Asymmetry and time-course of cutaneous sympathetic reflex responses following sustained excitation of chemosensitive nociceptors in humans

Interindividual variability in cold-pressor pain sensitivity is not explained by peripheral vascular responding and generalizes to a C-nociceptor-specific pain phenotype

ABSTRACT

Pain sensitivity of healthy subjects in the cold-pressor (CP) test was proposed to be dichotomously distributed and to represent a pain sensitivity trait. Still, it has not been systematically explored which factors influence this pain sensitivity readout. The aim of this study was to distinguish potential contributions of local tissue-related factors such as perfusion and thermoregulation or gain settings in nociceptive systems. Cold-pressor-sensitive and CP-insensitive students screened from a medical student laboratory course were recruited for a CP retest with additional cardiovascular and bilateral local vascular monitoring. In addition, comprehensive quantitative sensory testing according to Deutscher Forschungsverbund Neuropathischer Schmerz standards and a sustained pinch test were performed. Cold pressor was reproducible across sessions (Cohen kappa 0.61 ± 0.14, P < 0.005). At 30 seconds in ice water, CP-sensitive subjects exhibited not only more pain (78.6 ± 26.3 vs 29.5 ± 17.5, P < 0.0001) but also significantly stronger increases in mean arterial blood pressure (12.6 ± 9.3 vs 5.6 ± 8.1 mm Hg, P < 0.05) and heart rate (15.0 ± 8.2 vs 7.1 ± 6.2 bpm, P < 0.005), and lower baroreflex sensitivity, but not local or vasoconstrictor reflex-mediated microcirculatory responses. Cold-pressor-sensitive subjects exhibited significantly lower pain thresholds also for cold, heat, and blunt pressure, and enhanced pain summation, but no significant differences in Aδ-nociceptor-mediated punctate mechanical pain. In conclusion, differences in nociceptive signal processing drove systemic cardiovascular responses. Baroreceptor activation suppressed pain and cardiovascular responses more efficiently in CP-insensitive subjects. Cold-pressor sensitivity generalized to a pain trait of C-fiber-mediated nociceptive channels, which was independent of local thermal and vascular changes in the ice-water-exposed hand. Thus, the C-fiber pain trait reflects gain setting of the nociceptive system.

The sensory and affective components of pain differentially shape pupillary dilatation during cold pressor tests

Nociceptive and affective stimuli increase reflex sympathetic outflow to the pupils. To investigate effects of stimulus intensity, unpleasantness and distress on these pupillary reflexes, and to assess their stability, healthy participants immersed their hand in ice-water three times (for 20, 40 and 60 s; or 60, 40 and 20 s; or three times for 60 s) (N = 21 in each condition). Each ice-water immersion was preceded by a 90 s warm water immersion. To evaluate phasic sympathetic influences on pupil diameter, pupillary re-dilatation after 1 s of bright light was assessed during the last 10 s of each immersion. By-and-large, pain ratings and pupil diameter were greater during longer than shorter ice-water immersions, and ice-water immersions facilitated pupillary re-dilatation after the flash stimulus. However, mean pupil diameter during ice- and warm water immersions, minor ipsilateral amplification of the pupillary response, and ratings of pain unpleasantness and distress decreased across the experiment. Together, these findings suggest that nociceptive input increased sympathetic pupillary tone and amplified phasic increases in sympathetic activity after exposure to light. However, tonic sympathetic influences on pupil diameter and lateralization decreased across repeated immersions, possibly as novel or threatening aspects of the experience declined. Pupillary nociceptive and affective reflexes involve the locus coeruleus, an integral component of neural circuits that heighten cortical arousal and regulate pain. As these reflexes appear to reflect different aspects of sensory and affective processing, their combined assessment might increase the sensitivity and specificity of tests of locus coeruleus function in patients with suspected deficits.

[Physiology of pain]

Pain research is based broadly on physiological disciplines and its development follows the methodological progress of the era, from classical psychophysiology to electrophysiological investigations at peripheral and central nociceptive systems, single cells and ion channels to modern imaging of nociceptive processing. Physiological pain research in Germany has long been part of an interdisciplinary research network extending beyond all political boundaries, and this situation has continued since molecular techniques started to dominate all biomedical research. Current scientific questions, such as intracellular nociceptive signal mechanisms, interactions with other physiological systems including the immune system, or the genetic basis of epidemic and chronic pain diseases can only be solved interdisciplinary and with international collaboration.

