Organization of the Thermal Grill Illusion by Spinal Segments

Thermal illusions for thermal displays: a review

Thermal illusions, a subset of haptic illusions, have historically faced technical challenges and limited exploration. They have been underutilized in prior studies related to thermal displays. This review paper primarily aims to comprehensively categorize thermal illusions, offering insights for diverse applications in thermal display design. Recent advancements in the field have spurred a fresh perspective on thermal and pain perception, specifically through the lens of thermal illusions.

Thermal grill illusion of pain in patients with chronic pain: a clinical marker of central sensitization?

ABSTRACT

The thermal grill illusion of pain (TGIP) is a paradoxical burning pain sensation elicited by the simultaneous application of innocuous cutaneous warm and cold stimuli with a thermode ("thermal grill") consisting of interlaced heated and cooled bars. Its neurophysiological mechanisms are unclear, but TGIP may have some mechanisms in common with pathological pain, including central sensitization in particular, through the involvement of N-methyl- d -aspartate receptors. However, few studies have investigated TGIP in patients with chronic pain and its clinical relevance is uncertain. We hypothesized that the TGIP would be increased in comparison with controls in patients with fibromyalgia or irritable bowel syndrome, which are regarded as typical "nociplastic" primary pain syndromes related to changes in central pain processing. We compared the sensations elicited by a large range of combinations of temperature differentials between the warm and cold bars of a thermal grill applied to the hand between patients with fibromyalgia (n = 30) or irritable bowel syndrome (n= 30) and controls (n = 30). The percentage of TGIP responses and the intensity and unpleasantness of TGIP were significantly greater in patients than controls. Furthermore, positive correlations were found between TGIP intensity and clinical pain intensity and between TGIP intensity and the cold pain threshold measured on the hand. These results are consistent with our working hypothesis of shared mechanisms between TGIP and clinical pain mechanisms in patients with nociplastic chronic pain syndromes and suggest that TGIP might represent a clinical marker of central sensitization in these patients.

Cortical oscillatory changes during thermal grill illusion

OBJECTIVE

The thermal grill illusion (TGI) can cause a burning pain sensation when the skin is subjected to simultaneously harmless hot and cold stimuli, and the pain is reported to be similar to central neuropathic pain. Although electroencephalography (EEG) is commonly used in pain research, no reports have revealed EEG activity during TGI.

METHODS

One healthy subject was enrolled, and EEG activity was recorded during the experience of the TGI and a warm sensation. Independent component analysis (ICA) was applied to preprocessed EEG data, which was divided into several clusters.

RESULTS

Theta and alpha bands in the insular cortex and parietal operculum clusters were significantly more desynchronized under the TGI condition than under the warm condition ( P  < 0.05). Additionally, theta, alpha and beta bands in the frontal (middle and inferior frontal gyrus) cluster showed significantly more desynchronization under the TGI condition than under the warm condition ( P  < 0.05).

CONCLUSION

EEG oscillations in these brain areas could be useful markers of central neuropathic pain.

Conditioned pain modulation is not associated with thermal pain illusion

OBJECTIVES

Paradoxical sensations, known as thermal pain illusions, can be evoked by painful cold-heat pulse stimulation. They may provide diagnostic value; however, the possible interaction between conditioned pain modulation and thermal pain illusions has not been explored. The present study examined: (1) whether conditioned pain modulation could be induced by alternating tonic painful cold-heat pulse stimulation; and (2) whether the presence of thermal pain illusions during the conditioning stimulus influences the degree of conditioned pain modulation.

METHODS

This study was approved by the Ethics Committee of Meikai University (A1507). Conditioned pain modulation was provoked using alternating painful cold-heat pulses delivered at 20-s intervals applied to the forearm. Thermal pain illusions were qualitatively evaluated, and conditioned pain modulation was assessed quantitatively using the pressure pain threshold as a test stimulus. Differences in the conditioned pain modulation effect between the participants who experienced thermal pain illusions and those who did not were analysed using Student's t-test.

RESULTS

A significant positive conditioned pain modulation effect (51.0 ± 4.7%, overall effect) was detected. There was no significant difference in conditioned pain modulation between the participants who experienced thermal pain illusions and those who did not (44.3 ± 6.0% and 55.5 ± 6.8%, respectively; p = 0.255).

CONCLUSIONS

Conditioned pain modulation induced by alternating painful conditioning cold-heat pulse stimulation was identical during the conditioning stimulation in volunteers with and without thermal pain illusions. Conditioning cold-heat pulse stimulation is useful to evaluate conditioned pain modulation. Moreover, conditioned pain modulation is not influenced by the presence of thermal pain illusions, indicating partially different underlying supraspinal, neuronal networks.

