Effect of muscle relaxants on experimental jaw-muscle pain and jaw-stretch reflexes: a double-blind and placebo-controlled trial

Sterile water; a novel and promising human experimental craniofacial muscle pain model

BACKGROUND

The aim of this study was to investigate if intramuscular injection of sterile water can be used as a human experimental pain model that resembles clinical craniofacial muscle pain and to analyse if the effects differ between sexes.

METHODS

This randomised, double-blind, placebo-controlled cross-over study included 30 healthy age-matched women and men (23.6 ± 2.4 years). At three sessions, with at least one week of washout in between, 0.2 mL of either sterile water (test-substance), hypertonic saline (58.5 mg/mL; active control) or isotonic saline (0.9 mg/mL; passive control) was randomly injected into the right masseter muscle. Pain intensity (VAS) was continuously assessed during 5 min whereafter pain duration (s) and pain area (au) were calculated; pressure pain thresholds (PPT;kPa) were recorded every 5 minutes during 30 minutes.

RESULTS

Sterile water evoked pain of similar intensity (74.5 ± 49.9) as hypertonic saline (74.0 ± 50.5); whereas, isotonic saline evoked low-intensity pain (11.4 ± 23.4). The pain induced by sterile water and hypertonic saline had higher intensity (P < 0.001), longer duration (P < 0.001) and larger pain area (P < 0.001) than isotonic saline. There were no significant differences in any pain variable between sterile water and hypertonic saline. The PPT did not change significantly after any substance, except for in women 5 minutes after sterile water injection (P < 0.002). Pain duration was longer in the men for all substances (P < 0.006), while the pain area was larger in women after injection of hypertonic saline (P < 0.003).

CONCLUSION

These results indicate that pain evoked by sterile water resembles clinical muscle pain and may offer a novel and simpler alternative to hypertonic saline injections.

Effect of peripherally and cortically evoked swallows on jaw reflex responses in anesthetized rabbits

This study aimed to investigate whether the jaw-opening (JOR) and jaw-closing reflexes (JCR) are modulated during not only peripherally, but also centrally, evoked swallowing. Experiments were carried out on 24 adult male Japanese white rabbits. JORs were evoked by trigeminal stimulation at 1 Hz for 30 s. In the middle 10 s, either the superior laryngeal nerve (SLN) or cortical swallowing area (Cx) was simultaneously stimulated to evoke swallowing. The peak-to-peak JOR amplitude was reduced during the middle and late 10-s periods (i.e., during and after SLN or Cx stimulation), and the reduction was dependent on the current intensity of SLN/Cx stimulation: greater SLN/Cx stimulus current resulted in greater JOR inhibition. The reduction rate was significantly greater during Cx stimulation than during SLN stimulation. The amplitude returned to baseline 2 min after 10-s SLN/Cx stimulation. The effect of co-stimulation of SLN and Cx was significantly greater than that of SLN stimulation alone. There were no significant differences in any parameters of the JCR between conditions. These results clearly showed that JOR responses were significantly suppressed, not only during peripherally evoked swallowing but also during centrally evoked swallowing, and that the inhibitory effect is likely to be larger during centrally compared with peripherally evoked swallowing. The functional implications of these results are discussed.

Quantification of Meloxicam in Human Plasma Using Ionic Liquid-Based Ultrasound-Assisted In Situ Solvent Formation Microextraction Followed by High-Performance Liquid Chromatography

A robust extraction method against the variations of sample ionic strength viz. ionic liquid-based ultrasound-assisted in situ solvent formation microextraction (IL-UA-ISFME) was coupled for the first time with high-performance liquid chromatography-ultraviolet detection (HPLC-UV), and successfully used as a more sustainable approach for the determination of meloxicam (MEL) in human plasma. Herein, a hydrophobic IL (1-butyl-3-methylimidazolium hexafluorophosphate) was formed by adding a hydrophilic IL (1-butyl-3-methylimidazolium tetrafluoroborate) to aqueous sample solution containing an ion-exchange reagent (sodium hexafluorophosphate). The target analyte was transferred into the IL medium while the extraction solvent was completely dispersed into the sample using ultrasonic irradiation and then, the settled enriched phase was injected to HPLC. Firstly, main factors affecting the microextraction performance were evaluated and optimized. The linearity was in the range of 5-1,500 ng mL-1 with regression coefficient corresponding to 0.997. Limits of detection (LOD; signal-to-noise ratio (S/N) = 3) and quantification (LOQ, S/N = 10) were 1 and 5 ng mL-1, respectively. An acceptable recovery range of 82.1-93.6% and satisfactory intra-assay (3.6-4.8%, n = 6) and inter-assay (3.3-5.1%, n = 9) precision as well as remarkable sample clean up exhibited good efficiency of the method. The freeze-thaw stability study was performed for samples and standard solutions. To study the applicability of the proposed method, it was employed for the determination of MEL in human plasma after oral administration of the drug and some pharmacokinetic data were achieved. The technique proved to be accurate and reliable for the screening intentions.

