Imaging of acute versus pathological pain in humans

Pain subserves different functions. Acute pain from the intact body alerts the victim to immediately react and withdraw from the bodily threat, ideally before an injury happens. However, during manifest injury and tissue inflammation, withdrawal and flight are no longer adaptive. Instead, sparing the affected body part to promote healing requires heightened awareness and avoidance behaviour over longer periods of time. Quality and time scales of behavioural adaptations are therefore substantially different between pain during normal compared to abnormal tissue states. Given these functional differences we postulated that the two phenomena also recruit different forebrain systems. We used positron emission tomography (PET) and subtracted scans obtained during painful heating of normal skin from scans during equally intense but normally non-painful heating of capsaicin-treated skin. This comparison reveals the specific activation of a medial thalamic pathway to limbic forebrain structures such as anterior insula, perigenual anterior cingulate, ventral striatum, and prefrontal cortex during pain originating in the chemically sensitised skin. It is possible that the unique forebrain recruitment by pain under a patho-physiological tissue status is caused by a significantly greater facilitation of the multi-synaptic projections from the spino-parabrachial tract of the superficial dorsal horn to the medial thalamus compared to deeper and direct lateral thalamic projections from the spino-thalamic tract.

Keeping pain out of mind: the role of the dorsolateral prefrontal cortex in pain modulation

Frontal lobe activity during pain is generally linked to attentional processing. We addressed the question of whether 'bottom-up' processing and 'top-down' modulation of nociceptive information dissociate anatomically within the frontal lobe by using PET scanning during painful thermal stimulation of normal and capsaicin-treated skin. We showed recently that pain following normally non-painful heat stimuli on chemically irritated skin (heat allodynia) uniquely engages extensive areas of the bilateral dorsolateral prefrontal (DLPFC), ventral/orbitofrontal (VOFC) and perigenual anterior cingulate (ACC) cortices. Here, we applied principal component analysis (PCA) and multiple regression analysis to study the covariance structure of the volumes of interest (VOI) activated specifically during heat allodynia in 14 male healthy subjects and evaluated the relationship of these VOI to ratings of pain intensity and affect. Results yielded a primary principal component (PC) that correlated positively with intensity and unpleasantness and accounted for activity in the medial thalamus, bilateral anterior insula, ventral striatum, perigenual ACC and bilateral VOFC. Activities in the right and left DLPFC loaded on separate PC and correlated negatively with perceived intensity and unpleasantness. The inter-regional correlation of midbrain and medial thalamic activity was significantly reduced during high left DLPFC activity, suggesting that its negative correlation with pain affect may result from dampening of the effective connectivity of the midbrain-medial thalamic pathway. In contrast, right DLPFC activity was associated with a weakened relationship of the anterior insula with both pain intensity and affect. We propose that the DLPFC exerts active control on pain perception by modulating corticosubcortical and corticocortical pathways.

Relative reinforcing strength of three N-methyl-D-aspartate antagonists with different onsets of action

The potential contribution of onset and duration of pharmacological action to the reinforcing strength of three intravenously delivered N-methyl-D-aspartate antagonists was evaluated in this study. The onsets and durations of action of ketamine, phencyclidine, and dizocilpine were evaluated by observation and tabulation of their behavioral effects in rhesus monkeys after i.v. administration. The reinforcing effects of each drug were tested in a paradigm in which the fixed ratio requirements for i.v. drug injection were increased systematically. The peak observable effect of ketamine occurred immediately after its administration. There were some immediately observable effects of phencyclidine, although the peak effect of phencyclidine was delayed for 3 to 10 min. Dizocilpine had few immediate effects and a peak effect 32 min after administration. Ketamine had the shortest duration of action, followed by phencyclidine and dizocilpine. Analysis of demand curves and response output curves that were normalized to account for potency differences among the drugs revealed that ketamine and phencyclidine were equally effective as reinforcers, and they were both much stronger reinforcers than was dizocilpine. The data therefore suggest that a fast onset of action increases the reinforcing strength of drugs, although duration of action may play a role as well.

Attention-related, cross-modality modulation of somatosensory neurons in primate ventrobasal (VB) thalamus

Attention-related modulation (AM) of the somatosensory responses of single neurons has been demonstrated in the cerebral cortex and medullary dorsal horn, but not in the ventrobasal thalamus. The somatically evoked activity was recorded of single units in the ventral posterior lateral thalamus (VPL) of awake monkeys while they detected the termination of task-relevant somatic or visual stimuli. Eighteen of 56 somatically responsive VPL neurons are reported that were recorded for enough time for a complete analysis of their responses during both the visual and somatic attention tasks. All neurons were spontaneously active and responded either to innocuous cutaneous (13/18) or deep (5/18) stimuli. Seven neurons (7/18, 38.8%) showed AM of somatosensory responsiveness. Two cells (2/7, 28.6%) showed AM only during the visual task, two others (2/7, 28.6%) only during the somatosensory task, and three cells (3/7, 42.8%) showed AM during both tasks. All five cells showing AM during the somatosensory task had enhanced responses to the task-relevant somatic stimulus. In contrast, the somatosensory responses of all five cells showing AM during the visual task were reduced. It is concluded that selective attention is associated with a modality specific modulation of the somatosensory responses of a sub-population of neurons within the primate VPL nucleus.

Concepts of pain mechanisms: the contribution of functional imaging of the human brain

Functional imaging of the conscious human brain has a solid physiological basis in synaptically induced rCBF responses. We still do not know how these responses are generated, but recent studies have shown that the rCBF response is parametrically positively correlated with functional measures of neuronal activity. Technical advances in both fMRI and PET imaging have improved the spatial and temporal resolution of imaging methods. Further advances may be expected in the near future. Consequently, we now have an important tool to apply to the study of normal and, most importantly, pathological pain. There is a tendency to expect too much of this exciting technique, but the problems we wish to address are complex and will require considerable time, effort, and patience. We now know that the CNS adapts to both peripheral and central nervous system injury, sometimes in beneficial ways, but sometimes with reorganization that is maladaptive. An understanding of the pathophysiology of neuropathic pain is further complicated by the new knowledge, emphasized by functional brain imaging, that pain and pain modulation is mediated, not by a simple pathway with one or a few central targets, but by a network of multiple interacting modules of neuronal activity. Simplified phrenological thinking, with complete psychological functions separate and localized, is appealing, but wildly misleading. It is far more realistic and productive to apply qualitative and quantitative spatial and temporal analyses to the distributed activity of the conscious, communicating human brain. This will not be quick and easy, but there is every reason for optimism in our search for a thorough and useful understanding of both normal and pathological pain.

