy controls. Further analysis reveals that similar states characterize tinnitus and neuropathic pain patients, two of which differ from the healthy group and two of which are shared. Both pain and tinnitus patients spend half of the time in one specific microstate. Seed-based functional connectivity with the source within the predominant microstate shows delta, alpha1, and gamma lagged phase synchronization overlap with multiple brain areas between pain and tinnitus. These data suggest that auditory and somatosensory phantom perceptions share an overlapping brain network with common activation and connectivity patterns and are differentiated by specific sensory cortex gamma activation.

Employing pain and mindfulness to understand consciousness: a symbiotic relationship

Consciousness, defined here as the quality of awareness of self and the corresponding sensory environment, is considered to be one of most enigmatic and contentious areas of scholarly dissection and investigation. The subjective experience of pain is constructed and modulated by a myriad of sensory, cognitive and affective dimensions. Thus, the study of pain can provide many inroads to a concept like consciousness that the traditional sense modalities do not. Mindfulness defined here as non-reactive awareness of the present moment, can uniquely control and/or modulate particular substrates of conscious experience. Thus, in combination with brain imaging methodologies, we propose that the interactions between pain and mindfulness could serve as a more comprehensive platform to disentangle the biological and psychological substrates of conscious experience. The present review provides a brief synopsis on how combining the study of pain and mindfulness can inform the study of consciousness, delineates the multiple, unique brain mechanisms supporting mindfulness-based pain relief, and describes how mindfulness uniquely improves the affective dimension of pain, an important consideration for the treatment of chronic pain.

The intranasal trigeminal system

Many odors activate the intranasal chemosensory trigeminal system where they produce cooling and other somatic sensations such as tingling, burning, or stinging. Specific trigeminal receptors are involved in the mediation of these sensations. Importantly, the trigeminal system also mediates sensitivity to airflow. The intranasal trigeminal and the olfactory system are closely connected. With regard to central nervous processing, it is most interesting that trigeminal stimuli can activate the piriform cortex, which is typically viewed as the primary olfactory cortex. This suggests that interactions between the two systems may form at a relatively early stage of processing. For example, there is evidence showing that acquired olfactory loss leads to reduced trigeminal sensitivity, probably on account of the lack of interaction in the central nervous system. Decreased trigeminal sensitivity may also be responsible for changes in airflow perception, leading to the impression of congested nasal airways.

The Contribution of Endogenous Modulatory Systems to TMS- and tDCS-Induced Analgesia: Evidence from PET Studies

Chronic pain is an important public health issue. Moreover, its adequate management is still considered a major clinical problem, mainly due to its incredible complexity and still poorly understood pathophysiology. Recent scientific evidence coming from neuroimaging research, particularly functional magnetic resonance (fMRI) and positron emission tomography (PET) studies, indicates that chronic pain is associated with structural and functional changes in several brain structures that integrate antinociceptive pathways and endogenous modulatory systems. Furthermore, the last two decades have witnessed a huge increase in the number of studies evaluating the clinical effects of noninvasive neuromodulatory methods, especially transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), which have been proved to effectively modulate the cortical excitability, resulting in satisfactory analgesic effects with minimal adverse events. Nevertheless, the precise neuromechanisms whereby such methods provide pain control are still largely unexplored. Recent studies have brought valuable information regarding the recruitment of different modulatory systems and related neurotransmitters, including glutamate, dopamine, and endogenous opioids. However, the specific neurocircuits involved in the analgesia produced by those therapies have not been fully elucidated. This review focuses on the current literature correlating the clinical effects of noninvasive methods of brain stimulation to the changes in the activity of endogenous modulatory systems.

Distinct patterns of brain activity mediate perceptual and motor and autonomic responses to noxious stimuli

Pain is a complex phenomenon involving perceptual, motor, and autonomic responses, but how the brain translates noxious stimuli into these different dimensions of pain is unclear. Here, we assessed perceptual, motor, and autonomic responses to brief noxious heat stimuli and recorded brain activity using electroencephalography (EEG) in humans. Multilevel mediation analysis reveals that each pain dimension is subserved by a distinct pattern of EEG responses and, conversely, that each EEG response differentially contributes to the different dimensions of pain. In particular, the translation of noxious stimuli into autonomic and motor responses involved the earliest N1 wave, whereas pain perception was mediated by later N2 and P2 waves. Gamma oscillations mediated motor responses rather than pain perception. These findings represent progress towards a mechanistic understanding of the brain processes translating noxious stimuli into pain and suggest that perceptual, motor, and autonomic dimensions of pain are partially independent rather than serial processes.

Pain is a complex phenomenon involving not just the perception of pain, but also autonomic and motor responses. Here, the authors show that these different dimensions of pain are associated with distinct patterns of neural responses to noxious stimuli as measured using EEG.

Gamma-Band Oscillations Preferential for Nociception can be Recorded in the Human Insula

Transient nociceptive stimuli elicit robust phase-locked local field potentials (LFPs) in the human insula. However, these responses are not preferential for nociception, as they are also elicited by transient non-nociceptive vibrotactile, auditory, and visual stimuli. Here, we investigated whether another feature of insular activity, namely gamma-band oscillations (GBOs), is preferentially observed in response to nociceptive stimuli. Although nociception-evoked GBOs have never been explored in the insula, previous scalp electroencephalography and magnetoencephalography studies suggest that nociceptive stimuli elicit GBOs in other areas such as the primary somatosensory and prefrontal cortices, and that this activity could be closely related to pain perception. Furthermore, tracing studies showed that the insula is a primary target of spinothalamic input. Using depth electrodes implanted in 9 patients investigated for epilepsy, we acquired insular responses to brief thermonociceptive stimuli and similarly arousing non-nociceptive vibrotactile, auditory, and visual stimuli (59 insular sites). As compared with non-nociceptive stimuli, nociceptive stimuli elicited a markedly stronger enhancement of GBOs (150-300 ms poststimulus) at all insular sites, suggesting that this feature of insular activity is preferential for thermonociception. Although this activity was also present in temporal and frontal regions, its magnitude was significantly greater in the insula as compared with these other regions.