A literature review on the pharmacological sensitivity of human evoked hyperalgesia pain models

AIMS

Human evoked pain models can be used to determine the efficacy of new and existing analgesics and to aid in the identification of new targets. Aspects of neuropathic pain can be simulated by inducing hyperalgesia resulting from provoked sensitization. The present literature review aimed to provide insight into the sensitivity of different hyperalgesia and allodynia models of pharmacological treatment.

METHODS

A literature search was performed to identify randomized, double-blind, placebo-controlled studies that included human hyperalgesia pain models and investigated the pharmacodynamic effects of different classes of drugs.

RESULTS

Three hyperalgesia models [ultraviolet B (UVB) irradiation, capsaicin and thermode burn] have been used extensively. Assessment of hyperalgesia/allodynia and pharmacological effect are measured using challenge tests, which generally comprise thermal (heat/cold) or mechanical stimulation (pin-prick, stroking or impact). The UVB model was sensitive to the antihyperalgesic effects of nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids. The capsaicin model was partially sensitive to opioids. The burn model did not detect any antihyperalgesic effects when NSAIDs or local anaesthetics were administered but responded to the effects of N-methyl D-aspartate (NMDA) receptor antagonists by moderately reducing mechanical hyperalgesia.

CONCLUSIONS

Based on pharmacological sensitivity, the UVB model adequately reflects inflammatory pain and was sensitive to NSAIDs and opioids. Findings from the capsaicin and burn models raised questions about the translatability of these models to the treatment of neuropathic pain. There is a need for a reproducible and predictive model of neuropathic pain, either in healthy subjects or in patients.

The Scalp Confounds Near-Infrared Signal from Rat Brain Following Innocuous and Noxious Stimulation

Functional near-infrared imaging (fNIRI) is a non-invasive, low-cost and highly portable technique for assessing brain activity and functions. Both clinical and experimental evidence suggest that fNIRI is able to assess brain activity at associated regions during pain processing, indicating a strong possibility of using fNIRI-derived brain activity pattern as a biomarker for pain. However, it remains unclear how, especially in small animals, the scalp influences fNIRI signal in pain processing. Previously, we have shown that the use of a multi-channel system improves the spatial resolution of fNIRI in rats (without the scalp) during pain processing. Our current work is to investigate a scalp effect by comparing with new data from rats with the scalp during innocuous or noxious stimulation (n = 6). Results showed remarkable stimulus-dependent differences between the no-scalp and intact-scalp groups. In conclusion, the scalp confounded the fNIRI signal in pain processing likely via an autonomic mechanism; the scalp effect should be a critical factor in image reconstruction and data interpretation.

Enhanced pain and autonomic responses to ambiguous visual stimuli in chronic Complex Regional Pain Syndrome (CRPS) type I

Cortical reorganisation of sensory, motor and autonomic systems can lead to dysfunctional central integrative control. This may contribute to signs and symptoms of Complex Regional Pain Syndrome (CRPS), including pain. It has been hypothesised that central neuroplastic changes may cause afferent sensory feedback conflicts and produce pain. We investigated autonomic responses produced by ambiguous visual stimuli (AVS) in CRPS, and their relationship to pain. Thirty CRPS patients with upper limb involvement and 30 age and sex matched healthy controls had sympathetic autonomic function assessed using laser Doppler flowmetry of the finger pulp at baseline and while viewing a control figure or AVS. Compared to controls, there were diminished vasoconstrictor responses and a significant difference in the ratio of response between affected and unaffected limbs (symmetry ratio) to a deep breath and viewing AVS. While viewing visual stimuli, 33.5% of patients had asymmetric vasomotor responses and all healthy controls had a homologous symmetric pattern of response. Nineteen (61%) CRPS patients had enhanced pain within seconds of viewing the AVS. All the asymmetric vasomotor responses were in this group, and were not predictable from baseline autonomic function. Ten patients had accompanying dystonic reactions in their affected limb: 50% were in the asymmetric sub-group. In conclusion, there is a group of CRPS patients that demonstrate abnormal pain networks interacting with central somatomotor and autonomic integrational pathways.

