Congruency of body-related information induces somatosensory reorganization

Effects of Nature-Based Multisensory Stimulation on Pain Mechanisms in Women with Fibromyalgia Syndrome: A Randomized Double-Blind Placebo-Controlled Trial

BACKGROUND

The term "nature-based sensory stimuli" refers to the sensory information produced by biotic and abiotic agents from natural environments. The literature has reported the beneficial effects of these agents on various pain dimensions in non-clinical populations.

AIMS

To evaluate the potential analgesic effects of nature-based multisensory stimulation in women with fibromyalgia syndrome.

METHODS

A randomized, double-blind, placebo-controlled, parallel-group trial with a 1:1 allocation ratio was conducted. Forty-two women with fibromyalgia syndrome interacted with either different plant species with flowers, stones, and soil organic matter or their synthetic imitations for 30 minutes. Outcome measurements were performed before and after the intervention, including clinical pain intensity using the Numeric Rating Scale, cold pain thresholds using the Cold Pressor Test, mechanical hyperalgesia and wind-up using a monofilament, and pressure pain thresholds using a pressure algometer.

RESULTS

Analyses revealed group × time interactions for clinical pain intensity (F = 7.915, p = .008), cold-water immersion time (F = 7.271, p = .010), mechanical hyperalgesia (F = 4.701, p = .036), and pressure pain threshold (p ≤ .017). Between-group differences were found in clinical pain intensity (p = .012), cold pain thresholds (p = .002), and pressure pain thresholds (p < .05). The experimental group exhibited reduced clinical pain intensity (p = .001) and increased pressure pain thresholds (p ≤ .034).

CONCLUSIONS

Women with fibromyalgia syndrome may benefit from multisensory stimulation using biotic and abiotic agents from natural environments for 30 minutes. Interacting with flowering plants and soil components appears to induce analgesic effects.

Temporal Electroencephalography Traits Dissociating Tactile Information and Cross-Modal Congruence Effects

To explore whether temporal electroencephalography (EEG) traits can dissociate the physical properties of touching objects and the congruence effects of cross-modal stimuli, we applied a machine learning approach to two major temporal domain EEG traits, event-related potential (ERP) and somatosensory evoked potential (SEP), for each anatomical brain region. During a task in which participants had to identify one of two material surfaces as a tactile stimulus, a photo image that matched ('congruent') or mismatched ('incongruent') the material they were touching was given as a visual stimulus. Electrical stimulation was applied to the median nerve of the right wrist to evoke SEP while the participants touched the material. The classification accuracies using ERP extracted in reference to the tactile/visual stimulus onsets were significantly higher than chance levels in several regions in both congruent and incongruent conditions, whereas SEP extracted in reference to the electrical stimulus onsets resulted in no significant classification accuracies. Further analysis based on current source signals estimated using EEG revealed brain regions showing significant accuracy across conditions, suggesting that tactile-based object recognition information is encoded in the temporal domain EEG trait and broader brain regions, including the premotor, parietal, and somatosensory areas.

Role of Immersive Virtual Reality in Motor Behaviour Decision-Making in Chronic Pain Patients

Primary chronic pain is a major contributor to disability worldwide, with an estimated prevalence of 20-33% of the world's population. The high socio-economic impact of musculoskeletal pain justifies seeking an appropriate therapeutic strategy. Immersive virtual reality (VR) has been proposed as a first-line intervention for chronic musculoskeletal pain. However, the growing literature has not been accompanied by substantial progress in understanding how VR exerts its impact on the pain experience and what neurophysiological mechanisms might be involved in the clinical effectiveness of virtual reality interventions in chronic pain patients. The aim of this review is: (i) to establish the state of the art on the effects of VR on patients with chronic pain; (ii) to identify neuroplastic changes associated with chronic pain that may be targeted by VR intervention; and (iii) to propose a hypothesis on how immersive virtual reality could modify motor behavioral decision-making through an interactive experience in patients with chronic pain.

Identifying Body Awareness-Related Brain Network Changes after Cognitive Multisensory Rehabilitation for Neuropathic Pain Relief in Adults with Spinal Cord Injury: Delayed Treatment arm Phase I Randomized Controlled Trial

Background

Neuropathic pain after spinal cord injury (SCI) is notoriously hard to treat. Mechanisms of neuropathic pain are unclear, which makes finding effective treatments challenging. Prior studies have shown that adults with SCI have body awareness deficits. Recent imaging studies, including ours, point to the parietal operculum and insula as key areas for both pain perception and body awareness. Cognitive multisensory rehabilitation (CMR) is a physical therapy approach that helps improve body awareness for pain reduction and sensorimotor recovery. Based on our prior brain imaging work in CMR in stroke, we hypothesized that improving body awareness through restoring parietal operculum network connectivity leads to neuropathic pain relief and improved sensorimotor and daily life function in adults with SCI. Thus, the objectives of this study were to (1) determine baseline differences in resting-state and task-based functional magnetic resonance imaging (fMRI) brain function in adults with SCI compared to healthy controls and (2) identify changes in brain function and behavioral pain and pain-associated outcomes in adults with SCI after CMR.

