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Li HL, Lin M, Tan XP, Wang JL. Role of Sensory Pathway Injury in Central Post-Stroke Pain: A Narrative Review of Its Pathogenetic Mechanism. J Pain Res 2023; 16:1333-1343. [PMID: 37101520 PMCID: PMC10124563 DOI: 10.2147/jpr.s399258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 04/07/2023] [Indexed: 04/28/2023] Open
Abstract
Central post-stroke pain (CPSP) is a severe chronic neuropathic pain syndrome that is a direct result of cerebrovascular lesions affecting the central somatosensory system. The pathogenesis of this condition remains unclear owing to its extensive clinical manifestations. Nevertheless, clinical and animal experiments have allowed a comprehensive understanding of the mechanisms underlying CPSP occurrence, based on which different theoretical hypotheses have been proposed. We reviewed and collected the literature and on the mechanisms of CPSP by searching the English literature in PubMed and EMBASE databases for the period 2002-2022. Recent studies have reported that CPSP occurrence is mainly due to post-stroke nerve injury and microglial activation, with an inflammatory response leading to central sensitization and de-inhibition. In addition to the primary injury at the stroke site, peripheral nerves, spinal cord, and brain regions outside the stroke site are involved in the occurrence and development of CPSP. In the present study, we reviewed the mechanism of action of CPSP from both clinical studies and basic research based on its sensory pathway. Through this review, we hope to increase the understanding of the mechanism of CPSP.
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Affiliation(s)
- Hai-Li Li
- Department of Pain Management, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, 646000, People’s Republic of China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, Sichuan Province, 646000, People’s Republic of China
| | - Min Lin
- Department of Pain Management, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, 646000, People’s Republic of China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, Sichuan Province, 646000, People’s Republic of China
| | - Xing-Ping Tan
- Department of Pain Management, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, 646000, People’s Republic of China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, Sichuan Province, 646000, People’s Republic of China
| | - Jiang-Lin Wang
- Department of Pain Management, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, 646000, People’s Republic of China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, Sichuan Province, 646000, People’s Republic of China
- Correspondence: Jiang-Lin Wang, Pain Department, The Affiliated Hospital of Southwest Medical University, No. 25 Pacific Street, Luzhou, Sichuan Province, 646000, People’s Republic of China, Tel +8618090880626, Fax +86830-3165469, Email
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Ma Y, Luo J, Wang XQ. The effect and mechanism of exercise for post-stroke pain. Front Mol Neurosci 2022; 15:1074205. [PMID: 36533131 PMCID: PMC9755671 DOI: 10.3389/fnmol.2022.1074205] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/18/2022] [Indexed: 08/30/2023] Open
Abstract
One of the common negative effects of a stroke that seriously lowers patients' quality of life is post-stroke pain (PSP). Thus, exercise in PSP management has become a hot research topic. The main advantages of exercise therapy are affordability and ease of acceptance by patients compared to other treatment methods. Therefore, this article reviews the effectiveness and possible mechanisms of exercise interventions for PSP. Exercise training for patients with PSP not only improves physical function but also effectively reduces pain intensity and attenuates the behavioral response to pain. In addition, exercise therapy can improve brain function and modulate levels of pro-inflammatory and neurotrophic factors to exert specific analgesic effects. Potential mechanisms for exercise intervention include modulation of synaptic plasticity in the anterior cingulate gyrus, modulation of endogenous opioids in vivo, reversal of brain-derived neurotrophic factor overexpression, inhibition of purinergic receptor (P2X4R, P2X7R) expression, and inhibition of microglia activation. However, current research on exercise for PSP remains limited, and the sustainable benefits of exercise interventions for PSP need to be further investigated.