Perspectives on next steps in classification of oro-facial pain - Part 3: biomarkers of chronic oro-facial pain - from research to clinic

The purpose of this study was to review the current status of biomarkers used in oro-facial pain conditions. Specifically, we critically appraise their relative strengths and weaknesses for assessing mechanisms associated with the oro-facial pain conditions and interpret that information in the light of their current value for use in diagnosis. In the third section, we explore biomarkers through the perspective of ontological realism. We discuss ontological problems of biomarkers as currently widely conceptualised and implemented. This leads to recommendations for research practice aimed to a better understanding of the potential contribution that biomarkers might make to oro-facial pain diagnosis and thereby fulfil our goal for an expanded multidimensional framework for oro-facial pain conditions that would include a third axis.

Basic aspects of the pharmacodynamics of tolperisone, a widely applicable centrally acting muscle relaxant

Tolperisone (2-methyl-1-(4-methylphenyl)-3-piperidin-1-ylpropan-1-one hydro-chloride) was introduced in the clinical practice more than forty years ago and is still evaluated as a widely applicable compound in pathologically elevated skeletal muscle tone (spasticity) and related pains of different origin. In the present review, basic pharmacodynamic effects measured on whole animals, analyses of its actions on cell and tissue preparations and molecular mechanism of action on sodium and calcium channels are summarized as recently significantly new data were reported.

Effect of tolperisone on the resting brain and on evoked responses, an phMRI BOLD study

Tolperisone is a voltage gated sodium channel blocker, centrally acting muscle relaxant drug, with a very advantageous side effect profile. Like other sodium channel blockers, it has weak affinity to the resting state and high affinity to the open/inactivated state of the channel. In this paper, its effect on BOLD responses in rat brain were elucidated both on the resting brain and paw stimulation evoked BOLD responses. Tolperisone did not exert any visible effect on resting brain, but strongly inhibited the paw stimulation evoked BOLD responses, showing somewhat higher efficacy in brain areas involved in pain sensation. This finding is in a good agreement with its sodium channel blocking profile. In the resting brain, most of the channels are in resting state. Electric train stimuli of the paw results in over activated neurons, where most sodium channels are in open or inactivated state. These data suggest that the very advantageous profile of tolperisone can be explained by its selective action on open or inactivated sodium channels of over-activated neurons in various brain regions rather than by a selective effect in the spinal cord as suggested previously.

Enantioselective separation and simultaneous determination of tolperisone and eperisone in rat plasma by LC-MS/MS

Tolperisone and eperisone used as muscle relaxants possess one chiral center each and exist as two optical isomers for each drug. Therefore, enantioselective assays to measure each enantiomer in biological matrices are of great importance. In the present study a simple and complete reverse-phase liquid chromatography tandem mass spectrometric method for separation and enantioselective determination of tolperisone and eperisone in rat plasma was developed. The analytes were extracted from rat plasma by a simple protein precipitation method with acetonitrile as the extraction solvent. The enantioselective separation of analytes was achieved on a Cellulose Tris (4-chloro-3-methylphenylcarbamate) chiral column with a mobile phase of acetonitrile: 10 mM ammonium acetate in an isocratic mode of elution and mass spectrometric detection. The calibration curve for each enantiomer was found to be linear over 0.2 to 20 ng/mL for each enantiomer. The proposed method exhibited good intra- and interday precision (% CV) ranged between 0.95-6.05% and 1.11-8.21%, respectively. The intra- and interday accuracy for the proposed assay method ranged between 94.0-100.5% and 92.7-102.1%, respectively. The proposed method was validated as per regulatory guidelines.