Visually induced analgesia during face or limb stimulation in healthy and migraine subjects

Background

Visually induced analgesia (VIA) defines a phenomenon in which viewing one’s own body part during its painful stimulation decreases the perception of pain. VIA occurs during direct vision of the stimulated body part and also when seeing it reflected in a mirror. To the best of our knowledge, VIA has not been studied in the trigeminal area, where it could be relevant for the control of headache.

Subjects and methods

We used heat stimuli (53°C) to induce pain in the right forehead or wrist in 11 healthy subjects (HSs) and 14 female migraine without aura (MO) patients between attacks. The subjects rated pain on a visual analog scale (VAS) and underwent contact heat-evoked potential (CHEP) recordings (five sequential blocks of four responses) with or without observation of their face/wrist in a mirror.

Results

During wrist stimulation, amplitude of the first block of P1–P2 components of CHEPs decreased compared to that in the control recording when HSs were seeing their wrist reflected in the mirror (p = 0.036; Z = 2.08); however, this was not found in MO patients. In the latter, the VAS pain score increased viewing the reflected wrist (p = 0.049; Z = 1.96). Seeing their forehead reflected in the mirror induced a significant increase in N2 latency of CHEPs in HSs, as well as an amplitude reduction in the first block of P1–P2 components of CHEPs both in HSs (p = 0.007; Z = 2.69) and MO patients (p = 0.035; Z = 2.10). Visualizing the body part did not modify habituation of CHEP amplitudes over the five blocks of averaged responses, neither during wrist nor during forehead stimulation.

Conclusion

This study adds to the available knowledge on VIA and demonstrates this phenomenon for painful stimuli in the trigeminal area, as long as CHEPs are used as indices of central pain processing. In migraine patients during interictal periods, VIA assessed with CHEPs is within normal limits in the face but absent at the wrist, possibly reflecting dysfunctioning of extracephalic pain control.

Nonpharmacological Management of Persistent Pain in Elite Athletes: Rationale and Recommendations

Persistent pain is common in elite athletes. The current review arose from a consensus initiative by the International Olympic Committee to advance the development of a standardized, scientific, and evidence-informed approach to management. We suggest that optimal management of persistent pain in elite athletes requires an understanding of contemporary pain science, including the rationale behind and implementation of a biopsychosocial approach to care. We argue that athletes and clinicians need to understand the biopsychosocial model because it applies to both pain and the impact of pain with special reference to the sport setting. Management relies on thorough and precise assessment that considers contributing factors across nociceptive, inflammatory, neuropathic, and centrally acting domains; these can include contextual and psychosocial factors. Pain management seeks to remove contributing factors wherever possible through targeted education; adjustment of mechanical loading, training, and performance schedules; psychological therapies; and management of inflammation.

Sensory modulation dysfunction is associated with Complex Regional Pain Syndrome

OBJECTIVE

Complex Regional Pain Syndrome (CRPS), a chronic pain condition, develops mainly after limb trauma and severely inhibits function. While early diagnosis is essential, factors for CRPS onset are elusive. Therefore, identifying those at risk is crucial. Sensory modulation dysfunction (SMD), affects the capacity to regulate responses to sensory input in a graded and adaptive manner and was found associated with hyperalgesia in otherwise healthy individuals, suggestive of altered pain processing.

AIM

To test SMD as a potential risk factor for CRPS.

METHODS

In this cross-sectional study, forty-four individuals with CRPS (29.9±11 years, 27 men) and 204 healthy controls (27.4±3.7 years, 105 men) completed the Sensory Responsiveness Questionnaire-Intensity Scale (SRQ-IS). A physician conducted the CRPS Severity Score (CSS), testing individuals with CRPS.

RESULTS

Thirty-four percent of the individuals with CRPS and twelve percent of the healthy individuals were identified to have SMD (χ2 (1) = 11.95; p<0.001). Logistic regression modeling revealed that the risk of CRPS is 2.68 and 8.21 times higher in individuals with sensory over- and sensory under-responsiveness, respectively, compared to non-SMD individuals (p = 0.03 and p = 0.01, respectively).

CONCLUSIONS

SMD, particularly sensory under-responsiveness, might serve as a potential risk factor for CRPS and therefore screening for SMD is recommended. This study provides the risk index probability clinical tool a simple evaluation to be applied by clinicians in order to identify those at risk for CRPS immediately after injury. Further research is needed.

System neuroscience: Past, present, and future

In this review, we discuss first the anatomical and lesion studies that allowed the localization of fundamental functions in the cerebral cortex of primates including humans. Subsequently, we argue that the years from the end of the Second World War until the end of the last century represented the "golden age" of system neuroscience. In this period, the mechanisms-not only the localization-underlying sensory, and in particular visual functions were described, followed by those underlying cognitive functions and housed in temporal, parietal, and premotor areas. At the end of the last century, brain imaging techniques were developed that allowed the assessment of the functions of different cortical areas in a more precise and sophisticated way. However, brain imaging tells little about the neural mechanisms underlying functions. Furthermore, the brain imaging suffers from 3 major problems: time is absent, the data are merely correlative and the testing is often not ecological. We conclude our review discussing the possibility that these pitfalls might be overcome by using intracortical recordings (eg stereo-EEG), which have millisecond time resolution, allow direct electrical stimulation of specific sites, and finally enable to study patients while freely moving.

Mindfulness Meditation for Fibromyalgia: Mechanistic and Clinical Considerations

PURPOSE OF REVIEW

Fibromyalgia is a disorder characterized by widespread pain and a spectrum of psychological comorbidities, rendering treatment difficult and often a financial burden. Fibromyalgia is a complicated chronic pain condition that requires a multimodal therapeutic approach to optimize treatment efficacy. Thus, it has been postulated that mind-body techniques may prove fruitful in treating fibromyalgia. Mindfulness meditation, a behavioral technique premised on non-reactive sensory awareness, attenuates pain and improves mental health outcomes. However, the impact of mindfulness meditation on fibromyalgia-related outcomes has not been comprehensively characterized. The present review delineates the existing evidence supporting the effectiveness and hypothesized mechanisms of mindfulness meditation in treating fibromyalgia-related outcomes.