Temporal and spatial dynamics of human forebrain activity during heat pain: analysis by positron emission tomography

To learn about the sequence of brain activation patterns during heat pain, we acquired positron emission tomographic (PET) brain scans at different times during repetitive heat stimulation (40 or 50 degrees C; 5-s contact) of each subject's left forearm. Early scans began at the onset of 60 s of stimulation; late scans began after 40 s of stimulation, which continued throughout the 60-s scan period (total stimulus duration 100 s). Each subject (14 normal, right-handed subjects; 10 male, 4 female; ages 18-42) used a visual analog scale to rate the perceived stimulus intensity (0 = no heat, 7 = pain threshold, 10 = barely tolerable pain) after each scan. The 40 degrees C stimulation received an average intensity rating of 2.19 +/- 1.22 (mean +/- SD) and the 50 degrees C an average rating of 8.93 +/- 1.33. During the scan sessions, subjects did not report a difference between early and late scans. To examine the effect of the duration of stimulation specifically, 8 of these subjects rated the perceived intensity of each of 20 sequential 5-s duration contact heat stimuli (40 or 50 degrees C; 100 s of stimulation). We used a graphical method to detect changes in perceived unpleasantness. There was no difference in perceived intensity or unpleasantness during the 40 degrees C stimulation. However, during 50 degrees C stimulation, perceived unpleasantness increased and subjects perceived the last five, but not the second five, stimuli as more intense than the first five stimuli. These psychophysical changes could be mediated by brain structures with increasing activity from early to late PET scans or that are active only during late scans. These structures include the contralateral M1/S1 cortex, bilateral S2 and mid-insular cortex, contralateral VP thalamus, medial ipsilateral thalamus, and the vermis and paravermis of the cerebellum. Structures that are equally active throughout stimulation (contralateral mid-anterior cingulate and premotor cortex) are less likely to mediate these psychophysical changes. Some cortical, but not subcortical, structures showed significant or borderline activation only during the early scans (ipsilateral premotor cortex, contralateral perigenual anterior cingulate, lateral prefrontal, and anterior insular cortex); they may mediate pain-related attentive or anticipatory functions. Overall, the results reveal that 1) the pattern of brain activation and the perception of heat pain both change during repetitive noxious heat stimulation, 2) cortical activity can be detected before subcortical responses appear, and 3) timing the stimulation with respect to the scan period can, together with psychophysical measurements, identify brain structures that are likely to participate in the perception of pain.

Cerebral Responses to Warmth and Heat and Cold Pain Measured by Positron Emission Tomography

Phasic heat and tonic cold stimuli that have different temporal patterns, afferent fiber activations, and perceived pain characteristics produce a shared pattern of cerebral activation in addition to modality specific activations. These patterns are different from the cerebral representation of innocuous temperature sensation. Functional brain imaging techniques provide an opportunity to study somatosensory organization in conscious humans under physiologic conditions, despite certain limitations of imaging modalities.

Selective opiate modulation of nociceptive processing in the human brain

Fentanyl, a mu-opioid receptor agonist, produces analgesia while leaving vibrotactile sensation intact. We used positron emission tomography (PET) to study the mechanisms mediating this specific effect in healthy, right-handed human males (ages 18-28 yr). Subjects received either painful cold (n = 11) or painless vibratory (n = 9) stimulation before and after the intravenous injection of fentanyl (1.5 microgram/kg) or placebo (saline). Compared with cool water (29 degrees C), immersion of the hand in ice water (1 degrees C) is painful and produces highly significant increases in regional cerebral blood flow (rCBF) within the contralateral second somatosensory (S2) and insular cortex, bilaterally in the thalamus and cerebellum, and medially in the cerebellar vermis. Responses just below the statistical threshold (3.5 < Z < 4.0) are seen in the contralateral anterior cingulate, ipsilateral insular cortex, and dorsal medial midbrain. The contralateral primary sensory cortex (S1) shows a trend of activation. Except for slight changes in intensity, this pattern is unchanged following a saline placebo injection. Fentanyl reduces the average visual analogue scale ratings of perceived pain intensity (47%) and unpleasantness (50%), reduces pain-related cardioacceleration, and has positive hedonic effects. After fentanyl, but not placebo, all cortical and subcortical responses to noxious cold are greatly reduced. Subtraction analysis [(innocuous water + fentanyl) - (innocuous water + no injection)] shows that fentanyl alone increases rCBF in the anterior cingulate cortex, particularly in the perigenual region. Vibration (compared with mock vibration) evokes highly significant rCBF responses in the contralateral S1 cortex in the baseline (no injection) and placebo conditions; borderline responses (3.5 < Z < 4. 0) are detected also in the contralateral thalamus. Fentanyl has no effect on the perceived intensity or unpleasantness of vibratory stimulation, which continues to activate contralateral S1. Fentanyl alone [(mock vibration + fentanyl) - (mock vibration + no injection)] again produces highly significant activation of the perigenual and mid-anterior cingulate cortex. A specific comparison of volumes of interest, developed from activation peaks in the baseline condition (no injection), shows that fentanyl strongly attenuates both the contralateral thalamic and S1 cortical responses to noxious cold stimulation (P < 0.048 and 0.007, respectively) but fails to affect significantly these responses to vibrotactile stimulation (P > 0.26 and 0.91, respectively). In addition, fentanyl, compared with placebo, produces a unique activation of the mid-anterior cingulate cortex during fentanyl analgesia, suggesting that this region of the cingulate cortex participates actively in mediating opioid analgesia. The results are consistent with a selective, fentanyl-mediated suppression of nociceptive spinothalamic transmission to the forebrain. This effect could be implemented directly at the spinal level, indirectly through cingulate corticofugal pathways, or by a combination of both mechanisms.