Methods

Healthy adults underwent a one-time MRI scan and completed questionnaires. We recruited community-dwelling adults with SCI-related neuropathic pain, with complete or incomplete SCI >3 months, and highest neuropathic pain intensity level of >3 on the Numeric Pain Rating Scale (NPRS). Participants with SCI were randomized into two groups, according to a delayed treatment arm phase I randomized controlled trial (RCT): Group A immediately received CMR intervention, 3x/week, 45 min/session, followed by a 6-week and 1-year follow-up. Group B started with a 6-week observation period, then 6 weeks of CMR, and a 1-year follow-up. Highest, average, and lowest neuropathic pain intensity levels were assessed weekly with the NPRS as primary outcome. Other primary outcomes (fMRI resting-state and functional tasks; sensory and motor function with the INSCI AIS exam), as well as secondary outcomes (mood, function, spasms, and other SCI secondary conditions), were assessed at baseline, after the first and second 6-week period. The INSCI AIS exam and questionnaires were repeated at the 1-year follow-up.

Findings

Thirty-six healthy adults and 28 adults with SCI were recruited between September 2020 and August 2021, and of those, 31 healthy adults and 26 adults with SCI were enrolled in the study. All 26 participants with SCI completed the intervention and pre-post assessments. There were no study-related adverse events. Participants were 52±15 years of age, and 1-56 years post-SCI. During the observation period, group B did not show any reductions in neuropathic pain and did not have any changes in sensation or motor function (INSCI ASIA exam). However, both groups experienced a significant reduction in neuropathic pain after the 6-week CMR intervention. Their highest level of neuropathic pain of 7.81±1.33 on the NPRS at baseline was reduced to 2.88±2.92 after 6 weeks of CMR. Their change scores were 4.92±2.92 (large effect size Cohen's d =1.68) for highest neuropathic pain, 4.12±2.23 ( d =1.85) for average neuropathic pain, and 2.31±2.07 ( d =1.00) for lowest neuropathic pain. Nine participants out of 26 were pain-free after the intervention (34.62%). The results of the INSCI AIS testing also showed significant improvements in sensation, muscle strength, and function after 6 weeks of CMR. Their INSCI AIS exam increased by 8.81±5.37 points ( d =1.64) for touch sensation, 7.50±4.89 points ( d =1.53) for pin prick sensation, and 3.87±2.81 ( d =1.38) for lower limb muscle strength. Functional improvements after the intervention included improvements in balance for 17 out of 18 participants with balance problems at baseline; improved transfers for all of them and a returned ability to stand upright with minimal assistance in 12 out of 20 participants who were unable to stand at baseline. Those improvements were maintained at the 1-year follow-up. With regard to brain imaging, we confirmed that the resting-state parietal operculum and insula networks had weaker connections in adults with SCI-related neuropathic pain (n=20) compared to healthy adults (n=28). After CMR, stronger resting-state parietal operculum network connectivity was found in adults with SCI. Also, at baseline, as expected, right toe sensory stimulation elicited less brain activation in adults with SCI (n=22) compared to healthy adults (n=26). However, after CMR, there was increased brain activation in relevant sensorimotor and parietal areas related to pain and mental body representations (i.e., body awareness and visuospatial body maps) during the toe stimulation fMRI task. These brain function improvements aligned with the AIS results of improved touch sensation, including in the feet.

Interpretation

Adults with chronic SCI had significant neuropathic pain relief and functional improvements, attributed to the recovery of sensation and movement after CMR. The results indicate the preliminary efficacy of CMR for restoring function in adults with chronic SCI. CMR is easily implementable in current physical therapy practice. These encouraging impressive results pave the way for larger randomized clinical trials aimed at testing the efficacy of CMR to alleviate neuropathic pain in adults with SCI.

Clinical Trial registration

ClinicalTrials.gov Identifier: NCT04706208.