Pain quality of thermal grill illusion is similar to that of central neuropathic pain rather than peripheral neuropathic pain

OBJECTIVES

Application of spatially interlaced innocuous warm and cool stimuli to the skin elicits illusory pain, known as the thermal grill illusion (TGI). This study aimed to discriminate the underlying mechanisms of central and peripheral neuropathic pain focusing on pain quality, which is considered to indicate the underlying mechanism(s) of pain. We compared pain qualities in central and peripheral neuropathic pain with reference to pain qualities of TGI-induced pain.

METHODS

Experiment 1:137 healthy participants placed their hand on eight custom-built copper bars for 60 s and their pain quality was assessed by the McGill Pain Questionnaire. Experiment 2: Pain quality was evaluated in patients suffering from central and peripheral neuropathic pain (42 patients with spinal cord injury, 31 patients with stroke, 83 patients with trigeminal neuralgia and 131 patients with postherpetic neuralgia).

RESULTS

Experiment 1: Two components of TGI-induced pain were found using principal component analysis: component 1 included aching, throbbing, heavy and burning pain, component 2 included itching, electrical-shock, numbness, and cold-freezing. Experiment 2: Multiple correspondence analysis (MCA) and cross tabulation analysis revealed specific pain qualities including aching, hot-burning, heavy, cold-freezing, numbness, and electrical-shock pain were associated with central neuropathic pain rather than peripheral neuropathic pain.

CONCLUSIONS

We found similar qualities between TGI-induced pain in healthy participants and central neuropathic pain rather than peripheral neuropathic pain. The mechanism of TGI is more similar to the mechanism of central neuropathic pain than that of neuropathic pain.

Painful cold-heat segmental pulse stimulation provokes the thermal pain illusion

PURPOSE/AIM

The thermal grill illusion is a paradoxical pain sensation induced by simultaneous exposure to spatially separated, non-painful, cold, and warm stimuli. This study aimed to determine whether paradoxical sensations are also evoked by simultaneous exposure to painful cold-heat stimuli and whether the mechanism involves modulation by segmental and extra-segmental spatial integration.

MATERIALS AND METHODS

Sensory perceptions were triggered by simultaneous application of painful cold-heat pulse stimuli using a developed bedside tool equipped with quantitative thermal stimulator devices. Four conditions were investigated: (1) one device placed on the forearm (condition 1, control); (2) two devices placed on the forearm (condition 2, ipsilateral segmental integration); (3) two devices placed on the forearm and ipsilateral thigh (condition 3, extra-segmental integration); and (4) two devices placed bilaterally on the forearms (condition 4, contralateral segmental integration). The evoked perceptions of paradoxical heat sensation and the loss of cold or heat sensation were evaluated.

RESULTS

The aforementioned phenomena were experienced by 11(35.4%), 3(9.7%), 3(9.7%), and 0(0.0%) subjects for conditions 1-4, respectively. Fisher's exact test revealed significant differences (p=.001) among the four conditions. However, Bonferroni post hoc analysis revealed significant differences only between conditions 1 and 4 (p=.005).

CONCLUSIONS

Simultaneous painful cold-heat pulse stimulation can induce paradoxical sensations similar to those shown for non-painful thermal (cold and heat) stimuli. They were predominantly evoked by ipsilateral integration. Paradoxical sensations have diagnostic value, and quantifying them using a simple bedside tool may be useful in the clinical setting.

A Review on Various Topics on the Thermal Grill Illusion

The thermal grill illusion (TGI) is a paradoxical perception of burning heat and pain resulting from the simultaneous application of interlaced warm and cold stimuli to the skin. The TGI is considered a type of chronic centralized pain and has been used to apply nociceptive stimuli without inflicting harm to human participants in the study of pain mechanisms. In addition, the TGI is an interesting phenomenon for researchers, and various topics related to the TGI have been investigated in several studies, which we will review here. According to previous studies, the TGI is generated by supraspinal interactions. To evoke the TGI, cold and warm cutaneous stimuli should be applied within the same dermatome or across dermatomes corresponding to adjacent spinal segments, and a significant difference between cold and warm temperatures is necessary. In addition, due the presence of chronic pain, genetic factors, and sexual differences, the intensity of the TGI can differ. In addition, cold noxious stimulation, topical capsaicin, analgesics, self-touch, and the presence of psychological diseases can decrease the intensity of the TGI. Because the TGI corresponds to chronic centralized pain, we believe that the findings of previous studies can be applied to future studies to identify chronic pain mechanisms and clinical practice for pain management.

Central neuropathic pain in multiple sclerosis is associated with impaired innocuous thermal pathways and neuronal hyperexcitability

OBJECTIVE

About a third of patients with multiple sclerosis (MS) suffer from chronic and excruciating central neuropathic pain (CNP). The mechanism underlying CNP in MS is not clear, since previous studies are scarce and their results are inconsistent. Our aim was to determine whether CNP in MS is associated with impairment of the spinothalamic-thalamocortical pathways (STTCs) and/or increased excitability of the pain system.