Bilateral behavioral and regional cerebral blood flow changes during painful peripheral mononeuropathy in the rat

A unilateral chronic constriction injury (CCI) of the sciatic nerve produced bilateral effects in both pain related behaviors and in the pattern of forebrain activation. All CCI animals exhibited spontaneous pain-related behaviors as well as bilateral hyperalgesia and allodynia after CCI. Further, we identified changes in baseline (unstimulated) forebrain activation patterns 2 weeks following CCI by measuring regional cerebral blood flow (rCBF). Compared to controls, CCI consistently produced detectable, well-localized and typically bilateral increases in rCBF within multiple forebrain structures in unstimulated animals. For example, the hindlimb region of somatosensory cortex was significantly activated (22%) as well as multiple thalamc nuclei, including the ventral medial (8%), ventral posterior lateral (10%) and the posterior (9%) nuclear groups. In addition, several forebrain regions considered to be part of the limbic system showed pain-induced changes in rCBF, including the anterior dorsal nucleus of the thalamus (23%), cingulate cortex (18%), retrosplenial cortex (30%), habenular complex (53%), interpeduncular nucleus (45%) and the paraventricular nucleus of the hypothalamus (30%). Our results suggest that bilateral somatosensory and limbic forebrain structures participate in the neural mechanisms of prolonged persistent pain produced by a unilateral injury.

Chronic, selective forebrain responses to excitotoxic dorsal horn injury

Intraspinal injection of the AMPA/metabotropic receptor agonist quisqualic acid (QUIS) results in excitotoxic injury which develops pathological characteristics similar to those associated with ischemic and traumatic spinal cord injury (SCI) (R. P. Yezierski et al., 1998, Pain 75: 141-155; R. P. Yezierski et al., 1993, J. Neurotrauma 10: 445-456). Since spinal injury can lead to partial or complete deafferentation of ascending supraspinal structures, it is likely that secondary to the disruption of spinal pathways these regions could undergo significant reorganization. Recently, T. J. Morrow et al. (Pain 75: 355-365) showed that autoradiographic estimates of regional cerebral blood flow (rCBF) can be used to simultaneously identify alterations in the activation of multiple forebrain structures responsive to noxious formalin stimulation. Accordingly, we examined whether excitotoxic SCI produced alterations in the activation of supraspinal structures using rCBF as a marker of neuronal activity. Twenty-four to 41 days after unilateral injection of QUIS into the T12 to L3 spinal segments, we found significant increases in the activation of 7 of 22 supraspinal structures examined. As compared to controls, unstimulated SCI rats exhibited a significant bilateral increase in rCBF within the arcuate nucleus (ARC), the hindlimb region of S1 cortex (HL), parietal cortex (PAR), and the thalamic posterior (PO), ventral lateral (VL), ventral posterior lateral (VPL), and ventral posterior medial (VPM) nuclei. All structures showing significantly altered rCBF are associated with the processing of somatosensory information. These changes constitute remote responses to injury and suggest that widespread functional changes occur within cortical and subcortical regions following injury to the spinal cord.

Site- and modality-specific modulation of experimental muscle pain in humans

The neurophysiological mechanisms involved in diffuse noxious inhibitory controls (DNIC) have been investigated extensively, but information is lacking about the effect of different stimulus modalities and somatic locations on the effectiveness of DNIC. This study is the first to examine the hypoalgesic effects on a deep, tonic and painful test stimulus (TS) of both painful and non-painful conditioning stimuli (CS) applied to different sites of the body. Two separate experiments were performed using painful electrical stimulation of the left anterior tibialis muscle as the TS. In the first experiment (n = 9), injection of 5% hypertonic saline was used as a painful CS into one of four muscles: anterior tibialis of each leg and brachioradialis of each arm. In the second experiment (n = 5), a non-painful vibratory stimulus was used as the CS at the same four sites. Compared with TS alone, the perceived pain intensity of the TS increased (4.5 +/- 1.8%; P = 0.019) in combination with the painful CS applied to the same muscle (ipsilateral homotopic site), but decreased (-25.3 +/- 1.4%; P < 0.001) in combination with non-painful CS at the same site. Both painful and non-painful CS applied at the three heterotopic sites caused significant and site-dependent decreases in the perceived pain intensity of the TS (range 15%-37%; P < 0.05). We conclude that a hypoalgesic DNIC-like effect on muscle pain is not produced exclusively by painful stimuli, and that the valence and magnitude of the modulation depend on the nature of the CS and its location relative to the applied TS.

Forebrain mechanisms of nociception and pain: analysis through imaging

Pain is a unified experience composed of interacting discriminative, affective-motivational, and cognitive components, each of which is mediated and modulated through forebrain mechanisms acting at spinal, brainstem, and cerebral levels. The size of the human forebrain in relation to the spinal cord gives anatomical emphasis to forebrain control over nociceptive processing. Human forebrain pathology can cause pain without the activation of nociceptors. Functional imaging of the normal human brain with positron emission tomography (PET) shows synaptically induced increases in regional cerebral blood flow (rCBF) in several regions specifically during pain. We have examined the variables of gender, type of noxious stimulus, and the origin of nociceptive input as potential determinants of the pattern and intensity of rCBF responses. The structures most consistently activated across genders and during contact heat pain, cold pain, cutaneous laser pain or intramuscular pain were the contralateral insula and anterior cingulate cortex, the bilateral thalamus and premotor cortex, and the cerebellar vermis. These regions are commonly activated in PET studies of pain conducted by other investigators, and the intensity of the brain rCBF response correlates parametrically with perceived pain intensity. To complement the human studies, we developed an animal model for investigating stimulus-induced rCBF responses in the rat. In accord with behavioral measures and the results of human PET, there is a progressive and selective activation of somatosensory and limbic system structures in the brain and brainstem following the subcutaneous injection of formalin. The animal model and human PET studies should be mutually reinforcing and thus facilitate progress in understanding forebrain mechanisms of normal and pathological pain.

Central modulation of pain perception

The information presented in this article provides a basis for individual variability in the sensation of pain and the behavioral correlates associated with pain. The knowledge of pain-inhibitory and pain-facilitating pathways linked to cognitive, emotional, and stress-response systems leads to a greater understanding of the complexities of the experience of pain. Appreciation of the influence of these higher centers should lead to improvements in the clinical management of pain.

Gender differences in pain perception and patterns of cerebral activation during noxious heat stimulation in humans

The purpose of the present study was to determine whether gender differences exist in the forebrain cerebral activation patterns of the brain during pain perception. Accordingly, positron emission tomography (PET) with intravenous injection of H2(15)O was used to detect increases in regional cerebral blood flow (rCBF) in normal right-handed male and female subjects as they discriminated differences in the intensity of innocuous and noxious heat stimuli applied to the left forearm. Each subject was instructed in magnitude estimation based on a scale for which 0 indicated 'no heat sensation'; 7, 'just barely painful' and 10, 'just barely tolerable'. Thermal stimuli were 40 degrees C or 50 degrees C heat, applied with a thermode as repetitive 5-s contacts to the volar forearm. Both male and female subjects rated the 40 degrees C stimuli as warm but not painful and the 50 degrees C stimuli as painful but females rated the 50 degrees C stimuli as significantly more intense than did the males (P=0.0052). Both genders showed a bilateral activation of premotor cortex in addition to the activation of a number of contralateral structures, including the posterior insula, anterior cingulate cortex and the cerebellar vermis, during heat pain. However, females had significantly greater activation of the contralateral prefrontal cortex when compared to the males by direct image subtraction. Volume of interest comparison (t-statistic) also suggested greater activation of the contralateral insula and thalamus in the females (P < 0.05). These pain-related differences in brain activation may be attributed to gender, perceived pain intensity, or to both factors.