Immersing the foot in painfully-cold water evokes ipsilateral extracranial vasodilatation

Temporal pulse amplitude was recorded bilaterally in 56 participants before, during and after three ice-water immersions of the foot. Half of the participants were told that prolonged exposure to freezing temperatures could cause frostbite. Increases in pulse amplitude were greater in the ipsilateral than contralateral temple during and after the three foot-immersions. Although pulse amplitude decreased after threatening instructions and repeated immersion of the foot, the vasodilator response persisted during all three immersions. These findings suggest that nociceptive stimulation of the foot evokes an ipsilateral supra-spinal extracranial vasodilator response, possibly as part of a broader defense response.

Contributions of dorsal root reflex and axonal reflex to formalin-induced inflammation

The dorsal root reflex (DRR) and the axonal reflex (AR) are antidromic activities in primary afferents and are involved in neurogenic inflammation. DRRs and/or ARs lead to release of neuropeptides calcitonin gene-related peptide (CGRP) and substance P (SP). CGRP causes blood vessels to dilate leading to an increase in blood perfusion, whereas SP causes plasma extravasation, leading to edema. Both DRR and AR can be evoked by noxious stimuli. The goal of this study was to determine the role of DRR and AR in neurogenic inflammation by examining the blood perfusion (BP) change in hindpaws in response to formalin injection (an acute inflammatory agent). Laser Doppler images were collected simultaneously in both hindpaws in anesthetized rats to determine the level of BP. Local lidocaine was applied to the left sciatic nerve to block both orthodromic signals and antidromic DRRs without affecting ARs. All rats then received a subcutaneous formalin injection to the left hindpaw. Our results showed that (1) the mean BP of the left paw increased significantly following formalin injection, with or without lidocaine; (2) application of lidocaine in the left sciatic nerve alone significantly increased BP ipsilaterally; (3) formalin injection following lidocaine application significantly increased BP more than the group without lidocaine; and (4) there was delayed significant BP increase in the right (contralateral) hindpaw following formalin injection with or without lidocaine. It is concluded that ARs play a more important role than DRRs in formalin-induced neurogenic inflammation.

Immersion of the hand in ice water releases adrenergic vasoconstrictor tone in the ipsilateral temple

Immersion of the hand in painfully cold water induces cutaneous vasodilatation in the temples, more so ipsilaterally than contralaterally. To investigate the mechanism of this response, guanethidine or saline was administered by transcutaneous iontophoresis to a recording site in the temple of ten participants before they immersed one of their hands in ice water. Guanethidine displaces noradrenaline from sympathetic nerve terminals and inhibits sympathetic noradrenergic neurotransmission. Therefore, it was hypothesized that guanethidine pre-treatment would block vasodilatation mediated by release of sympathetic vasoconstrictor tone in cutaneous vessels in the temple. During hand immersion, increases in the amplitude of the pulse waveform detected by laser Doppler flowmetry were greater in the ipsilateral than contralateral temple (86% vs. 34% above baseline, p<0.05), and pre-treatment with guanethidine prevented this asymmetric response (ipsilateral response 21% above baseline and contralateral response 32%, difference not significant). Guanethidine also inhibited ipsilateral increases in cutaneous blood flow during hand immersion in responsive participants. These findings suggest that limb pain inhibited ipsilateral adrenergic vasoconstrictor outflow in the temple. Thus, the findings challenge the concept of the sympathetic nervous system as a "mass action" system that discharges in unison to meet environmental demands. Instead, they suggest that the sympathetic nervous system is highly differentiated, with separate control of discrete reflex pathways on each side of the body.

Effects of repeated electrocutaneous pain stimulation on facial blood flow

The purpose of the study was to examine the effects of repeated electrocutaneous pain stimulation of the hand on facial blood flow responses in healthy human subjects (58 adult women). Finger blood flow, mean arterial blood pressure, and heart rate were also monitored. To investigate the influence of psychological factors, the subjects' affect states were assessed, and physiological responding was explored during cognitive distraction, i.e., when attention was turned away from the unpleasant stimulus. Consistently, electrocutaneous stimulation elicited vasodilatation in the cheek, together with finger vasoconstriction. This response pattern was evident even at non-painful stimulation intensities. The facial blood flow response showed habituation across stimulation trials and was largely unrelated to systemic cardiovascular changes, affect states, and attentional manipulation. These findings indicate (1) that the experimentally induced facial blood flow changes are part of a non-specific physiological response pattern elicited during noxious stimulation, and (2) that they are not dependent on regional (orofacial) stimulation for their occurrence.