RECENT FINDINGS

Mindfulness-based interventions premised on cultivating acceptance, non-attachment, and social engagement may be most effective in decreasing fibromyalgia-related pain and psychological symptoms. Mindfulness-based therapies may alleviate fibromyalgia-related outcomes through multiple neural, psychological, and physiological processes. Mindfulness meditation may provide an effective complementary treatment approach for fibromyalgia patients, especially when combined with other reliable techniques (exercise; cognitive behavioral therapy). However, characterizing the specific analgesic mechanisms supporting mindfulness meditation is a critical step to fostering the clinical validity of this technique. Identification of the specific analgesic mechanisms supporting mindfulness-based pain relief could be utilized to better design behavioral interventions to specifically target fibromyalgia-related outcomes.

Lysergic acid diethylamide and psilocybin for the management of patients with persistent pain: a potential role?

Recently, there has been interest in lysergic acid diethylamide (LSD) and psilocybin for depression, anxiety and fear of death in terminal illness. The aim of this review is to discuss the potential use of LSD and psilocybin for patients with persistent pain. LSD and psilocybin are 5-hydroxytryptamine receptor agonists and may interact with nociceptive and antinociceptive processing. Tentative evidence from a systematic review suggests that LSD (7 studies, 323 participants) and psilocybin (3 studies, 92 participants) may be beneficial for depression and anxiety associated with distress in life-threatening diseases. LSD and psilocybin are generally safe if administered by a healthcare professional, although further investigations are needed to assess their utility for patients with persistent pain, especially associated with terminal illness.

The salience of self, not social pain, is encoded by dorsal anterior cingulate and insula

The human neural correlates of social rejection have attracted significant research interest, but remain subject to vigorous debate. Specifically, it has been proposed that a matrix of brain regions overlapping with the classical pain matrix, and including the dorsal anterior cingulate cortex (dACC) and the anterior insular cortex (AI) is critical for processing of social rejection. The present study expands on this conceptualization, by showing that these areas are involved in processing of self-relevant social evaluation, irrespective of valence. Forty healthy adolescents (N = 20 females) were tested in a magnetic resonance imaging (MRI) scanner. We used a novel paradigm that balanced participants' experience of rejection and acceptance. In addition, the paradigm also controlled for whether the social judgment was towards the participants or towards other fictitious players. By creating a "self" and "other" distinction, we show that right AI and dACC are involved in processing the salience of being judged by others, irrespective of the quality of this judgment. This finding supports the idea that these regions are not specific to social rejection or even to pain or metaphorically painful experiences, but activate to self-relevant, highly salient information.

Assessment of Nociception and Pain in Participants in an Unresponsive or Minimally Conscious State After Acquired Brain Injury: The Relation Between the Coma Recovery Scale-Revised and the Nociception Coma Scale-Revised

OBJECTIVES

To investigate the relation between consciousness and nociceptive responsiveness (ie, Nociception Coma Scale-Revised [NCS-R]), to examine the suitability of the NCS-R for assessing nociception in participants with disorders of consciousness (DOC), and to replicate previous findings on psychometric properties of the scale.

DESIGN

Specialized DOC program.

SETTING

Specialized DOC program and university hospitals.

PARTICIPANTS

Participants (N=85) diagnosed with DOC.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We prospectively assessed consciousness with the Coma Recovery Scale-Revised (CRS-R). Responses during baseline, non-noxious, and noxious stimulations were scored with the NCS-R and CRS-R oromotor and motor subscales.

RESULTS

CRS-R total scores correlated with NCS-R total scores and subscores. CRS-R motor subscores correlated with NCS-R total scores and motor subscores, and CRS-R oromotor subscores correlated with NCS-R total scores as well as verbal and facial expression subscores. There was a difference between unresponsive wakefulness syndrome and minimally conscious state in the proportion of grimacing and/or crying participants during noxious conditions. We replicated previous findings on psychometric properties of the scale but found a different score as the best threshold for nociception.

CONCLUSIONS

We report a strong relation between the responsiveness to nociception and the level of consciousness. The NCS-R seems to be a valuable tool for assessing nociception in an efficient manner, but additional studies are needed to allow recommendations for clinical assessment of subjective pain experience.

Pain Neuroimaging in Humans: A Primer for Beginners and Non-Imagers

Human pain neuroimaging has exploded in the past 2 decades. During this time, the broader neuroimaging community has continued to investigate and refine methods. Another key to progress is exchange with clinicians and pain scientists working with other model systems and approaches. These collaborative efforts require that non-imagers be able to evaluate and assess the evidence provided in these reports. Likewise, new trainees must design rigorous and reliable pain imaging experiments. In this article we provide a guideline for designing, reading, evaluating, analyzing, and reporting results of a pain neuroimaging experiment, with a focus on functional and structural magnetic resonance imaging. We focus in particular on considerations that are unique to neuroimaging studies of pain in humans, including study design and analysis, inferences that can be drawn from these studies, and the strengths and limitations of the approach.