Funding

AIRP2-IND-30: Academic Investment Research Program (AIRP) University of Minnesota School of Medicine. National Center for Advancing Translational Sciences of the National Institutes of Health Award Number UL1TR002494; the Biotechnology Research Center: P41EB015894, the National Institute of Neurological Disorders & Stroke Institutional Center Core Grants to Support Neuroscience Research: P30 NS076408; and theHigh-Performancee Connectome Upgrade for Human 3T MR Scanner: 1S10OD017974.

Identifying Body Awareness-Related Brain Network Changes After Cognitive Multisensory Rehabilitation for Neuropathic Pain Relief in Adults With Spinal Cord Injury: Protocol of a Phase I Randomized Controlled Trial

Background

About 69% of the 299,000 Americans living with spinal cord injury (SCI) experience long-term debilitating neuropathic pain. New treatments are needed because current treatments do not provide enough pain relief. We have found that insular-opercular brain network alterations may contribute to neuropathic pain and that restoring this network could reduce neuropathic pain. Here, we outline a study protocol using a physical therapy approach, cognitive multisensory rehabilitation (CMR), which has been shown to restore OP1/OP4 connections in adults post stroke, to test our hypothesis that CMR can normalize pain perception through restoring OP1/OP4 connectivity in adults with SCI and relieve neuropathic pain.

Objectives

To compare baseline brain function via resting-state and task-based functional magnetic resonance imaging in adults with SCI versus uninjured controls, and to identify changes in brain function and behavioral pain outcomes after CMR in adults with SCI.

Methods

In this phase I randomized controlled trial, adults with SCI will be randomized into two groups: Group A will receive 6 weeks of CMR followed by 6 weeks of standard of care (no therapy) at home. Group B will start with 6 weeks of standard of care (no therapy) at home and then receive 6 weeks of CMR. Neuroimaging and behavioral measures are collected at baseline, after the first 6 weeks (A: post therapy, B: post waitlist), and after the second 6 weeks (A: post-therapy follow-up, B: post therapy), with follow-up of both groups up to 12 months.

Conclusion

The successful outcome of our study will be a critical next step toward implementing CMR in clinical care to improve health in adults with SCI.

Somatosensory evoked potentials that index lateral inhibition are modulated according to the mode of perceptual processing: comparing or combining multi-digit tactile motion

Many perceptual studies focus on the brain's capacity to discriminate between stimuli. However, our normal experience of the world also involves integrating multiple stimuli into a single perceptual event. Neural mechanisms such as lateral inhibition are believed to enhance local differences between sensory inputs from nearby regions of the receptor surface. However, this mechanism would seem dysfunctional when sensory inputs need to be combined rather than contrasted. Here, we investigated whether the brain can strategically regulate the strength of suppressive interactions that underlie lateral inhibition between finger representations in human somatosensory processing. To do this, we compared sensory processing between conditions that required either comparing or combining information. We delivered two simultaneous tactile motion trajectories to index and middle fingertips of the right hand. Participants had to either compare the directions of the two stimuli, or to combine them to form their average direction. To reveal preparatory tuning of somatosensory cortex, we used an established event-related potential design to measure the interaction between cortical representations evoked by digital nerve shocks immediately before each tactile stimulus. Consistent with previous studies, we found a clear suppression between cortical activations when participants were instructed to compare the tactile motion directions. Importantly, this suppression was significantly reduced when participants had to combine the same stimuli. These findings suggest that the brain can strategically switch between a comparative and a combinative mode of somatosensory processing, according to the perceptual goal, by preparatorily adjusting the strength of a process akin to lateral inhibition.

A Continuous Illusion of Having a Sixth Finger

Our body is central to our sense of self and personal identity, yet it can be manipulated in the laboratory in surprisingly easy ways. Several multisensory illusions have shown the flexibility of the mental representation of our bodies by inducing the illusion of owning an artificial body part or having a body part with altered features. Recently, new studies showed we can embody additional body parts such as a supernumerary finger. Newport et al. recently reported a novel six-finger illusion using conflicting visual and tactile signals induced with the mirror box to create the illusory perception of having a sixth finger for a brief moment. In this study, we aimed to replicate this result and to investigate whether the experience of embodiment of a sixth finger could be prolonged for an extended duration by applying continuous visual-tactile stimulation. Results showed that a continuous illusion of having a sixth finger can be clearly induced. This shows that the six-finger illusion does not reflect merely a momentary confusion due to conflicting multisensory signals but can reflect an enduring representation of a supernumerary finger.