Convergence of cutaneous, muscular and visceral noxious inputs onto ventromedial thalamic neurons in the rat

We have recently described a population of neurons in the lateral part of the ventromedial thalamus (VMl), that respond exclusively to noxious cutaneous stimuli, regardless of which part of the body is stimulated. The purpose of the present study was to investigate the convergence of cutaneous, muscular and visceral noxious inputs onto single, VMl neurons in anesthetized rats. VMl neurons were characterized by their responses to Adelta- and C-fiber activation as well as noxious heat applied to the hindpaw. We investigated whether they responded also to colorectal distensions. In an additional series of experiments, we tested the effects of colorectal, intraperitoneal, intramuscular and subcutaneous applications of the chemical irritant mustard oil (MO). The present study shows that a population of neurons located within the thalamic VMl nucleus, carries nociceptive somatosensory signals from the entire body. All these neurons responded to noxious cutaneous and intramuscular stimuli but not to levels of distension that could be considered innocuous or noxious, of the intact and inflammed colon and rectum. Although colorectal distension did not elicit VMl responses, convergence of visceral as well as muscle and cutaneous nociceptors was demonstrated by the increases in ongoing (background) discharges following intracolonic MO. A distinct effect is seen after MO injection into the lumen of the colon: an increase in ongoing activity for 15min but still a lack of effect of colorectal distension. Moreover, following inflammation induced by subcutaneous injections of MO VMl neurons developed responses to both thermal and mechanical innocuous skin stimulation, reminiscent of allodynia phenomena. It is suggested that the VMl contributes to attentional aspects of nociceptive processing and/or to the integration of widespread noxious events in terms of the appropriate potential motor responses.

Biphasic vasomotor reflex responses of the hand skin following intradermal injection of melittin into the forearm skin

Melittin is the main toxin of honeybee venom. Previously, we have reported that intradermal injection of melittin into the volar aspect of forearm in humans produces a temporary pain and a subsequent sustained increase in the skin temperature due to axon reflex. To clarify the interaction between nociceptive inputs and vascular changes, we studied the influence of noxious stimulation by intradermal melittin on the vasomotor control of the distal extremities in human volunteers. Temperature changes of the bilateral palmar surface were recorded by means of a computer-assisted infrared thermography. Unexpectedly, we found a biphasic response of skin temperature. The skin temperature of both fingers and hands decreased immediately after the melittin injection and then increased well above the control level, prior to the injection. There was a considerable individual variation in the baseline skin temperature, prior to melittin. The skin temperature in a finger/hand with lower preinjection value increased more markedly in the second phase. Consequently, the individual variation in the peak temperature of the second phase was less pronounced. The initial decrease was interpreted as sympathetic vasoconstrictor reflex induced by noxious stimulation and the later increase as release of sympathetic vasomotor tone.

Effect of local application of cold or heat for relief of pricking pain

The present study was designed to determine the effect of the application of cold or heat on the sensation of pricking pain based on autonomic responses. Electrical stimulation was applied to the antebrachium or brachium of subjects as an artificial pricking pain, and skin blood flow (BF) and skin conductance level (SCL) at the fingertip were measured. Pain sensation was evaluated using the visual analog scale. Pain stimulation produced a significant increase in SCL and a significant decrease in BF at both the antebrachium and brachium. Application of cold to the stimulation site using an ice-water pack reduced BF and SCL responses and pain sensation. Application of heat using a hot water bottle caused a significant increase in pain sensation and enhancement of BF and SCL responses. These results suggest that application of cold promotes relief of pricking pain sensation and suppression of autonomic responses, and that application of heat has no such effect. It is important that nurses ascertain the type of pain or source of pain and take proper measures for its relief.