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Affiliation(s)
- Yue Ma
- Department of Sport Rehabilitation, Xi’an Physical Education University, Xi’an, China
| | - Jing Luo
- Department of Sport Rehabilitation, Xi’an Physical Education University, Xi’an, China
| | - Xue-Qiang Wang
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
- Department of Rehabilitation Medicine, Shanghai Shangti Orthopaedic Hospital, Shanghai, China
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Infantino R, Schiano C, Luongo L, Paino S, Mansueto G, Boccella S, Guida F, Ricciardi F, Iannotta M, Belardo C, Marabese I, Pieretti G, Serra N, Napoli C, Maione S. MED1/BDNF/TrkB pathway is involved in thalamic hemorrhage-induced pain and depression by regulating microglia. Neurobiol Dis 2022; 164:105611. [PMID: 34995755 DOI: 10.1016/j.nbd.2022.105611] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 12/29/2021] [Accepted: 01/03/2022] [Indexed: 02/07/2023] Open
Abstract
Central post-stroke pain (CPSP) and associated depression remain poorly understood and pharmacological treatments are unsatisfactory. Recently, microglia activation was suggested to be involved in CPSP pathophysiology. The goal of this study was to investigate the effectiveness of a co-ultramicronized combination of N-palmitoylethanolamide and luteolin (PEALut) in a mouse model of thalamic hemorrhage (TH)-induced CPSP. TH was established through the collagenase-IV injection in thalamic ventral-posterolateral-nucleus. PEALut effects in CPSP-associated behaviors were evaluated during a 28-days observation period. We found that repeated administrations of co-ultra PEALut significantly reduced mechanical hypersensitivity after TH, as compared to vehicle, by reducing the early microglial activation in the perilesional site. Moreover, PEALut prevented the development of depressive-like behavior (21 days post-TH). These effects were associated with the restoration of synaptic plasticity in LEC-DG pathway and monoamines levels found impaired in TH mice. Hippocampal MED1 and TrkB expressions were significantly increased in TH compared to sham mice 21 days post-TH, whereas BDNF levels were decreased. PEALut restored MED1/TrkB/BDNF expression in mice. Remarkably, we found significant overexpression of MED1 in the human autoptic brain specimens after stroke, indicating a translational potential of our findings. These results pave the way for better-investigating depression in TH- induced CPSP, together with the involvement of MED1/TrkB/BDNF pathway, proposing PEALut as an adjuvant treatment.
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Affiliation(s)
- Rosmara Infantino
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Concetta Schiano
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Livio Luongo
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy; IRCSS, Neuromed, Pozzilli, Italy
| | - Salvatore Paino
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Gelsomina Mansueto
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Naples, Italy; Legal Medicine Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Serena Boccella
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesca Guida
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Flavia Ricciardi
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Monica Iannotta
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Carmela Belardo
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Ida Marabese
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Gorizio Pieretti
- Multidisciplinary Department of Surgical and Dental Specialities, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Nicola Serra
- Department of Public Health, University Federico II, Naples, Italy
| | - Claudio Napoli
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Sabatino Maione
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy; IRCSS, Neuromed, Pozzilli, Italy.
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Shi X, Bai H, Wang J, Wang J, Huang L, He M, Zheng X, Duan Z, Chen D, Zhang J, Chen X, Wang J. Behavioral Assessment of Sensory, Motor, Emotion, and Cognition in Rodent Models of Intracerebral Hemorrhage. Front Neurol 2021; 12:667511. [PMID: 34220676 PMCID: PMC8248664 DOI: 10.3389/fneur.2021.667511] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/20/2021] [Indexed: 11/15/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is the second most common type of stroke and has one of the highest fatality rates of any disease. There are many clinical signs and symptoms after ICH due to brain cell injury and network disruption resulted from the rupture of a tiny artery and activation of inflammatory cells, such as motor dysfunction, sensory impairment, cognitive impairment, and emotional disturbance, etc. Thus, researchers have established many tests to evaluate behavioral changes in rodent ICH models, in order to achieve a better understanding and thus improvements in the prognosis for the clinical treatment of stroke. This review summarizes existing protocols that have been applied to assess neurologic function outcomes in the rodent ICH models such as pain, motor, cognition, and emotion tests. Pain tests include mechanical, hot, and cold pain tests; motor tests include the following 12 types: neurologic deficit scale test, staircase test, rotarod test, cylinder test, grid walk test, forelimb placing test, wire hanging test, modified neurologic severity score, beam walking test, horizontal ladder test, and adhesive removal test; learning and memory tests include Morris water maze, Y-maze, and novel object recognition test; emotion tests include elevated plus maze, sucrose preference test, tail suspension test, open field test, and forced swim test. This review discusses these assessments by examining their rationale, setup, duration, baseline, procedures as well as comparing their pros and cons, thus guiding researchers to select the most appropriate behavioral tests for preclinical ICH research.