Assessment of Responsiveness to Everyday Non-Noxious Stimuli in Pain-Free Migraineurs With Versus Without Aura

Migraineurs with aura (MWA) express higher interictal response to non-noxious and noxious experimental sensory stimuli compared with migraineurs without aura (MWoA), but whether these differences also prevail in response to everyday non-noxious stimuli is not yet explored. This is a cross-sectional study testing 53 female migraineurs (30 MWA; 23 MWoA) who underwent a wide battery of noxious psychophysical testing at a pain-free phase, and completed a Sensory Responsiveness Questionnaire and pain-related psychological questionnaires. The MWA group showed higher questionnaire-based sensory over-responsiveness (P = .030), higher magnitude of pain temporal summation (P = .031) as well as higher monthly attack frequency (P = .027) compared with the MWoA group. Overall, 45% of migraineurs described abnormal sensory (hyper- or hypo-) responsiveness; its incidence was higher among MWA (19 of 30, 63%) versus MWoA (6 of 23, 27%, P = .012), with an odds ratio of 3.58 for MWA. Sensory responsiveness scores were positively correlated with attack frequency (r = .361, P = .008) and temporal summation magnitude (r = .390, P = .004), both regardless of migraine type. MWA express higher everyday sensory responsiveness than MWoA, in line with higher response to experimental noxious stimuli. Abnormal scores of sensory responsiveness characterize people with sensory modulation dysfunction, suggesting possible underlying mechanisms overlap, and possibly high incidence of both clinical entities.

PERSPECTIVE

This article presents findings distinguishing MWA, showing enhanced pain amplification, monthly attack frequency, and over-responsiveness to everyday sensations, compared with MWoA. Further, migraine is characterized by a high incidence of abnormal responsiveness to everyday sensation, specifically sensory over-responsiveness, that was also found related to pain.

Burst Spinal Cord Stimulation: Review of Preclinical Studies and Comments on Clinical Outcomes

BACKGROUND

Burst spinal cord stimulation (SCS) technology uses a novel waveform that consists of closely packed high-frequency electrical impulses followed by a quiescent period. Within the growing field of neuromodulation, burst stimulation is unique in that it mimics the natural burst firing of the nervous system, in particular the thalamo-cingulate rhythmicity, resulting in modulation of the affective and attentional components of pain processing (e.g., medial thalamic pathways).

STUDY DESIGN

A review of preclinical and clinical studies regarding burst SCS for various chronic pain states.

METHODS

Available literature was reviewed on burst stimulation technology. Data sources included relevant literature identified through searches of PubMed, MEDLINE/OVID, SCOPUS, and manual searches of the bibliographies of known primary and review articles.

OUTCOME MEASURES

The primary outcome measure was to understand the mechanisms of action with regards to burst stimulation and to review clinical data on the indications of burst SCS for various chronic pain states.

RESULTS

We present both mechanisms of action and review uses of burst stimulation for various pain states.

CONCLUSIONS

Burst stimulation offers a novel pain reduction tool with the absence of uncomfortable paresthesia for failed back surgery syndrome, diabetic neuropathic pain, and anesthesia dolorosa. Preclinical models have emphasized that the potential mechanisms for burst therapy could be related to neural coding algorithms that mimic the natural nervous system firing patterns, resulting in effects on both the medial and lateral pain pathways. Other mechanisms include frequency dependent opioid release, modulation of the pain gate, and activation of electrical and chemical synapses.

Retrieving autobiographical experience of painful events in a phantom limb: brain concomitants in a case report

We report the case of a patient who had an important experience with painful events, allowing the investigation of brain concomitants to painful (P) memories in fMRI. The patient had to recall P events that were contrasted with non-painful (NP) memories. Painful memories of the right lower limb activated the left paracentral lobule,fronto-insular operculum and superior parietal cortex. Additionally, whilst the recall of non-painful events activated the hippocampus, the recall of painful events did not enhance the hippocampal signal to significant levels. These suggest that brain activations differ for the autobiographical recall of painful and non-painful memories.

Altered low-frequency oscillation amplitude of resting state-fMRI in patients with discogenic low-back and leg pain

Objective

The aim of this study was to explore the amplitude of intrinsic low-frequency oscillations (LFOs) in patients with discogenic low-back and leg pain (LBLP).

Participants and methods

We obtained and compared the LFO amplitude from 25 right-handed discogenic LBLP patients (13 males; mean age 55.16±1.83 years) and 27 well-matched healthy controls (15 males; mean age 52.96±1.63 years). The LFO amplitude was examined using the voxel-wise amplitude of low-frequency fluctuations (ALFFs), and partial correlation analysis was performed to determine the relationship between the regions with altered ALFF values and clinical parameters in discogenic LBLP patients.

Results

Compared with healthy controls, the patients with discogenic LBLP showed a significant increase in ALFF in the affective system of the pain matrix (left anterior cingulate cortex, right anterior insula/frontal operculum, and bilateral orbitofrontal cortex) and information-processing regions (middle occipital/temporal gyrus). In addition, a significant decrease in ALFF was observed in the default mode network (DMN; inferior parietal lobule (IPL) and medial prefrontal cortex [mPFC]) and the processing system of the pain matrix (basal ganglia/thalamus/midbrain, postcentral gyrus [PoCG], and fusiform gyrus). Several regions with altered ALFF were associated with disease duration, visual analog scale scores, Barthel index, and fine sensory modality measurements (two-point tactile discrimination of the left and/or right leg). Further operating characteristic curves analysis suggested that the mean ALFF values in the right IPL, left IPL/PoCG, left anterior cingulate cortex, and left mPFC could serve as markers to separate individuals with discogenic LBLP from healthy subjects.

Conclusion

Our results revealed widespread abnormalities in ALFF in the pain matrix and information-processing regions as well as a decrease in ALFF in the DMN. These results open up an important new avenue to better understand the nature of the link between intrinsic activity and peripheral pain and sensory impairment in discogenic LBLP patients.