DESIGN

Cross sectional study.

SETTING

General hospital.

SUBJECTS

47 MS patients with CNP, 42 MS patients without CNP, and 32 healthy controls.

METHODS

Sensory testing included the measurement of temperature, pain, and touch thresholds and the thermal grill illusion (TGI) for evaluating STTCs function, and hyperpathia and allodynia as indicators of hyperexcitability. CNP was characterized using interviews and questionnaires.

RESULTS

The CNP group had higher cold and warm thresholds (p < 0.01), as well as higher TGI perception thresholds (p < 0.05), especially in painful body regions compared to controls, whereas touch and pain thresholds values were normal. The CNP group also had a significantly greater prevalence of hyperpathia and allodynia. Regression analysis revealed that whereas presence of CNP was associated with a higher cold threshold, CNP intensity, and the number of painful body regions were associated with allodynia and hyperpathia, respectively.

CONCLUSIONS

CNP in MS is characterized by a specific impairment of STTC function; the innocuous thermal pathways, and by pain hyperexcitability. Whereas CNP presence is associated with STTC impairment, its severity and extent are associated with pain hyperexcitability. Interventions that reduce excitability level may therefore mitigate CNP severity.

The cornucopia of central disinhibition pain - An evaluation of past and novel concepts

Central disinhibition (CD), as applied to pain, decreases thresholds of endogenous systems. This provokes onset of spontaneous or evoked pain in an individual beyond the ability of the nervous system to inhibit pain resulting from a disease or tissue damage. The original CD concept as proposed by Craig entails a shift from the lateral pain pathway (i.e. discriminative pain processing) towards the medial pain pathway (i.e. emotional pain processing), within an otherwise neurophysiological intact environment. In this review, the original CD concept as proposed by Craig is extended by the primary "nociceptive pathway damage - CD" concept and the secondary "central pathway set point - CD". Thereby, the original concept may be transferred into anatomical and psychological non-functional conditions. We provide examples for either primary or secondary CD concepts within different clinical etiologies as well as present surrogate models, which directly mimic the underlying pathophysiology (A-fiber block) or modulate the CD pathway excitability (thermal grill). The thermal grill has especially shown promising advancements, which may be useful to examine CD pathway activation in the future. Therefore, within this topical review, a systematic review on the thermal grill illusion is intended to stimulate future research. Finally, the authors review different mechanism-based treatment approaches to combat CD pain.

Using electrodermal activity to validate multilevel pain stimulation in healthy volunteers evoked by thermal grills

We have tested the feasibility of thermal grills, a harmless method to induce pain. The thermal grills consist of interlaced tubes that are set at cool or warm temperatures, creating a painful "illusion" (no tissue injury is caused) in the brain when the cool and warm stimuli are presented collectively. Advancement in objective pain assessment research is limited because the gold standard, the self-reporting pain scale, is highly subjective and only works for alert and cooperative patients. However, the main difficulty for pain studies is the potential harm caused to participants. We have recruited 23 subjects in whom we induced electric pulses and thermal grill (TG) stimulation. The TG effectively induced three different levels of pain, as evidenced by the visual analog scale (VAS) provided by the subjects after each stimulus. Furthermore, objective physiological measurements based on electrodermal activity showed a significant increase in levels as stimulation level increased. We found that VAS was highly correlated with the TG stimulation level. The TG stimulation safely elicited pain levels up to 9 out of 10. The TG stimulation allows for extending studies of pain to ranges of pain in which other stimuli are harmful.

Thermonociceptive interaction: interchannel pain modulation occurs before intrachannel convergence of warmth

Nonnoxious warmth reduces both perceived pain intensity and the amplitude of EEG markers of pain. However, the spatial properties of thermonociceptive interaction, and the level of sensory processing at which it occurs, remain unclear. We investigated whether interchannel warmth-pain interactions occur before or after intrachannel spatial summation of warmth. Warm stimuli were applied to the fingers of the right hand. Their number and location were manipulated in different conditions. A concomitant noxious test pulse was delivered to the middle finger using a CO₂ laser. We replicated the classical suppressive effect of warmth on both perceived pain intensity and EEG markers. Importantly, inhibition of pain was not affected by the location and the number of thermal stimuli, even though they increased the perceived intensity of warmth. Our results therefore suggest that the inhibitory effect of warmth on pain is not somatotopically organized. The results also rule out the possibility that warmth affects nociceptive processing after intrachannel warmth summation. NEW & NOTEWORTHY We used spatial summation of warmth as a model to investigate thermonociceptive interactions. Painful CO₂ laser pulses were delivered during different thermal conditions. We found that warmth inhibited pain regardless of its location. Crucially, spatial summation of multiple warm stimuli did not further inhibit pain. These findings suggest that warmth-pain interaction occurs independently of or after spatial summation of warmth.