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Affiliation(s)
- Xiaoyu Shi
- Department of Human Anatomy, College of Basic Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Huiying Bai
- Zhengzhou University Hospital Outpatient Surgery Center, Zhengzhou, China
| | - Junmin Wang
- Department of Human Anatomy, College of Basic Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Jiarui Wang
- Keieger School of Arts and Sciences, The Johns Hopkins University, Baltimore, MD, United States
| | - Leo Huang
- Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - Meimei He
- Department of Human Anatomy, College of Basic Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Xuejun Zheng
- Department of Human Anatomy, College of Basic Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Zitian Duan
- Department of Human Anatomy, College of Basic Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Danyang Chen
- Department of Human Anatomy, College of Basic Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Jiaxin Zhang
- Saint John Paul the Great Catholic High School, Dumfries, VA, United States
| | - Xuemei Chen
- Department of Human Anatomy, College of Basic Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Jian Wang
- Department of Human Anatomy, College of Basic Medical Sciences, Zhengzhou University, Zhengzhou, China
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Hyakkoku K, Umeda N, Shimada S, Imai T, Morioka Y, Sakaguchi G, Hara H. Post-stroke pain caused by peripheral sensory hypersensitization after transient focal cerebral ischemia in rats. Brain Res 2019; 1715:35-40. [PMID: 30898673 DOI: 10.1016/j.brainres.2019.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 02/28/2019] [Accepted: 03/16/2019] [Indexed: 01/15/2023]
Abstract
The mechanisms underlying central post-stroke pain are not well understood and there is no satisfactory treatment. Here, in a rat model of stroke, we measured nociceptive threshold using current stimulation of primary afferent neurons in both hind paws. Male Wistar rats underwent middle cerebral artery occlusion (MCAO) for 50 min. Nociceptive thresholds for Aβ, Aδ and C fiber stimulation (at 2000, 250, and 5 Hz, respectively, using a Neurometer), and neurological deficits, were measured for 23 days after MCAO. Sensory thresholds in both hind paws were significantly lower in MCAO model rats than in control rats for 23 days after MCAO, with the greatest difference seen in Aδ fibers and the smallest in C fibers. Brain infarct area was measured histologically, and the correlation between neurological deficit and infarct size was examined. Neurological deficits were worse in animals with larger infarcts. Furthermore, correlations were observed between infarct size, neurological deficit, and sensory threshold of Aδ fibers 1 day after MCAO. These findings indicate that rats develop hyperalgesia after MCAO and that sensory abnormalities in Aδ fibers after cerebral ischemia may play an important role in post-stroke pain.
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Affiliation(s)
- Kana Hyakkoku
- Pain & Neuroscience, Discovery Research Laboratories for Core Therapeutic Areas, Shionogi & Co., Ltd., 1-1 Futaba-cho, 3-chome, Toyonaka, Osaka 561-0825, Japan.
| | - Nanae Umeda
- Shionogi TechnoAdvance Research & Co., Ltd., 1-1 Futaba-cho, 3-chome, Toyonaka, Osaka 561-0825, Japan
| | - Shinji Shimada
- Shionogi TechnoAdvance Research & Co., Ltd., 1-1 Futaba-cho, 3-chome, Toyonaka, Osaka 561-0825, Japan
| | - Takahiko Imai
- Molecular Pharmacology, Department of Biofunctional Evaluation, Gifu Pharmaceutical University, 1-25-4 Digakunishi, Gifu 501-1196, Japan
| | - Yasuhide Morioka
- Pain & Neuroscience, Discovery Research Laboratories for Core Therapeutic Areas, Shionogi & Co., Ltd., 1-1 Futaba-cho, 3-chome, Toyonaka, Osaka 561-0825, Japan
| | - Gaku Sakaguchi
- Pain & Neuroscience, Discovery Research Laboratories for Core Therapeutic Areas, Shionogi & Co., Ltd., 1-1 Futaba-cho, 3-chome, Toyonaka, Osaka 561-0825, Japan
| | - Hideaki Hara
- Molecular Pharmacology, Department of Biofunctional Evaluation, Gifu Pharmaceutical University, 1-25-4 Digakunishi, Gifu 501-1196, Japan.