Regional changes in forebrain activation during the early and late phase of formalin nociception: analysis using cerebral blood flow in the rat

This is the first neural imaging study to use regional cerebral blood flow (rCBF) in an animal model to identify the patterns of forebrain nociceptive processing that occur during the early and late phase of the formalin test. We measured normalized rCBF increases by an autoradiographic method using the radiotracer [99mTc]exametazime. Noxious formalin consistently produced detectable, well-localized and typically bilateral increases in rCBF within multiple forebrain structures, as well as the interpeduncular nucleus (Activation Index, AI = 66) and the midbrain periaqueductal gray (AI = 20). Structures showing pain-induced changes in rCBF included several forebrain regions considered part of the limbic system. The hindlimb region of somatosensory cortex was significantly activated (AI = 31), and blood flow increases in VPL (AI = 8.7) and the medial thalamus (AI = 9.0) exhibited a tendency to be greater in the late phase as compared to the early phase of the formalin test. The spatial pattern and intensity of activation varied as a function of the time following the noxious formalin stimulus. The results highlight the important role of the limbic forebrain in the neural mechanisms of prolonged persistent pain and provide evidence for a forebrain network for pain.

Comparative psychophysical characteristics of cutaneous CO2 laser and contact heat stimulation

Psychophysical visual analog scaling can be used to reveal critical determinants of the neural processing underlying non-painful and painful heat sensations produced by radiant and contact heat stimulation. This study determined the stimulus-response (S-R) functions of cutaneous non-painful and painful heat stimuli delivered by an infra-red CO2 laser or by a contact thermode in a series of experiments in healthy volunteers. In experiments 1 (n = 12), with the rating scale anchored at pain threshold, the S-R curve for brief (60 ms) laser pulse stimulation with a beam diameter of 10 mm was a negatively accelerating function. Transformation of laser stimulus intensity (W) into temperatures (degree C) did not change the form of the S-R curve. In experiment 2 (n = 9), using the same laser stimulus parameters as in experiment 1, but without an anchored rating scale, the form of the S-R relationship did not change. In experiment 3 (n = 9), increases of the laser pulse duration up to 5 s and the beam diameter up to 18 mm produced linear S-R curves. In contrast, in experiment 4 (n = 21), the S-R curve for cutaneous contact heat stimuli applied for 5 s with an 18 mm diameter probe was best described by a positively accelerating power function with an exponent greater than 2.0. These experiments have (1) characterized the S-R functions for different parameters of infra-red laser stimulation of the skin, and (2) have shown that the form of the S-R function for innocuous and noxious heat sensation is influenced strongly by the physical conditions of heat stimulus application, including mechanical contact with the skin.

Setters and samoyeds: the emergence of subordinate level categories as a basis for inductive inference in preschool-age children

Basic level categories are a rich source of inductive inference for children and adults. These 3 experiments examine how preschool-age children partition their inductively rich basic level categories to form subordinate level categories and whether these have inductive potential. Children were taught a novel property about an individual member of a familiar basic level category (e.g., a collie). Then, children's extensions of that property to other objects from the same subordinate (e.g., other collies), basic (e.g., other dogs), and superordinate (e.g., other animals) level categories were examined. The results suggest (a) that contrastive information promotes the emergence of subordinate categories as a basis of inductive inference and (b) that newly established subordinate categories can retain their inductive potential in subsequent reasoning over a week's time.

Setters and samoyeds: the emergence of subordinate level categories as a basis for inductive inference in preschool-age children

Basic level categories are a rich source of inductive inference for children and adults. These 3 experiments examine how preschool-age children partition their inductively rich basic level categories to form subordinate level categories and whether these have inductive potential. Children were taught a novel property about an individual member of a familiar basic level category (e.g., a collie). Then, children's extensions of that property to other objects from the same subordinate (e.g., other collies), basic (e.g., other dogs), and superordinate (e.g., other animals) level categories were examined. The results suggest (a) that contrastive information promotes the emergence of subordinate categories as a basis of inductive inference and (b) that newly established subordinate categories can retain their inductive potential in subsequent reasoning over a week's time.

Pain-related laser-evoked potentials in awake monkeys: identification of components, behavioral correlates and drug effects

Cutaneous stimulation with CO2 laser pulses activates small diameter sensory afferents and evokes a pain-related potential best recorded from the vertex (Cz) of humans. We report here the first successful recording of pain-related laser evoked potentials (LEPs) from awake monkeys. Laser pulses with stimulus intensities adjusted to the lowest level giving reproducible cerebral responses were delivered to the shaved tail of three awake African green monkeys. The proximal and distal tail were stimulated to calculate the conduction velocity of the activated fibers. The effects of subcutaneous injections of morphine and cocaine on the LEPs were evaluated. The results indicate that reproducible LEPs, with a morphology similar to those obtained from humans, can be recorded from the awake monkey. The calculated conduction velocity of the activated fibers averaged 8.7 m/s, which is in the range of A delta fibers. Following subcutaneous morphine injections, the LEPs disappeared and were quickly restored to their baseline amplitude following administration of naloxone. Cocaine administered subcutaneously led to a significant attenuation of LEP amplitudes without producing behavioral sedation. These findings suggest that the LEPs recorded from monkeys represent analgesic-sensitive, nociceptive-related potentials similar to those recorded from humans.