Brain activity associated with pain in inherited erythromelalgia: stimulus-free pain engages brain areas involved in valuation and learning

Inherited erythromelalgia (IEM) is a chronic pain disorder caused by gain-of-function mutations of peripheral sodium channel Nav1.7, in which warmth triggers severe pain. Little is known about the brain representation of pain in IEM. Here we study two subjects with the IEM Nav1.7-S241T mutation using functional brain imaging (fMRI). Subjects were scanned during each of five visits. During each scan, pain was first triggered using a warming boot and subjects rated their thermal-heat pain. Next, the thermal stimulus was terminated and subjects rated stimulus-free pain. Last, subjects performed a control visual rating task. Thermal-heat induced pain mapped to the frontal gyrus, ventro-medial prefrontal cortex, superior parietal lobule, supplementary motor area, insula, primary and secondary somato-sensory motor cortices, dorsal and ventral striatum, amygdala, and hippocampus. Stimulus-free pain, by contrast, mapped mainly to the frontal cortex, including dorsal, ventral and medial prefrontal cortex, and supplementary motor area. Examination of time periods when stimulus-free pain was changing showed further activations in the valuation network including the rostral anterior cingulate cortex, striatum and amygdala, in addition to brainstem, thalamus, and insula. We conclude that, similar to other chronic pain conditions, the brain representation of stimulus-free pain during an attack in subjects with IEM engages brain areas involved in acute pain as well as valuation and learning.

A critical evaluation of validity and utility of translational imaging in pain and analgesia: Utilizing functional imaging to enhance the process

Assessing clinical pain and metrics related to function or quality of life predominantly relies on patient reported subjective measures. These outcome measures are generally not applicable to the preclinical setting where early signs pointing to analgesic value of a therapy are sought, thus introducing difficulties in animal to human translation in pain research. Evaluating brain function in patients and respective animal model(s) has the potential to characterize mechanisms associated with pain or pain-related phenotypes and thereby provide a means of laboratory to clinic translation. This review summarizes the progress made towards understanding of brain function in clinical and preclinical pain states elucidated using an imaging approach as well as the current level of validity of translational pain imaging. We hypothesize that neuroimaging can describe the central representation of pain or pain phenotypes and yields a basis for the development and selection of clinically relevant animal assays. This approach may increase the probability of finding meaningful new analgesics that can help satisfy the significant unmet medical needs of patients.

How do morphological alterations caused by chronic pain distribute across the brain? A meta-analytic co-alteration study

•In chronic pain, gray matter (GM) alterations are not distributed randomly across the brain.•The pattern of co-alterations resembles that of brain connectivity.•The alterations' distribution partly rely on the pathways of functional connectivity.•This method allows us to identify tendencies in the distribution of GM co-alteration related to chronic pain.

Acupuncture analgesia involves modulation of pain-induced gamma oscillations and cortical network connectivity

Recent studies support the view that cortical sensory, limbic and executive networks and the autonomic nervous system might interact in distinct manners under the influence of acupuncture to modulate pain. We performed a double-blind crossover design study to investigate subjective ratings, EEG and ECG following experimental laser pain under the influence of sham and verum acupuncture in 26 healthy volunteers. We analyzed neuronal oscillations and inter-regional coherence in the gamma band of 128-channel-EEG recordings as well as heart rate variability (HRV) on two experimental days. Pain ratings and pain-induced gamma oscillations together with vagally-mediated power in the high-frequency bandwidth (vmHF) of HRV decreased significantly stronger during verum than sham acupuncture. Gamma oscillations were localized in the prefrontal cortex (PFC), mid-cingulate cortex (MCC), primary somatosensory cortex and insula. Reductions of pain ratings and vmHF-power were significantly correlated with increase of connectivity between the insula and MCC. In contrast, connectivity between left and right PFC and between PFC and insula correlated positively with vmHF-power without a relationship to acupuncture analgesia. Overall, these findings highlight the influence of the insula in integrating activity in limbic-saliency networks with vagally mediated homeostatic control to mediate antinociception under the influence of acupuncture.

Current evidence of cannabinoid-based analgesia obtained in preclinical and human experimental settings

Cannabinoids have a long record of recreational and medical use and become increasingly approved for pain therapy. This development is based on preclinical and human experimental research summarized in this review. Cannabinoid CB₁ receptors are widely expressed throughout the nociceptive system. Their activation by endogenous or exogenous cannabinoids modulates the release of neurotransmitters. This is reflected in antinociceptive effects of cannabinoids in preclinical models of inflammatory, cancer and neuropathic pain, and by nociceptive hypersensitivity of cannabinoid receptor-deficient mice. Cannabis-based medications available for humans mainly comprise Δ⁹ -tetrahydrocannabinol (THC), cannabidiol (CBD) and nabilone. During the last 10 years, six controlled studies assessing analgesic effects of cannabinoid-based drugs in human experimental settings were reported. An effect on nociceptive processing could be translated to the human setting in functional magnetic resonance imaging studies that pointed at a reduced connectivity within the pain matrix of the brain. However, cannabinoid-based drugs heterogeneously influenced the perception of experimentally induced pain including a reduction in only the affective but not the sensory perception of pain, only moderate analgesic effects, or occasional hyperalgesic effects. This extends to the clinical setting. While controlled studies showed a lack of robust analgesic effects, cannabis was nearly always associated with analgesia in open-label or retrospective reports, possibly indicating an effect on well-being or mood, rather than on sensory pain. Thus, while preclinical evidence supports cannabinoid-based analgesics, human evidence presently provides only reluctant support for a broad clinical use of cannabinoid-based medications in pain therapy.

SIGNIFICANCE

Cannabinoids consistently produced antinociceptive effects in preclinical models, whereas they heterogeneously influenced the perception of experimentally induced pain in humans and did not provide robust clinical analgesia, which jeopardizes the translation of preclinical research on cannabinoid-mediated antinociception into the human setting.

Effect of sufentanil on bispectral index in the elderly

We examined the impact of adding sufentanil during anaesthesia induction with propofol on bispectral index values in elderly patients (≥ 65 years). Patients were randomly assigned to receive a target-controlled sufentanil infusion (effect-site concentration of 0.3 ng.ml^-1 ) or matching placebo, followed by a target-controlled propofol induction (initial effect-site concentration of 0.5 μg.ml^-1 ; step-wise increase of 0.5 μg.ml^-1 ) until loss of consciousness defined as an Observer's Assessment of Alertness/Sedation score < 2. Seventy-one patients (sufentanil 35, placebo 36) completed the study. Mean (SD) age was 72.3 (5.8) years; 41% were women. At loss of consciousness, mean (SD) bispectral index value was 75.0 (8.6) with sufentanil and 70.0 (8.0) with placebo; mean difference -5.0 (95% confidence interval -8.9 to -1.1), p = 0.013. Post-hoc analyses suggest that the difference was significant in men only (mean difference -7.3 (-11.8 to -2.6), p = 0.003). Sufentanil co-induction with propofol results in higher bispectral index values at loss of consciousness in elderly patients.