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Anttila JE, Pöyhönen S, Airavaara M. Secondary Pathology of the Thalamus after Focal Cortical Stroke in Rats is not Associated with Thermal or Mechanical Hypersensitivity and is Not Alleviated by Intra-Thalamic Post-Stroke Delivery of Recombinant CDNF or MANF. Cell Transplant 2019; 28:425-438. [PMID: 31037983 PMCID: PMC6628565 DOI: 10.1177/0963689719837915] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
A stroke affecting the somatosensory pathway can trigger central post-stroke pain
syndrome (CPSP). The symptoms often include hyperalgesia, which has also been described in
rodents after the direct damage of the thalamus. Previous studies have shown that
hemorrhagic stroke or ischemia caused by vasoconstriction in the thalamus induces
increased pain sensitivity. We investigated whether inducing secondary damage in the
thalamus by a cortical stroke causes similar pain hypersensitivity as has previously been
reported with direct ischemic injury. We induced a focal cortical ischemia-reperfusion
injury in male rats, quantified the amount of secondary neurodegeneration in the thalamus,
and measured whether the thalamic neurodegeneration is associated with thermal or
mechanical hypersensitivity. After one month, we observed extensive neuronal degeneration
and found approximately 40% decrease in the number of NeuN+ cells in the ipsilateral
thalamus. At the same time, there was a massive accumulation—a 30-fold increase—of
phagocytic cells in the ipsilateral thalamus. However, despite the evident damage in the
thalamus, we did not observe thermal or mechanical sensitization. Thus, thalamic
neurodegeneration after cortical ischemia-reperfusion does not induce CPSP-like symptoms
in rats, and these results suggest that direct ischemic damage is needed for CPSP
induction. Despite not observing hyperalgesia, we investigated whether administration of
cerebral dopamine neurotrophic factor (CDNF) and mesencephalic astrocyte-derived
neurotrophic factor (MANF) into the ipsilateral thalamus would reduce the secondary
damage. We gave a single injection (10 µg) of recombinant CDNF or MANF protein into the
thalamus at 7 days post-stroke. Both CDNF and MANF treatment promoted the functional
recovery but had no effect on the neuronal loss or the amount of phagocytic cells in the
thalamus.
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Affiliation(s)
- Jenni E. Anttila
- Institute of Biotechnology, HiLIFE, University of Helsinki, Helsinki,
Finland
| | - Suvi Pöyhönen
- Institute of Biotechnology, HiLIFE, University of Helsinki, Helsinki,
Finland
| | - Mikko Airavaara
- Institute of Biotechnology, HiLIFE, University of Helsinki, Helsinki,
Finland
- Mikko Airavaara, Institute of Biotechnology, HiLIFE,
University of Helsinki, P.O. Box 56, Helsinki 00014, Finland.
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Botulinum Toxin for Central Neuropathic Pain. Toxins (Basel) 2018; 10:toxins10060224. [PMID: 29857568 PMCID: PMC6024683 DOI: 10.3390/toxins10060224] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 05/26/2018] [Accepted: 05/28/2018] [Indexed: 11/17/2022] Open
Abstract
Botulinum toxin (BTX) is widely used to treat muscle spasticity by acting on motor neurons. Recently, studies of the effects of BTX on sensory nerves have been reported and several studies have been conducted to evaluate its effects on peripheral and central neuropathic pain. Central neuropathic pain includes spinal cord injury-related neuropathic pain, post-stroke shoulder pain, multiple sclerosis-related pain, and complex regional pain syndrome. This article reviews the mechanism of central neuropathic pain and assesses the effect of BTX on central neuropathic pain.