Non-painful and painful stimulation of human skin and muscle: analysis of cerebral evoked potentials

The present study compared the cerebral processing of non-painful and painful cutaneous CO2 laser stimulation and intramuscular electrical stimulation in 11 normal subjects. The overall wave form morphology of the long-latency evoked potentials (EPs) at the central vertex (Cz) was identical and surface topographic mappings of the 21-channel recordings showed similar distributions, suggesting involvement of common neural generators. However, the EPs caused by intramuscular stimulation differed from cutaneous stimulation in several distinct ways. First, the latency of the major positive and negative components were significantly shorter with intramuscular stimulation (N 128-145 ms; P 274-298 ms) compared to cutaneous stimulation (N 235-286 ms; P 371-383 ms) (P < 0.001). Second, the peak-to-peak amplitude and root-mean-square values of intramuscular EPs recorded at Cz showed a ceiling effect in the painful range, whereas the laser EPs continued to increase in this range. Third, painful intramuscular, but not non-painful, stimulation caused a frontal activity which not was observed with cutaneous laser stimulation at any intensity. Conduction velocity measurements indicated activation of nociceptive A-delta afferents with cutaneous laser stimulation (10.2 +/- 0.2 m/s) and activation of a mixed nerve fiber population with intramuscular electrical stimulation (65.8 +/- 25.8 m/s). Differences between laser and intramuscular EPs may be due to different types and origins of activated afferent fibers. Laser EPs can be used specifically to assess cutaneous A-delta fiber function, whereas intramuscular EPs reflect the cerebral processing of a mixed afferent input from muscle tissue.

Cerebral processing of acute skin and muscle pain in humans

The human cerebral processing of noxious input from skin and muscle was compared with the use of positron emission tomography with intravenous H2(15)O to detect changes in regional cerebral blood flow (rCBF) as an indicator of neuronal activity. During each of eight scans, 11 normal subjects rated the intensity of stimuli delivered to the nondominant (left) forearm on a scale ranging from 0 to 100 with 70 as pain threshold. Cutaneous pain was produced with a high-energy CO2 laser stimulator. Muscle pain was elicited with high-intensity intramuscular electrical stimulation. The mean ratings of perceived intensity for innocuous and noxious stimulation were 32.6 +/- 4.5 (SE) and 78.4 +/- 1.7 for cutaneous stimulation and 15.4 +/- 4.2 and 73.5 +/- 1.4 for intramuscular stimulation. The pain intensity ratings and the differences between noxious and innocuous ratings were similar for cutaneous and intramuscular stimuli (P > 0.05). After stereotactic registration, statistical pixel-by-pixel summation (Z score) and volumes-of-interest (VOI) analyses of subtraction images were performed. Significant increases in rCBF to both noxious cutaneous and intramuscular stimulation were found in the contralateral secondary somatosensory cortex (SII) and inferior parietal lobule [Brodmann area (BA) 40]. Comparable levels of rCBF increase were found in the contralateral anterior insular cortex, thalamus, and ipsilateral cerebellum. Noxious cutaneous stimulation caused significant activation in the contralateral lateral prefrontal cortex (BA 10/46) and ipsilateral premotor cortex (BA 4/6). Noxious intramuscular stimulation evoked rCBF increases in the contralateral anterior cingulate cortex (BA 24) and subsignificant responses in the contralateral primary sensorimotor cortex (MI/SI) and lenticular nucleus. These activated cerebral structures may represent those recruited early in nociceptive processing because both forms of stimuli were near pain threshold. Correlation analyses showed a negative relationship between changes in rCBF for thalamus and MI/SI for cutaneous stimulation, and positive relationships between thalamus and anterior insula for both stimulus modalities. Direct statistical comparisons between innocuous cutaneous and intramuscular stimulation with the use of Z scores and VOI analyses showed no reliable differences between these two forms of noxious stimulation, indicating a substantial overlap in brain activation pattern. The comparison of noxious cutaneous and intramuscular stimulation indicated more activation in the premotor cortex, SII, and prefrontal cortex with cutaneous stimulation, but these differences did not reach statistical significance. The similar cerebral activation patterns suggest that the perceived differences between acute skin and muscle pain are mediated by differences in the intensity and temporospatial pattern of neuronal activity within similar sets of forebrain structures.

Human intramuscular and cutaneous pain: psychophysical comparisons

We used psychophysical methods to compare the central processing of nociceptive inputs from skin and muscle in ten normal humans. Both intramuscular electrical and infrared CO2 laser cutaneous stimulation showed increasing but decelerating (downward concave) stimulus-response curves and similar temporal summation characteristics. Intramuscular stimulation was rated significantly more unpleasant than cutaneous stimulation. The results are consistent with a common mode of central nociceptive processing for skin and muscle pain intensity but suggest a relatively larger activation of affective mechanisms by muscle afferents.

Comparison of human cerebral activation pattern during cutaneous warmth, heat pain, and deep cold pain

1. We wished to determine whether there are differences in the spatial pattern and intensity of synaptic activity within the conscious human forebrain when different forms and intensities of innocuous and noxious thermal stimuli are experienced. Accordingly, positron emission tomography (PET) with intravenous injection of H2(15)O was used to detect increases in regional cerebral blood flow (rCBF) in normal humans as they discriminated differences in the intensity of noxious and innocuous thermal stimulation applied to the nondominant (left) arm. After stereotactic registration, subtraction images were formed from each subject by subtracting counts of emissions obtained during lower-intensity stimulation from those obtained during stimulation at higher intensities. A statistical summation analysis (Z score) of individual voxels was performed. In addition, volumes of interest were chosen on the basis of a priori hypotheses and the results of previously published PET studies. In both types of analysis, statistical thresholds were established with corrections for multiple comparisons. 2. Twenty-seven subjects were divided into three groups of nine subjects each for the three phases of this investigation. For studies in which repetitive contact heat stimuli were used, each subject was instructed in magnitude estimation on the basis of a scale for which 0 indicated "no heat sensation," 7 "just barely painful," and 10 "just barely tolerable." For the study of pain elicited by immersion of the hand in cold water, subjects were instructed to use a scale in which 0 represented "no pain" and 10 represented just barely tolerable pain. 3. In the warm-discrimination study, two intensities of innocuous heat (36 and 43 degrees C) were applied with a thermode as repetitive 5-s contacts to the volar forearm for a total of approximately 100 s, 8 stimuli before and 12 during each scan. Each temperature was applied on alternate scans for a total of four scans per subject. Neither stimulus was rated painful. All subjects discriminated the 43 degrees C stimulus (average rating 5.90 +/- 1.43, mean +/- SD) from the 36 degrees C stimulus (1.96 +/- 1.08, mean +/- SD; t = 13.19, P < 0.0001). Significant increases in rCBF to the 43 degrees C stimuli were found in the contralateral ventral posterior thalamus, lenticular nucleus, medial prefrontal cortex (Brodmann's areas 10 and 32), and cerebellar vermis. 4. The procedure for discriminating between noxious and innocuous heat stimuli was identical to that used for warm discrimination except that the stimulation temperatures were 40 and 50 degrees C. All subjects rated the 50 degrees C stimuli as painful (average rating 8.9 +/- 0.9, mean +/- SD) and the 40 degrees C stimuli as warm, but not painful (2.1 +/- 1.0). Significant rCBF increases to 50 degrees C stimuli were found contralaterally in the thalamus, anterior cingulate cortex, premotor cortex, and secondary somatosensory (S2) and posterior insular cortices. Significant activity also appeared within the region of the contralateral anterior insula and lenticular nucleus. The ipsilateral premotor cortex and thalamus, and the medial dorsal midbrain and cerebellar vermis, also showed significant rCBF increases. Cerebral blood flow (CBF) increases just below the threshold for statistical significance were seen in the contralateral sensorimotor cortex [primary motor cortex (M1)/primary somatosensory cortex (S1)]. 5. For discrimination between tonic innocuous cold and tonic cold pain, the left hand was immersed to the wrist, throughout each of six scans, in water kept at an average temperature of either 20.5 +/- 1.15 degrees C (mean +/- SD) or 6.02 +/- 1.18 degrees C (mean +/- SD) on alternate scans. All subjects rated the intensity of the stimuli on a scale in which 0 indicated no pain and 10 represented barely tolerable pain. Subjects rated the 20 degrees C water immersion as painless (average rating 0.18 +/- 0.48, mean +/- SD), but gave ratings indicating i