Modality-specific attention attenuates visual-tactile integration and recalibration effects by reducing prior expectations of a common source for vision and touch

At any moment in time, streams of information reach the brain through the different senses. Given this wealth of noisy information, it is essential that we select information of relevance - a function fulfilled by attention - and infer its causal structure to eventually take advantage of redundancies across the senses. Yet, the role of selective attention during causal inference in cross-modal perception is unknown. We tested experimentally whether the distribution of attention across vision and touch enhances cross-modal spatial integration (visual-tactile ventriloquism effect, Expt. 1) and recalibration (visual-tactile ventriloquism aftereffect, Expt. 2) compared to modality-specific attention, and then used causal-inference modeling to isolate the mechanisms behind the attentional modulation. In both experiments, we found stronger effects of vision on touch under distributed than under modality-specific attention. Model comparison confirmed that participants used Bayes-optimal causal inference to localize visual and tactile stimuli presented as part of a visual-tactile stimulus pair, whereas simultaneously collected unity judgments - indicating whether the visual-tactile pair was perceived as spatially-aligned - relied on a sub-optimal heuristic. The best-fitting model revealed that attention modulated sensory and cognitive components of causal inference. First, distributed attention led to an increase of sensory noise compared to selective attention toward one modality. Second, attending to both modalities strengthened the stimulus-independent expectation that the two signals belong together, the prior probability of a common source for vision and touch. Yet, only the increase in the expectation of vision and touch sharing a common source was able to explain the observed enhancement of visual-tactile integration and recalibration effects with distributed attention. In contrast, the change in sensory noise explained only a fraction of the observed enhancements, as its consequences vary with the overall level of noise and stimulus congruency. Increased sensory noise leads to enhanced integration effects for visual-tactile pairs with a large spatial discrepancy, but reduced integration effects for stimuli with a small or no cross-modal discrepancy. In sum, our study indicates a weak a priori association between visual and tactile spatial signals that can be strengthened by distributing attention across both modalities.

Tool Use Modulates Somatosensory Cortical Processing in Humans

Tool use leads to plastic changes in sensorimotor body representations underlying tactile perception. The neural correlates of this tool-induced plasticity in humans have not been adequately characterized. This study used ERPs to investigate the stage of sensory processing modulated by tool use. Somatosensory evoked potentials, elicited by median nerve stimulation, were recorded before and after two forms of object interaction: tool use and hand use. Compared with baseline, tool use-but not use of the hand alone-modulated the amplitude of the P100. The P100 is a mid-latency component that indexes the construction of multisensory models of the body and has generators in secondary somatosensory and posterior parietal cortices. These results mark one of the first demonstrations of the neural correlates of tool-induced plasticity in humans and suggest that tool use modulates relatively late stages of somatosensory processing outside primary somatosensory cortex. This finding is consistent with what has been observed in tool-trained monkeys and suggests that the mechanisms underlying tool-induced plasticity have been preserved across primate evolution.

Incongruent multisensory stimuli alter bodily self-consciousness: Evidence from a first-person perspective experience

In our study, we aimed to reduce bodily self-consciousness using a multisensory illusion (MI), and tested whether this manipulation increases Self-objectification (the psychological attitude to perceive one's own body as an object). Participants observed their own body from a first-person perspective, through a head-mounted display, while receiving incongruent (or congruent) visuo-tactile stimulation on their abdomen or arms. Results showed stronger feelings of disownership, loss of agency and sensation of being out of ones' own body during incongruent compare to congruent stimulation. This reduced bodily self-consciousness did not affect Self-objectification. However, self-objectification (as measured by the appearance of control beliefs subscale of the Objectified Body Consciousness questionnaire) was positively correlated with the MI strength. Moreover, we investigated the impact of MI and Self-objectification on body size estimation. We found systematic body size underestimation, irrespective of type of stimulation or tendency to Self-objectification. These results document a simple yet effective approach to alter bodily self-consciousness, which however spare Self-objectification and body size-perception.

Neuropsychology of Human Body Parts: Exploring Categorical Boundaries of Tactile Perception Using Somatosensory Mismatch Responses

The focus of the current study is on a particular aspect of tactile perception: categorical segmentation on the body surface into discrete body parts. The MMN has been shown to be sensitive to categorical boundaries and language experience in the auditory modality. Here we recorded the somatosensory MMN (sMMN) using two tactile oddball protocols and compared sMMN amplitudes elicited by within- and across-boundary oddball pairs. Both protocols employed the identity MMN method that controls for responsivity at each body location. In the first protocol, we investigated the categorical segmentation of tactile space at the wrist by presenting pairs of tactile oddball stimuli across equal spatial distances, either across the wrist or within the forearm. Amplitude of the sMMN elicited by stimuli presented across the wrist boundary was significantly greater than for stimuli presented within the forearm, suggesting a categorical effect at an early stage of somatosensory processing. The second protocol was designed to investigate the generality of this MMN effect, and involved three digits on one hand. Amplitude of the sMMN elicited by a contrast of the third digit and the thumb was significantly larger than a contrast between the third and fifth digits, suggesting a functional boundary effect that may derive from the way that objects are typically grasped. These findings demonstrate that the sMMN is a useful index of processing of somatosensory spatial discrimination that can be used to study body part categories.