Locus coeruleus phasic discharge is essential for stimulus-induced gamma oscillations in the prefrontal cortex

The locus coeruleus (LC) noradrenergic (NE) neuromodulatory system is critically involved in regulation of neural excitability via its diffuse ascending projections. Tonic NE release in the forebrain is essential for maintenance of vigilant states and increases the signal-to-noise ratio of cortical sensory responses. The impact of phasic NE release on cortical activity and sensory processing is less explored. We previously reported that LC microstimulation caused a transient desynchronization of population activity in the medial prefrontal cortex (mPFC), similar to noxious somatosensory stimuli. The LC receives nociceptive information from the medulla and therefore may mediate sensory signaling to its forebrain targets. Here we performed extracellular recordings in LC and mPFC while presenting noxious stimuli in urethane-anesthetized rats. A brief train of foot shocks produced a robust phasic response in the LC and a transient change in the mPFC power spectrum, with the strongest modulation in the gamma (30-90 Hz) range. The LC phasic response preceded prefrontal gamma power increase, and cortical modulation was proportional to the LC excitation. We also quantitatively characterized distinct cortical states and showed that sensory responses in both LC and mPFC depend on the ongoing cortical state. Finally, cessation of the LC firing by bilateral local iontophoretic injection of clonidine, an α₂-adrenoreceptor agonist, completely eliminated sensory responses in the mPFC without shifting cortex to a less excitable state. Together, our results suggest that the LC phasic response induces gamma power increase in the PFC and is essential for mediating sensory information along an ascending noxious pathway. NEW & NOTEWORTHY Our study shows linear relationships between locus coeruleus phasic excitation and the amplitude of gamma oscillations in the prefrontal cortex. Results suggest that the locus coeruleus phasic response is essential for mediating sensory information along an ascending noxious pathway.

Sensory Over-Responsiveness among Healthy Subjects is Associated with a Pronociceptive State

OBJECTIVE

Chronic pain patients show hypersensitivity to sensory nonpainful stimuli. Sensory over-responsiveness (SOR) to innocuous daily stimuli, experienced as painful, is prevalent in 10% of the healthy population. This altered sensory processing may be an expression of overfacilitation, or a less efficient pain-inhibitory process in the pain pathways. We therefore aimed to investigate specifically the pain-inhibitory system of subjects with SOR who are otherwise healthy, not studied as of yet.

METHODS

Thirty healthy subjects, divided into an SOR group (n = 14) and a non-SOR group (n = 16) based on responses to the Sensory Responsiveness Questionnaire, were psychophysically tested in order to evaluate (1) hyperalgesic responses; (2) adaptation/sensitization to 14 phasic heat stimuli; (3) habituation; (4) 6-minute after-sensations; and (5) conditioned pain modulation (CPM) (ie, phasic heat stimuli applied with and without hand immersion in a hot water bath).

RESULTS

The SOR group differed from the non-SOR group in (1) a steeper escalation in NPS ratings to temperature increase (P = 0.003), indicating hyperalgesia; (2) increased sensitization (P < 0.001); (3) habituation responses (P < 0.001); (4) enhanced pain ratings during the after-sensation (P = 0.006); and (5) no group difference was found in CPM.

CONCLUSIONS

SOR is associated with a pronociceptive state, expressed by amplification of experimental pain, yet with sufficient inhibitory processes. Our results support previous findings of enhanced facilitation of pain-transmitting pathways but also reveal preserved inhibitory mechanisms, although they were slower to react.

Brain imaging tests for chronic pain: medical, legal and ethical issues and recommendations

Chronic pain is the greatest source of disability globally and claims related to chronic pain feature in many insurance and medico-legal cases. Brain imaging (for example, functional MRI, PET, EEG and magnetoencephalography) is widely considered to have potential for diagnosis, prognostication, and prediction of treatment outcome in patients with chronic pain. In this Consensus Statement, a presidential task force of the International Association for the Study of Pain examines the capabilities of brain imaging in the diagnosis of chronic pain, and the ethical and legal implications of its use in this way. The task force emphasizes that the use of brain imaging in this context is in a discovery phase, but has the potential to increase our understanding of the neural underpinnings of chronic pain, inform the development of therapeutic agents, and predict treatment outcomes for use in personalized pain management. The task force proposes standards of evidence that must be satisfied before any brain imaging measure can be considered suitable for clinical or legal purposes. The admissibility of such evidence in legal cases also strongly depends on laws that vary between jurisdictions. For these reasons, the task force concludes that the use of brain imaging findings to support or dispute a claim of chronic pain - effectively as a pain lie detector - is not warranted, but that imaging should be used to further our understanding of the mechanisms underlying pain.

Prestimulus Theta Oscillations and Connectivity Modulate Pain Perception

The perception of pain is strongly influenced by cognitive processes, such as expectations toward the efficacy of pain medication. It is reasonable to assume that such processes, among other sources of fluctuation, are reflected in ongoing brain activity, which in turn influences perceptual processing. To identify specific prestimulus EEG activity, and connectivity patterns related to subsequent pain perception in humans, we contrasted painful with nonpainful sensations delivered at the individual threshold level determined by the psychophysical QUEST estimation method (Watson and Pelli, 1983). The 64-channel EEG was recorded using active electrodes during a constant stimulation procedure. The power contrast between trials sorted by rating revealed a signal decrease of 8% before stimulus onset in theta-band (4-7 Hz) at T7/FT7 as well as increased theta-power by 6% at T8/FT8. Gamma-band power was increased (12%, 28-32 Hz) at frontocentral sites (all p < 0.05). Changes in theta-band power are covarying with subsequent pain perception, as well as lowered frontolateral theta-band connectivity for painful percepts. A decrease in frontoparietal connectivity for painful sensations was also identified in the gamma-band (28-32 Hz). A single-trial logistic regression revealed significant information content in the EEG signal at temporal electrode T7 in theta-band (p < 0.01) and frontal electrode F1 in gamma-band (all p < 0.02). The observed patterns suggest top-down modulation of the theta-band effects by a frontocentral network node. These findings contribute to the understanding of ongoing subjective pain sensitivity, potentially relevant to both clinical diagnostics and pain management.