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Shih HC, Kuan YH, Shyu BC. Targeting brain-derived neurotrophic factor in the medial thalamus for the treatment of central poststroke pain in a rodent model. Pain 2017; 158:1302-1313. [PMID: 28394853 PMCID: PMC5472007 DOI: 10.1097/j.pain.0000000000000915] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/15/2017] [Accepted: 03/27/2017] [Indexed: 12/17/2022]
Abstract
Approximately 7% to 10% of patients develop a chronic pain syndrome after stroke. This chronic pain condition is called central poststroke pain (CPSP). Recent studies have observed an abnormal increase in the secretion of brain-derived neurotrophic factor (BDNF) in spinal cord tissue after spinal cord injury. An animal model of CPSP was established by an intrathalamus injection of collagenase. Mechanical and thermal allodynia was induced after lesions of the thalamic ventral basal complex in rats. Four weeks after the injection, the number of neurons decreased, the number of astrocytes, microglia, and P2X4 receptors increased, and BDNF mRNA expression increased in the brain lesion area. Nociceptive activity in the medial thalamus (MT) and the coherence coefficient of spontaneous field potential oscillations in the anterior cingulate cortex were enhanced in CPSP animals, and these enhancements were blocked by an acute injection of TrkB-Fc and TrkB antagonist Tat Cyclotraxin-B. Instead of being inhibited by the γ-aminobutyric acid (GABA) system in normal rats, multiunit activity in the MT was enhanced after a microinjection of muscimol, a GABAA receptor agonist, in CPSP animals. After CPSP, BDNF expression was enhanced in the MT, whereas the expression of GABAA channels and the cotransporter KCC2 decreased in the same area. These findings suggest that neuronal plasticity in the MT that was induced by BDNF overexpression after the thalamic lesion was a key factor in CPSP.
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Affiliation(s)
- Hsi-Chien Shih
- Neuroscience, Institute of Biomedical Science, Academia Sinica, Taipei, Taiwan
| | - Yung-Hui Kuan
- Neuroscience, Institute of Biomedical Science, Academia Sinica, Taipei, Taiwan
| | - Bai-Chung Shyu
- Neuroscience, Institute of Biomedical Science, Academia Sinica, Taipei, Taiwan
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Effects of thalamic hemorrhagic lesions on explicit and implicit learning during the acquisition and retrieval phases in an animal model of central post-stroke pain. Behav Brain Res 2016; 317:251-262. [PMID: 27681112 DOI: 10.1016/j.bbr.2016.09.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/18/2016] [Accepted: 09/24/2016] [Indexed: 12/21/2022]
Abstract
Hemorrhagic stroke has many symptoms, including central pain, learning and memory impairments, motor deficits, language problems, emotional disturbances, and social maladjustment. Lesions of the ventral basal complex (VBC) of the thalamus elicit thermal and mechanical hyperalgesia, forming an animal model of central post-stroke pain (CPSP). However, no research has yet examined the involvement of learning and memory in CPSP using an animal model. The present study examined whether VBC lesions affect motor function, conditioned place preference (CPP; implicit memory), and spatial learning (explicit memory) in the acquisition and retrieval phases. The results showed that rats with VBC lesions exhibited thermal hyperalgesia in the acquisition and retrieval phases, indicating that these lesions can induce CPSP. During these phases, the rats with VBC lesions exhibited enhanced (morphine-induced) CPP learning. These lesions did not affect the rats' total distance travelled, time spent, or velocity in the spatial learning tasks. The lesions also did not affect motor function in the rotarod task. Altogether, VBC lesions resulted in CPSP and facilitated CPP (implicit memory). However, the lesions did not affect spatial learning (explicit memory) or motor function. The relationship between CPSP and learning and memory is important for patients who suffer from such central pain. The implications of the present study may provide insights into helping reduce CPSP and its associated symptoms.
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