Clinical pharmacology of analgesics assessed with human experimental pain models: bridging basic and clinical research

The medical impact of pain is such that much effort is being applied to develop novel analgesic drugs directed towards new targets and to investigate the analgesic efficacy of known drugs. Ongoing research requires cost-saving tools to translate basic science knowledge into clinically effective analgesic compounds. In this review we have re-examined the prediction of clinical analgesia by human experimental pain models as a basis for model selection in phase I studies. The overall prediction of analgesic efficacy or failure of a drug correlated well between experimental and clinical settings. However, correct model selection requires more detailed information about which model predicts a particular clinical pain condition. We hypothesized that if an analgesic drug was effective in an experimental pain model and also a specific clinical pain condition, then that model might be predictive for that particular condition and should be selected for development as an analgesic for that condition. The validity of the prediction increases with an increase in the numbers of analgesic drug classes for which this agreement was shown. From available evidence, only five clinical pain conditions were correctly predicted by seven different pain models for at least three different drugs. Most of these models combine a sensitization method. The analysis also identified several models with low impact with respect to their clinical translation. Thus, the presently identified agreements and non-agreements between analgesic effects on experimental and on clinical pain may serve as a solid basis to identify complex sets of human pain models that bridge basic science with clinical pain research.

Clinical comparative study: efficacy and tolerability of tolperisone and thiocolchicoside in acute low back pain and spinal muscle spasticity

Study Design

We performed a multicentric, randomized, comparative clinical trial. Eligible patients were randomly assigned to receive 150 mg of Tolperisone thrice daily or 8 mg of Thiocolchicoside twice daily for 7 days.

Purpose

To assess the efficacy and tolerability of Tolperisone in comparison with Thiocolchicoside in the treatment of acute low back pain with spasm of spinal muscles.

Overview of Literature

No head on clinical trial of Tolperisone with Thiocolchicoside is available and so this study is done.

Methods

The assessment of muscle spasm was made by measuring the finger-to-floor distance (FFD), articular excursion in degrees on performing Lasegue's maneuver and modified Schober's test. Assessment of pain on movement and spontaneous pain (pain at rest) of the lumbar spine was made with the help of visual analogue scale score.

Results

The improvement in articular excursion on Lasegue's maneuver was significantly greater on day 3 (p = 0.017) and day 7 (p = 0.0001) with Tolperisone as compared to Thiocolchicoside. The reduction in FFD score was greater on day 7 (p = 0.0001) with Tolperisone. However there was no significant difference in improvement in Schober's test score on day 3 (p = 0.664) and day 7 (p = 0.192). The improvement in pain score at rest and on movement was significantly greater with Tolperisone (^p = 0.0001).

Conclusions

Tolperisone is an effective and well tolerated option for treatment of patients with skeletal muscle spasm associated with pain.

Development and validation of a dissolution test for meloxicam and pridinol mesylate from combined tablet formulation

The association of meloxicam and pridinol is indicated for treating muscular contractures and low back pain. A dissolution test for the meloxicam-pridinol combined tablet formulation was developed and validated, using a suitable HPLC method for simultaneously quantitating both dissolved drugs. The optimized conditions include the use of USP apparatus 2 at a paddle rotation rate of 75 rpm and 900 ml of 50 mM phosphate buffer (pH= 7.5) as dissolution medium, at 37.0±0.5°. The test, which demonstrated to be robust against small changes in bath temperature, paddle rotation speed and pH of the dissolution medium, was applied to two different brands of tablets; the corresponding dissolution profiles were constructed and both brands showed to dissolve at least 75% of the drugs at the 45 min time point.

Effects of intense chewing exercises on the masticatory sensory-motor system

Nociceptive substances, injected into the masseter muscle, induce pain and facilitate the jaw-stretch reflex. It is hypothesized that intense chewing would provoke similar effects. Fourteen men performed 20 bouts of 5-minute chewing. After each bout, 20 min and 24 hrs after the exercise, muscle fatigue and pain scores and the normalized reflex amplitude from the left masseter muscle were recorded. Before, 20 min, and 24 hrs after the exercise, signs of temporomandibular disorders and pressure-pain thresholds of the masticatory muscles were also recorded. Fatigue and pain scores had increased during the exercise (P < 0.001), but the reflex amplitude did not (P = 0.123). Twenty minutes after the exercises, 12 participants showed signs of myofascial pain or arthralgia. Pressure-pain thresholds were decreased after 20 min (P = 0.009) and 24 hrs (P = 0.049). Intense chewing can induce fatigue, pain, and decreased pressure-pain thresholds in the masticatory muscles, without concomitant changes in the jaw-stretch reflex amplitude.

Tolperisone: a typical representative of a class of centrally acting muscle relaxants with less sedative side effects

Tolperisone, a piperidine derivative, is assigned to the group of centrally acting muscle relaxants and has been in clinical use now for decades. The review summarizes the known pharmacokinetics, pharmacodynamics, toxicology and side effects in humans and the clinical use of tolperisone. A future perspective for further exploration of this drug is given.