Match and mismatch: identifying the neuronal determinants of pain

Despite the increased intensity and sophistication of research on pain mechanisms in the past three decades, serious uncertainties remain about the neuronal origin of pain, especially in painful clinical conditions. Although a positive correlation between nociceptive afferent activity and the subjective perception of pain has been seen under controlled experimental conditions, important mismatches point to the critical importance of central nervous system processes as determinants of pain. Multiple peripheral, segmental, and supraspinal neuronal activities control nociceptive processing at all levels of the neuraxis. Three studies in this issue highlight the problem of identifying the neuronal determinants of pain by addressing contrasting mismatches: angina-like chest pain without an obvious cause and a potential source of angina (myocardial ischemia) without pain. The results of these studies suggest that selective visceral hyperalgesia and hypoalgesia of peripheral or central origin may be present without other clinical evidence for neurologic abnormality. Complex mechanisms interacting at several levels of the nervous system appear to be involved.

Topical capsaicin selectively attenuates heat pain and A delta fiber-mediated laser-evoked potentials

Cutaneous stimulation with CO2 laser pulses activates A delta of nociceptive afferents and evokes late cerebral potentials (LEPs), the amplitude of which correlates parametrically with the perceived magnitude estimation of laser pulses. Capsaicin is known to desensitize the nociceptive terminals of C fibers. In this double-blind, vehicle-controlled experiment, we tested the hypothesis that topical capsaicin would inactivate A delta afferents and lead to an attenuation of the LEPs. Subjects applied capsaicin cream to the dorsum of one hand and vehicle cream to the other 3 times daily for a period of 5 weeks. At weekly intervals before starting, during administration and after discontinuation of capsaicin, LEPs were recorded and psychophysical thresholds and magnitude estimation for several sensory modalities were determined. The results of this study showed that topical capsaicin significantly and reversibly decreased the magnitude estimation of suprathreshold heat pain, laser pulses and amplitude of the LEPs. There was no statistically significant difference in light touch, deep pain and mechanical pain detection thresholds between the capsaicin- and vehicle-treated hands. It indicated that topical capsaicin caused a definite functional and reversible inactivation of A delta nociceptive afferent transmission. The decline in the magnitude estimation of laser pulses concomitantly with the attenuation of LEP amplitudes supports the hypothesis that some A delta afferents mediate noxious heat in humans. These findings demonstrate the usefulness of LEP in the physiological evaluation of nociceptive pathways and its potential usefulness in objectively documenting the effect of pharmacological treatment on pain perception.

Laser-evoked cerebral potentials and sensory function in patients with central pain

Central pain syndromes (CPS) could be caused by disinhibition of spinothalamic excitability or by other central nervous system (CNS) changes caused by reduced spinothalamic function. To examine these possibilities, we studied 11 patients (ages 51-82 years) with unilateral central pain and with reproducible cerebral evoked vertex potentials in response to cutaneous stimulation of the normal side with pulses from an infra-red CO2 laser. All patients had normal tactile and kinesthetic sensation; one had slightly decreased vibratory sense bilaterally. All showed, from the unaffected (asymptomatic) side, laser evoked potentials (LEPs) with negative (N) components ranging from 208 to 280 msec peak latency (av: 240 +/- 6 SE msec) and peak amplitudes of 1-7 microV (av: 2.9 +/- 0.5 SE microV), followed, in all but 1 patient, by positive (P) potentials ranging from 288 to 370 msec peak latency (av: 319 +/- 7.7 SE msec) with peak amplitudes of 1-7 microV (2.8 +/- 0.5 SE microV). Laser stimulation of the affected (symptomatic) side in 5 patients evoked LEPs with N-P interpeak amplitudes that were within 20% of those evoked from the normal side. All but one of these patients had thresholds for warm, heat pain, and deep pain that were normal in comparison with the unaffected side. The excepted patient had the largest N-P interpeak amplitude asymmetry (18.5%) of this group. Ratings of laser pulse intensity were either symmetrical (n = 2) or increased on the affected side (n = 3) in these patients. In contrast, laser stimulation of the affected side failed to evoke either N or P potentials in 6 patients, all of whom had lateralized increased thresholds for warm, heat pain, or deep pain, or reduced ratings of laser pulse sensation. Although 1 patient had increased ratings of laser pulse sensation, the amplitude of the LEP was always reduced on the side of increased pain or heat threshold in these CPS patients (Fisher exact test: P = 0.015). These results reflect primarily a deficit in spinothalamic tract function and do not suggest excessive CNS responses to synchronous activation of cutaneous heat nociceptors in patients with CPS.