SIGNIFICANCE STATEMENT

The perceived intensity of a constant stimulus is known to vary considerably across multiple presentations. Here, we used state-of-the-art psychophysical methods in an EEG experiment to identify the specific neuronal activity before stimulus onset that reflects the subsequent perception of pain. We found specific oscillatory activity at the bilateral insular cortices as well as connectivity patterns that reflect and correlate with subsequent ratings. These results further the understanding of pain perception and are potentially relevant for the decoding of ongoing pain sensitivity and pain management.

Neurodevelopmental Hypothesis about the Etiology of Autism Spectrum Disorders

Previous models or hypotheses of autism spectral disorder (ASD) failed to take into full consideration the chronological and causal developmental trajectory, leading to the emergence of diverse phenotypes through a complex interaction between individual etiologies and environmental factors. Those phenotypes include persistent deficits in social communication and social interaction (criteria A in DSM-5), and restricted, repetitive patterns of behavior, interests, or activities (criteria B in DSM-5). In this article, we proposed a domain-general model that can explain criteria in DSM-5 based on the assumption that the same etiological mechanism would trigger the various phenotypes observed in different individuals with ASD. In the model, we assumed the following joint causes as the etiology of autism: (1) Hypoplasia of the pons in the brainstem, occurring immediately following neural tube closure; and (2) Deficiency in the GABA (γ-aminobutyric acid) developmental switch during the perinatal period. Microstructural abnormalities of the pons directly affect both the structural and functional development of the brain areas strongly connected to it, especially amygdala. The impairment of GABA switch could not only lead to the deterioration of inhibitory processing in the neural network, but could also cause abnormal cytoarchitecture. We introduced a perspective that atypical development in both brain structure and function can give full explanation of diverse phenotypes and pathogenetic mechanism of ASD. Finally, we discussed about neural mechanisms underlying the phenotypic characteristics of ASD that are not described in DSM-5 but should be considered as important foundation: sleep, global precedence, categorical perception, intelligence, interoception and motor control.

Resting state electrical brain activity and connectivity in fibromyalgia

The exact mechanism underlying fibromyalgia is unknown, but increased facilitatory modulation and/or dysfunctional descending inhibitory pathway activity are posited as possible mechanisms contributing to sensitization of the central nervous system. The primary goal of this study is to identify a fibromyalgia neural circuit that can account for these abnormalities in central pain. The second goal is to gain a better understanding of the functional connectivity between the default and the executive attention network (salience network plus dorsal lateral prefrontal cortex) in fibromyalgia. We examine neural activity associated with fibromyalgia (N = 44) and compare these with healthy controls (N = 44) using resting state source localized EEG. Our data support an important role of the pregenual anterior cingulate cortex but also suggest that the degree of activation and the degree of integration between different brain areas is important. The inhibition of the connectivity between the dorsal lateral prefrontal cortex and the posterior cingulate cortex on the pain inhibitory pathway seems to be limited by decreased functional connectivity with the pregenual anterior cingulate cortex. Our data highlight the functional dynamics of brain regions integrated in brain networks in fibromyalgia patients.

Brain mechanisms of abnormal temperature perception in cold allodynia induced by ciguatoxin

OBJECTIVE

Cold allodynia occurs as a major symptom of neuropathic pain states. It remains poorly treated with current analgesics. Ciguatoxins (CTXs), ichthyosarcotoxins that cause ciguatera, produce a large peripheral sensitization to dynamic cold stimuli in Aδ-fibers by activating sodium channels without producing heat or mechanical allodynia. We used CTXs as a surrogate model of cold allodynia to dissect the framework of cold allodynia-activated central pain pathways.

METHODS

Reversible cold allodynia was induced in healthy male volunteers by shallow intracutaneous injection of low millimolar concentrations of CTX into the dorsal skin of the forefoot. Cold and warm stimuli were delivered to the treated and the control site using a Peltier-driven thermotest device. Functional magnetic resonance imaging (fMRI) scans were acquired with a 3T MRI scanner using a blood oxygen level-dependent (BOLD) protocol.

RESULTS

The CTX-induced substantial peripheral sensitization to cooling stimuli in Aδ-fibers is particularly retrieved in BOLD changes due to dynamic temperature changes and less during constant cooling. Brain areas that responded during cold allodynia were almost always located bilaterally and appeared in the medial insula, medial cingulate cortex, secondary somatosensory cortex, frontal areas, and cerebellum. Whereas these areas also produced changes in BOLD signal during the dynamic warming stimulus on the control site, they remained silent during the warming stimuli on the injected site.

INTERPRETATION

We describe the defining feature of the cold allodynia pain percept in the human brain and illustrate why ciguatera sufferers often report a perceptual temperature reversal. ANN NEUROL 2017;81:104-116.

Characterization of cortical source generators based on electroencephalography during tonic pain

Objective

The aim of the present study was to characterize the cortical source generators evoked by experimental tonic pain.

Methods

Electroencephalography (EEG) was recorded on two separate days during rest and with immersion of the hand in ice water for 2 minutes (cold pressor test). Exact low-resolution brain electromagnetic tomography source localization was performed in 31 healthy volunteers to characterize the cortical source generators.