Effect of pinching-evoked pain on jaw-stretch reflexes and exteroceptive suppression periods in healthy subjects

OBJECTIVE

To investigate the influence of conditioning cutaneous nociceptive inputs by a new "pinch" model on the jaw-stretch reflex and the exteroceptive suppression periods (ES1 and ES2) in jaw muscles.

METHODS

The jaw-stretch reflex was evoked with the use of a custom-made muscle stretcher and electrical stimuli were used to evoke an early and late exteroceptive suppression period (ES1 and ES2) in the jaw-closing muscles. Electromyographic (EMG) activity was recorded bilaterally from the masseter and temporalis muscles. These brainstem reflexes were recorded in 19 healthy men (28.8+/-1.1 years) during three different conditions: one painful clip applied to the earlobe; one painful clip applied to the nostril, and four painful clips applied simultaneously to the earlobe, nostril, eyebrow, and lower lip. Pain intensity induced by the application of the clips was scored continuously by the subjects on a 100mm visual analogue scale (VAS).

RESULTS

The highest VAS pain scores were evoked by placement of four clips (79+/-0.5mm). There was no significant modulation of the jaw-stretch reflex (ANOVAs: P=0.929), the ES1 (P=0.298) or ES2 (P=0.082) in any of the three painful conditions.

CONCLUSIONS

Intense and tonic cutaneous pain could be elicited by this new "pinch" pain model; however, there was no significant modulation on either excitatory or inhibitory brainstem reflex responses.

SIGNIFICANCE

The novel observation that high-intensity pinch stimuli applied to the craniofacial region fail to modulate two different brainstem reflexes is in contrast to other experimental pain studies documented facilitation of the jaw-stretch reflexes or inhibition of exteroceptive suppression periods. The clinical implication of the present findings is that only some craniofacial pain conditions could be expected to show perturbation of the brainstem reflex responses.

HPLC determination of tolperisone in human plasma

A simple high performance liquid chromatographic (HPLC) method was developed for the determination of tolperisone in human plasma. Tolperisone and internal standard (chlorphenesin) were isolated from 1 mL of plasma using 8 mL of dichlormethane. The organic phase was collected and evaporated under nitrogen gas. The residue was then reconstituted with 300 mL aliquot of mobile phase and a 100 mL aliquot was injected onto the C18 reverse-phased column. The mobile phase, 45% methanol containing 1% glacial acetic acid and 0.05% 1-hexanesulfonic acid was run at a flow rate of 1 mL/min. The column effluent was monitored using UV detector at 260 nm. The retention times for tolperisone and the internal standard were approximately 7.1 and 8.4 min, respectively. The standard curve was linear with minimal intra-day and inter-day variability. The quantification limit of tolperisone in human plasma was 10 ng/ mL. The proposed method has been applied to the determination of pharmacokinetic profile of tolperisone in Koreans. The Tmax of tolperisone in Koreans (0.94 +/- 0.42 h) was not significantly differ from that reported in Europeans (0.5-1 h), but the mean half-life in Koreans (1.14 +/- 0.27 h) was shorter than that in Europeans (2.56 +/- 0.2 h). The proposed HPLC method is simple, accurate, reproducible and suitable for pharmacokinetic study of tolperisone.

Tolperisone-type drugs inhibit spinal reflexes via blockade of voltage-gated sodium and calcium channels

The spinal reflex depressant mechanism of tolperisone and some of its structural analogs with central muscle relaxant action was investigated. Tolperisone (50-400 microM), eperisone, lanperisone, inaperisone, and silperisone (25-200 microM) dose dependently depressed the ventral root potential of isolated hemisected spinal cord of 6-day-old rats. The local anesthetic lidocaine (100-800 microM) produced qualitatively similar depression of spinal functions in the hemicord preparation, whereas its blocking effect on afferent nerve conduction was clearly stronger. In vivo, tolperisone and silperisone as well as lidocaine (10 mg/kg intravenously) depressed ventral root reflexes and excitability of motoneurons. However, in contrast with lidocaine, the muscle relaxant drugs seemed to have a more pronounced action on the synaptic responses than on the excitability of motoneurons. Whole-cell measurements in dorsal root ganglion cells revealed that tolperisone and silperisone depressed voltage-gated sodium channel conductance at concentrations that inhibited spinal reflexes. Results obtained with tolperisone and its analogs in the [3H]batrachotoxinin A 20-alpha-benzoate binding in cortical neurons and in a fluorimetric membrane potential assay in cerebellar neurons further supported the view that blockade of sodium channels may be a major component of the action of tolperisone-type centrally acting muscle relaxant drugs. Furthermore, tolperisone, eperisone, and especially silperisone had a marked effect on voltage-gated calcium channels, whereas calcium currents were hardly influenced by lidocaine. These data suggest that tolperisone-type muscle relaxants exert their spinal reflex inhibitory action predominantly via a presynaptic inhibition of the transmitter release from the primary afferent endings via a combined action on voltage-gated sodium and calcium channels.