Spinal antinociception mediated by a cocaine-sensitive dopaminergic supraspinal mechanism

The role of dopaminergic descending supraspinal processes in mediating the antinociceptive action of cocaine was studied in the rat using a combination of extracellular neuronal recording and behavioral techniques. Neurons in the superficial laminae (I-II) of the spinal dorsal horn with receptive fields on the tail were recorded in anesthetized rats using insulated metal microelectrodes. Stimulation of the receptive field with either high intensity transcutaneous electrical pulses or with an infrared CO2 laser beam produced a biphasic increase in dorsal horn unit discharge. Conduction velocity estimates indicated that the early discharge corresponded to activity in A delta whereas the late response corresponded to activity in C afferent fibers. Cumulative doses of cocaine (0.1-3.1 mg/kg i.v.) inhibited the late response to either electrical or laser stimulation in a dose-related manner. The early response to laser, but not electrical, stimulation was also suppressed by cocaine. Neurons in the spinal dorsal horn with receptive fields on the ipsilateral hindpaw were activated by natural noxious (pinch) or innocuous (tap) somatic stimulation. Cocaine selectively suppressed nociceptively evoked dorsal horn unit discharge. This antinociceptive effect was dose-related (0.3-3.1 mg/kg, i.v.) and antagonized by eticlopride (0.05-0.1 mg/kg, i.v.), a selective D2 dopamine receptor blocker. The same doses of cocaine failed to inhibit the responses of dorsal horn neurons to low threshold innocuous stimulation. Complete thoracic spinal cord transection eliminated the antinociceptive effect of cocaine on dorsal horn neurons and also eliminated the cocaine-induced attenuation of the tail-flick reflex.(ABSTRACT TRUNCATED AT 250 WORDS)

Positron emission tomographic analysis of cerebral structures activated specifically by repetitive noxious heat stimuli

1. To identify the forebrain and brain stem structures that are active during the perception of acute heat pain in humans, we performed H2 15O positron emission tomographic (PET) analyses of cerebral blood flow (CBF) on nine normal volunteers while they received repetitive noxious (50 degrees C) and innocuous (40 degrees C) 5 s heat pulses to the forearm (average resting temperature of 31.8 degrees C). Each subject rated the subjective intensity of each stimulation series according to a magnitude estimation procedure in which 0 = no heat sensation, 7 = barely painful, and 10 = barely tolerable. 2. Three scans were performed at each temperature. Mean CBF images were created for each experimental condition and oriented onto standardized stereotaxic coordinates. Subtraction images were created between conditions for each subject and averaged across subjects. Volumes of interest (VOI) were chosen, based on a priori hypotheses and the results of previously published PET studies. In addition, a separate statistical summation analysis of individual voxels was performed. Statistical thresholds were established with corrections for multiple comparisons. 3. Significant CBF increases to 50 degrees C stimuli were found in the contralateral thalamus, cingulate cortex, S2 and S1 cortex, and insula. The ipsilateral S2 cortex and thalamus, and the medial dorsal midbrain and cerebellar vermis also showed significant CBF increases. All subjects rated the 50 degrees C stimuli as painful (average subjective rating = 8.9 +/- 0.9 SD) and the 40 degrees C stimuli as warm, but not painful (average subjective rating = 2.1 +/- 1.0).(ABSTRACT TRUNCATED AT 250 WORDS)

Variability of laser-evoked potentials: attention, arousal and lateralized differences

We recorded laser-evoked potentials (LEPs) from 20 normal subjects by stimulating the skin with pulses from an infrared CO2 laser. The conduction velocity of the peripheral afferent fibers mediating the LEPs averaged 14.9 m/sec. The amplitude of the LEP components correlated significantly with perceived stimulus intensity. During repetitive constant intensity stimulation, the peak-to-peak LEP amplitude decreased 38% during a distraction task and 42% during drowsiness and was absent during stage 2 sleep, indicating a modulation of responsiveness to laser stimulation during distraction and decreased states of arousal. Normative data revealed considerable intersubject variability in LEP latencies and amplitudes. Analysis of intrasubject lateralized (side-to-side) differences revealed that the relative peak-to-peak amplitude was less variable than that of the N or P components. For clinical applications using 3 S.D.s to define the normal range, a lateral interpeak amplitude difference greater than 28% would suggest focal or lateralized sensory abnormality in an individual patient. Vigilance and attentiveness to the stimuli should be monitored during the acquisition of LEPs.

Afferent modulation of warmth sensation and heat pain in the human hand

The hands of 14 normal humans were used to determine the somatotopic organization of the modulation of warmth sensation and heat pain by different forms of cutaneous stimuli. Test stimuli were 5-sec heat pulses ranging from 36 degrees to 51 degrees C, delivered to the fingerpads of digits 1, 2, 4, and 5 with a contact thermode. Conditioning stimuli (15 sec) bracketed the test stimuli and included vibration, noxious and innocuous heat, cold, and electrical pulses delivered to the fingerpads of digits that were adjacent or nonadjacent to the tested digits. Noxious (48 degrees +/- 1.3 degrees C), but not innocuous (43 degrees C), heat stimuli increased the perceived magnitude estimation of innocuous test stimuli (36-43 degrees C) by 20-37% when delivered to adjacent, but not to nonadjacent, digits. No other conditioning stimuli had any effect on the intensity of warmth perception. In contrast, both noxious and innocuous heat or electrical conditioning reduced the magnitude estimation of noxious (50-51 degrees C), but not innocuous, test pulses by 12-22% when delivered to adjacent digits. Conditioning of nonadjacent digits was significantly less effective. The analgesic effects of noxious and innocuous conditioning were approximately equal. Vibratory (120 Hz, 3.5 microns) and cold (15 degrees C) conditioning stimuli were ineffective. The results are consistent with a dermatomal somatotopic organization of tactile and heat modulatory influences on warmth sensation and heat pain. The results further suggest that the neural mechanism subserving warmth mediate a negative feedback influence on heat pain intensity.

Neurophysiological, pharmacological and behavioral evidence for medial thalamic mediation of cocaine-induced dopaminergic analgesia

These studies examined the effects of cocaine on thalamic neurons that respond maximally either to noxious or to innocuous somatic stimulation. Cocaine attenuated high intensity electrically-evoked nociceptive responses of all 25 units studied in the parafascicular and central lateral nuclei of the medial thalamus. A dose of 1 mg/kg intravenously (i.v.) suppressed medial thalamic unit discharge evoked by both noxious somatic stimulation (49.4 +/- 8.7% of control response) and spinal cord stimulation (76.2 +/- 6.6% of control response). The effect of cocaine on unit responses to noxious somatic stimulation was dose-related in the range of 0.3-3.5 mg/kg i.v. and was attenuated by eticlopride, a D-2 selective dopamine receptor antagonist. Morphine also suppressed noxious somatic evoked responses of medial thalamic units in a dose-dependent manner. Units in the lateral (ventrobasal) thalamus (n = 4) that responded only to innocuous stimuli were not affected by cocaine at doses up to 3.5 mg/kg i.v. Ibotenic acid lesions in the parafascicular nucleus of the medial thalamus attenuated the analgesic effect of cocaine in the formalin test. These results suggest that both cocaine and the parafascicular nucleus interact with dopaminergic mechanisms that attenuate nociceptive spinal projections to the medial thalamus.