Insular balance of glutamatergic and GABAergic signaling modulates pain processing

Neuroimaging studies of patients with chronic pain have shown that neurotransmitter abnormalities, including increases in glutamate and decreases in GABA, could be responsible for the cortical hyperactivity and hyperalgesia/allodynia observed in some pain conditions. These finding are particularly evident in the insula, a brain region known to play a role in both the sensory-discriminative and the affective-motivational aspects of pain processing. However, clinical studies are not entirely able to determine the directionality of these findings, nor whether they are causal or epiphenomenon. Thus, a set of animal studies was performed to determine whether alterations in glutamate and GABA are the result of injury, the cause of augmented pain processing, or both. Compared with controls, the excitatory neurotransmitters glutamate and aspartate are significantly higher in the rat insula after chronic constriction injury of the sciatic nerve (CCI). The CCI also produced significant increases in allodynia (mechanical and cold), thermal hyperalgesia, and nociceptive aversiveness. Unilateral microinjection of ionotropic glutamate receptor antagonists restored these nociceptive behaviors to preinjury values. Increasing endogenous levels of GABA or enhancing signaling at inhibitory glycinergic receptors had similar effects as the glutamate receptor antagonists. In naive rats, increasing endogenous levels of glutamate, decreasing endogenous levels of GABA, or blocking strychnine-sensitive glycine receptors in the insula significantly increased thermal hyperalgesia and mechanical allodynia. These data support the hypothesis that an altered balance of excitatory and inhibitory neurotransmitters in brain regions such as the insula occurs in chronic pain states and leads to augmented central pain processing and increased pain sensitivity.

Bodily Sensory Inputs and Anomalous Bodily Experiences in Complex Regional Pain Syndrome: Evaluation of the Potential Effects of Sound Feedback

Neuroscientific studies have shown that human's mental body representations are not fixed but are constantly updated through sensory feedback, including sound feedback. This suggests potential new therapeutic sensory approaches for patients experiencing body-perception disturbances (BPD). BPD can occur in association with chronic pain, for example in Complex Regional Pain Syndrome (CRPS). BPD often impacts on emotional, social, and motor functioning. Here we present the results from a proof-of-principle pilot study investigating the potential value of using sound feedback for altering BPD and its related emotional state and motor behavior in those with CRPS. We build on previous findings that real-time alteration of the sounds produced by walking can alter healthy people's perception of their own body size, while also resulting in more active gait patterns and a more positive emotional state. In the present study we quantified the emotional state, BPD, pain levels and gait of twelve people with CRPS Type 1, who were exposed to real-time alteration of their walking sounds. Results confirm previous reports of the complexity of the BPD linked to CRPS, as participants could be classified into four BPD subgroups according to how they mentally visualize their body. Further, results suggest that sound feedback may affect the perceived size of the CRPS affected limb and the pain experienced, but that the effects may differ according to the type of BPD. Sound feedback affected CRPS descriptors and other bodily feelings and emotions including feelings of emotional dominance, limb detachment, position awareness, attention and negative feelings toward the limb. Gait also varied with sound feedback, affecting the foot contact time with the ground in a way consistent with experienced changes in body weight. Although, findings from this small pilot study should be interpreted with caution, they suggest potential applications for regenerating BDP and its related bodily feelings in a clinical setting for patients with chronic pain and BPD.

Visual illusion of tool use recalibrates tactile perception

Brief use of a tool recalibrates multisensory representations of the user's body, a phenomenon called tool embodiment. Despite two decades of research, little is known about its boundary conditions. It has been widely argued that embodiment requires active tool use, suggesting a critical role for somatosensory and motor feedback. The present study used a visual illusion to cast doubt on this view. We used a mirror-based setup to induce a visual experience of tool use with an arm that was in fact stationary. Following illusory tool use, tactile perception was recalibrated on this stationary arm, and with equal magnitude as physical use. Recalibration was not found following illusory passive tool holding, and could not be accounted for by sensory conflict or general interhemispheric plasticity. These results suggest visual tool-use signals play a critical role in driving tool embodiment.