Glutamate evoked neck and jaw muscle pain facilitate the human jaw stretch reflex

OBJECTIVE

Although pain and neuromuscular function are clearly linked in several clinical conditions manifested in the craniofacial and cervical regions, it is unclear if pain in these regions influences reflexly evoked activity in the jaw or neck muscles in humans. The aim of the present study was to test the effects of glutamate-evoked jaw or neck muscle pain on the jaw stretch reflex recorded in both jaw and neck muscles.

METHODS

Nineteen healthy men participated in the study. Electromyographic (EMG) recordings were made from the left masseter (MAL) and right masseter (MAR) muscles and the right sternocleidomastoid (SCM) and splenius (SP) muscles. Glutamate (1 M) or isotonic saline was injected into the MAR or right SP in random order and then the other solution was injected 1-3 weeks later. Pain intensity was scored on a 10 cm visual analogue scale. Stretch reflexes were evoked by standardized jaw stretches before, during and 15 min after the end of the experimental muscle pain. Twenty trials were averaged in each condition.

RESULTS

Pain evoked by MAR or SP glutamate injections was associated with a significant increase in the stretch reflex amplitude recorded in both MAR and SCM. The onset and offset times and duration of the stretch reflex did not change in any muscle during the various pain conditions. Injection of isotonic saline into the MAR or SP did not produce any significant change in the reflex parameters in any of the muscles.

CONCLUSIONS

The results indicate the close interplay between the craniofacial and cervical regions in the neuromuscular changes that may result from musculoskeletal pain in either region.

SIGNIFICANCE

The changes in neuromuscular activity documented in this study may be involved in the clinical occurrence of altered muscle activity in the orofacial and cervical regions as a result of deep tissue trauma and pain.

Prophylactic tolperisone for post-exercise muscle soreness causes reduced isometric force--a double-blind randomized crossover control study

The role of tolperisone hydrochloride, a centrally acting muscle relaxant in relieving painful muscle spasm is recently being discussed. The present study hypothesizes that the prophylactic use of tolperisone hydrochloride may effectively relieve post-exercise muscle soreness, based on the spasm theory of exercise pain. Twenty male volunteers, aged 25.2 +/- 0.82 years (mean +/- SEM) participated in 10 sessions in which they received oral treatment with placebo or the centrally acting muscle relaxant tolperisone hydrochloride (150 mg) three times daily for 8 days, in randomized crossover double-blind design. Time course assessments were made for pressure pain threshold, Likert's pain score (0-5), pain areas, range of abduction, isometric force, and electromyography (EMG) root mean square (RMS) during maximum voluntary isometric force on day 1 and 6, immediately after an eccentric exercise of first dorsal interosseous muscle, and 24 and 48 h after the exercise. Treatment with placebo or tolperisone hydrochloride was initiated immediately after the assessments on the first day baseline assessments. On the sixth day baseline investigations were repeated and then the subjects performed six bouts of standardized intense eccentric exercise of first dorsal interosseous muscle for provocation of post-exercise muscle soreness (PEMS). Perceived intensity of warmth, tiredness, soreness and pain during the exercise bouts were recorded on a 10 cm visual analogue pain scale. VAS scores and pressure pain thresholds did not differ between tolperisone and placebo treatment. All VAS scores increased during the exercise bouts 2, 3, 4, 5 and 6 as compared to bout 1. Increased pain scores and pain areas were reported immediately after, 24 and 48 h after exercise. Pressure pain thresholds were reduced at 24 and 48 h after the exercise in the exercised hand. Range of abduction of the index finger was reduced immediately after the exercise and was still reduced at 24 h as compared to the non-exercised hand. The EMG RMS amplitude was also reduced immediately after the exercise, but was increased at 24 and 48 h. Isometric force was reduced immediately after the exercise as compared to days 1, 6, and the 24 and 48 h post-exercise assessments with a greater reduction following the tolperisone hydrochloride treatment and the reduction was more in tolperisone group as compared to the placebo group. The results suggest, that the prophylactic intake of tolperisone hydrochloride provides no relief to pain in course of post-exercise muscle soreness but results in reduction in isometric force.