The importance of stimulus site and intensity in differences of pain-induced vascular reflexes in human orofacial regions

Studies in anaesthetized animals have indicated that noxious stimulation may produce marked blood flow changes in various orofacial structures, but the influence of painful stimulation on the blood flow regulation of the orofacial area of humans has been studied only to a limited extent. The purpose of this investigation was to study whether there are differences in temporal and spatial patterns of pain-induced vasoactive reflexes between various orofacial regions and hand in healthy human volunteers. Dynamic changes in blood flow in various orofacial regions elicited by painful stimulation of the tooth and finger were measured by means of Laser Doppler imaging (LDI) and computer-assisted infrared thermography (IRT). Blood flow of the finger was recorded by laser Doppler flowmetry (LDF) and plethysmography (PLET). During both stimulus paradigms there was a transient elevation in heart rate (HR) and blood pressure (BP). At the same time there was a significant blood flow decrease in the finger (LDF, PLET) and in the nose (LDI, IRT). In contrast to tooth stimulation, finger stimulation caused a more marked blood flow reduction in the finger. Only high intensity tooth stimulation, but not finger stimulation, caused a long-lasting vasodilatation both in lower and upper lip. The blood flow changes in the lips were not correlated with changes in systemic blood pressure or heart rate. In the cheek, there were no marked flow changes during either finger or tooth stimulation. These data indicate that painful tooth (regional) stimulation, but not finger (remote) stimulation, can induce a long-lasting vasodilatation in parts of orofacial tissues which cannot be explained by changes in central cardiovascular parameters. This tooth-stimulation-induced blood flow increase supports the hypothesis of a special vasodilator reflex mechanism in the orofacial area. Furthermore, tooth-stimulation-induced vasoconstriction in the nose and dilatation in the lips indicate that separate vasoactive reflex mechanisms may exist for different orofacial regions.

Computer-assisted infrared thermographic study of axon reflex induced by intradermal melittin

The aim of the present study was to investigate whether melittin, the principal toxin of the honeybee (Apis mellifera) venom, can be used as an algogenic agent in the study of pain in humans. Five micrograms of melittin in 0.5 ml of saline was intradermally injected into the volar aspect of the forearm. Resultant pain was scored by a visual analogue scale (VAS), and skin temperature change was analyzed by means of a computer-assisted infrared thermography. Intradermal melittin temporarily produced severe pain, followed by a sustained increase in skin temperature. The skin temperature increase peaked in about 10 min and outlasted 1 h. Topical application of 10% lidocaine gel did not significantly suppress the melittin-induced pain, but markedly suppressed both the increase in the peak temperature and the area of temperature increase. In conclusion, 5 microg of melittin is sufficient to produce pain in humans and 10% lidocaine gel differentially decreases the melittin-induced axon reflex without any significant analgesic effect.

Rhythmic sympathetic discharges and 'escape behaviour'

The characteristic rhythmical discharges of single postganglionic sympathetic neurones (PSNs) innervating the caudal ventral tail artery (CVA) of anaesthetised rats can still be recorded following the sectioning of afferents arising from the tail and hindquarters. Consequently, we suggest that such rhythmical discharges are neither a 'local sign' sympathetic response nor a sympathetic correlate of 'escape behaviour'.

Correlation between local vascular and sensory changes following tissue inflammation induced by repetitive application of topical capsaicin

The aim of the present study was to investigate local vascular and sensory changes and their correlation in order to obtain a better understanding of the mechanisms of allodynia, hyperalgesia and vascular changes following tissue inflammation induced by repetitive application of capsaicin cream. This type of application was utilized as a controlled model of inflammation which was altered in intensity due to its repetitive applicability. Ten healthy volunteers participated in two experiments separated by at least five days. Each experiment consisted of a baseline session followed by five additional sessions. Before these sessions either 1.5 g capsaicin (1%) or placebo cream was applied to the volar site of the forearm for 15 min. The areas of stroking allodynia and pin-prick hyperalgesia were mapped and the intensity of spontaneous pain (VAS) was assessed after each application of the cream. In addition, the visible flare, temperature (IR-Thermography), and blood- flow (Laser-Doppler) were measured. The first application of capsaicin was perceived as painful; it induced both secondary hyperalgesia and allodynia. Compared to placebo, the first application of capsaicin cream also resulted in an increased blood-flow, elevated temperature and visible flare. The highest values of these sensory and vascular parameters were reached after the third application. A direct correlation between visible flare, secondary mechanical hyperalgesia and allodynia following repetitive application of capsaicin indicates that both common central and peripheral mechanisms were involved in these changes.