Results

Reliability was high in all eight frequency bands during rest and cold pressor conditions (intraclass coefficients =0.47–0.83 in the cingulate and insula). Tonic pain increased cortical activities in the delta (1–4 Hz), theta (4–8 Hz), beta1 (12–18 Hz), beta2 (18–24 Hz), beta3 (24–32 Hz), and gamma (32–60 Hz) bands (all P<0.011) in widespread areas mainly in the limbic system, whereas decreased cortical activities were found in cingulate and pre- and postcentral gyri in the alpha2 (10–12 Hz) band (P=0.007). The pain intensity was correlated with cingulate activity in the beta2, beta3, and gamma bands (all P<0.04).

Conclusion

Source localization of EEG is a reliable method to estimate cortical source generators. Activities in different brain regions, mainly in the limbic system, showed fluctuations in various frequency bands. Cingulate changes were correlated with pain intensity.

Significance

This method might add information to the objective assessment of the cortical pain response in future experimental pain studies.

Empathy and moral emotions in post-apartheid South Africa: an fMRI investigation

Moral emotions elicited in response to others' suffering are mediated by empathy and affect how we respond to their pain. South Africa provides a unique opportunity to study group processes given its racially divided past. The present study seeks insights into aspects of the moral brain by investigating behavioral and functional MRI responses of White and Black South Africans who lived through apartheid to in- and out-group physical and social pain. Whereas the physical pain task featured faces expressing dynamic suffering, the social pain task featured victims of apartheid violence from the South African Truth and Reconciliation Commission to elicit heartfelt emotion. Black participants' behavioral responses were suggestive of in-group favoritism, whereas White participants' responses were apparently egalitarian. However, all participants showed significant in-group biases in activation in the amygdala (physical pain), as well as areas involved in mental state representation, including the precuneus, temporoparietal junction (TPJ) and frontal pole (physical and social pain). Additionally, Black participants reacted with heightened moral indignation to own-race suffering, whereas White participants reacted with heightened shame to Black suffering, which was associated with blunted neural empathic responding. These findings provide ecologically valid insights into some behavioral and brain processes involved in complex moral situations.

Functional dissociation of stimulus intensity encoding and predictive coding of pain in the insula

The computational principles by which the brain creates a painful experience from nociception are still unknown. Classic theories suggest that cortical regions either reflect stimulus intensity or additive effects of intensity and expectations, respectively. By contrast, predictive coding theories provide a unified framework explaining how perception is shaped by the integration of beliefs about the world with mismatches resulting from the comparison of these beliefs against sensory input. Using functional magnetic resonance imaging during a probabilistic heat pain paradigm, we investigated which computations underlie pain perception. Skin conductance, pupil dilation, and anterior insula responses to cued pain stimuli strictly followed the response patterns hypothesized by the predictive coding model, whereas posterior insula encoded stimulus intensity. This novel functional dissociation of pain processing within the insula together with previously observed alterations in chronic pain offer a novel interpretation of aberrant pain processing as disturbed weighting of predictions and prediction errors.

Human primary somatosensory cortex is differentially involved in vibrotaction and nociception

The role of the primary somatosensory cortex (S1) in vibrotaction is well established. In contrast, its involvement in nociception is still debated. Here we test whether S1 is similarly involved in the processing of nonnociceptive and nociceptive somatosensory input in humans by comparing the aftereffects of high-definition transcranial direct current stimulation (HD-tDCS) of S1 on the event-related potentials (ERPs) elicited by nonnociceptive and nociceptive somatosensory stimuli delivered to the ipsilateral and contralateral hands. Cathodal HD-tDCS significantly affected the responses to nonnociceptive somatosensory stimuli delivered to the contralateral hand: both early-latency ERPs from within S1 (N20 wave elicited by transcutaneous electrical stimulation of median nerve) and late-latency ERPs elicited outside S1 (N120 wave elicited by short-lasting mechanical vibrations delivered to index fingertip, thought to originate from bilateral operculo-insular and cingulate cortices). These results support the notion that S1 constitutes an obligatory relay for the cortical processing of nonnociceptive tactile input originating from the contralateral hemibody. Contrasting with this asymmetric effect of HD-tDCS on the responses to nonnociceptive somatosensory input, HD-tDCS over the sensorimotor cortex led to a bilateral and symmetric reduction of the magnitude of the N240 wave of nociceptive laser-evoked potentials elicited by stimulation of the hand dorsum. Taken together, our results demonstrate in humans a differential involvement of S1 in vibrotaction and nociception.NEW & NOTEWORTHY Whereas the role of the primary somatosensory cortex (S1) in vibrotaction is well established, its involvement in nociception remains strongly debated. By assessing, in healthy volunteers, the effect of high-definition transcranial direct current stimulation over S1, we demonstrate a differential involvement of S1 in vibrotaction and nociception.

Activity and connectivity changes of central projection areas revealed by functional magnetic resonance imaging in NaV1.8-deficient mice upon cold signaling

The voltage-gated sodium channel subtype Na_V1.8 is expressed in the peripheral nervous system in primary afferent nociceptive C-fibers and is essential for noxious cold signaling. We utilized functional magnetic resonance imaging on Na_V1.8-deficient (Na_V1.8^−/−) compared with wildtype (WT) mice to identify brain structures decoding noxious cold and/or heat signals. In Na_V1.8^−/− mice functional activity patterns, activated volumes and BOLD signal amplitudes are significantly reduced upon noxious cold stimulation whereas differences of noxious heat processing are less pronounced. Graph-theoretical analysis of the functional connectivity also shows dramatic alterations in noxious cold sensation in Na_V1.8^−/− mice and clearly reduced interactions between certain brain structures. In contrast, upon heat stimulation qualitatively quite the same functional connectivity pattern and consequently less prominent connectivity differences were observed between Na_V1.8^−/− and WT mice. Thus, the fact that Na_V1.8^−/− mice do not perceive nociceptive aspects of strong cooling in contrast to their WT littermates seems not only to be a pure peripheral phenomenon with diminished peripheral transmission, but also consists of upstream effects leading to altered subsequent nociceptive processing in the central nervous system and consequently altered connectivity between pain-relevant brain structures.