State-related modulation of thalamic somatosensory responses in the awake monkey

1. These experiments were performed to assess the nature and extent of the modulation of somatosensory transmission through the thalamus of the awake primate brain. We investigated physiologically induced modulation occurring during changes in state of arousal within the waking state. Changes in thalamic responsiveness during the sleep-waking cycle were not studied. 2. We recorded from single units in several nuclei within the ventral posterior region of the thalamus (VP) of awake squirrel monkeys (Saimiri sciureus). Recording sites included the ventral posterior lateral, ventral posterior medial, ventral posterior inferior, ventral lateral, and thalamic reticular nuclei. Four hundred twenty-seven thalamic units were tested for responsiveness to innocuous and noxious somatic stimulation of cutaneous (hair and skin) and deep (muscle and tendon) structures and to innocuous electrical stimulation of the spinal lemniscus (SL). Noxious stimuli were just sufficient to evoke withdrawal and did not cause tissue damage. 3. All neurons were spontaneously active in the absence of intentional stimulation. Only 260 (60.9%) of the neurons recorded in VP responded to somatic or SL stimulation. Based on their responsiveness to somatic stimuli, we classified neurons as cutaneous (67.7% or 176/260) if responsive to hair and/or skin stimulation or as deep (18.8% or 49/260) if responsive only to manipulation of joints or palpation of muscles or tendons. Thirty-five other cells (13.5%) responded best to brisk innocuous taps applied to the somatic receptive field and were placed in a separate group. Cutaneous units were subclassified as low-threshold (LT, 86.9% or 153/176) if responding maximally to innocuous stimuli only or as wide dynamic range (WDR, 13.1% or 23/176) if responding preferentially to noxious stimuli. No neurons responded exclusively to noxious stimuli. Single-pulse SL stimulation evoked discharges at an average latency of 3.3 +/- 4.8 (SD) ms in 51/132 (38.6%) LT neurons tested and similarly affected 7 of 12 WDR cells tested at an average latency of 1.54 +/- 0.39 ms. 4. We tested 88 neurons for changes in activity as the monkey's state of arousal shifted between quiet waking (QW), waking movement (WM), and drowsy (D) states as defined by behavioral and electroencephalographic criteria. The responses of 42% of the 88 somatically activated cells tested (n = 37) showed arousal-related response modulation (ARM). ARM produced a mean change in evoked activity of 40.1% (+/- 23.5 SD) relative to that cell's maximal response and the specific state of arousal during which the maximal response occurred. Neurons classified as WDR were equally likely to exhibit ARM as LT neurons.(ABSTRACT TRUNCATED AT 400 WORDS)

The effect of systemic cocaine on the responses to noxious stimuli and spontaneous activity of medial bulboreticular projection neurons

The effect of antinociceptive doses of cocaine (25 mg/kg, i.p.) on unit responses to noxious somatic stimuli and spontaneous activity of antidromically identified projection neurons in the medial medullary reticular formation (MRF) was studied in the rat. Thirty-three antidromically activated neurons were recorded from the medullary raphe, gigantocellular, or paragigantocellular nuclei in an acute anaesthetized preparation; 25 cells projected to the spinal cord and 8 neurons had rostral projections through the medial forebrain bundle (n = 4) or the medial thalamus (n = 4). After cocaine administration, 24 (73%) of these cells showed immediate (less than 5 min) and prolonged (45-70 min) increases in their level of spontaneous activity. Associated with this increased interstimulus activity, 21 of 29 (72%) neurons responsive to noxious somatic stimulation reduced their responsiveness, relative to prestimulus activity, after cocaine administration. In 5 animals tested, the cocaine-induced changes in spontaneous activity and changes in evoked responsiveness were unaffected by naloxone (1 mg/kg, i.p.) but partially reversed within 5 min of the administration of chlorpromazine (3 mg/kg, i.p.). There were no obvious differences in neuronal response characteristics or the effect of cocaine that correlated with anatomical location or direction of axonal projection. Similar results were obtained while recording from 14 somatically responsive units in chronic, unrestrained, lightly anesthetized or awake rats. These findings provide direct evidence that cocaine, in doses that are antinociceptive for the rat, affects both unit responses to noxious stimuli and the spontaneous activity of caudally and rostrally projecting bulboreticular neurons over a time course that parallels the behavioral antinociception. The observation that unit responses to somatic stimuli were reduced while spontaneous activity was unchanged or increased in most cells suggests that cocaine antinociception may be due to the activation of sensory inhibitory mechanisms mediated by the MRF.

The effect of systemic cocaine on spontaneous and nociceptively evoked activity of neurons in the medial and lateral thalamus

In rats, analgesic doses of cocaine (25 mg/kg, i.p.) suppressed the responses of 20 of 22 medial and lateral thalamic neurons to reticular formation and somatic noxious stimuli. The responses of 7 of 8 lateral thalamic neurons to innocuous somatic stimuli were unaffected or enhanced. The suppression of thalamic responses to noxious stimuli may be part of the mechanism underlying cocaine analgesia.

Problems in the differential diagnosis of chronic pain

Differential diagnosis is the systematic consideration of the possible cause of signs and symptoms. It requires establishing an anatomic diagnosis, in which the site of pathology is identified, and then an etiiologic diagnosis of the causal pathologic agent. The differential diagnosis is based on a knowledge of the pathophysiology of 1) the presenting signs and symptoms, and 2) the natural history of various diseases and their causative agents. Consequently, the accuracy and reliability of the differential diagnosis is limited by a lack of knowledge about the pathophysiology of various diseases that produce chronic pain. Most painful conditions affecting ectodermally derived tissues are relatively easily localized; the major problems are in the diagnosis of central nervous system pain syndromes and in our knowledge about the pathophysiology of painful neurologic disorders. The anatomic diagnosis of painful diseases of mesodermal and endodermal tissues may be difficult because of the phenomena of referred pain and tenderness. The etiologic diagnosis is made difficult by our lack of knowledge about how various pathologic processes activate nociceptors in these tissues. Finally, the differential diagnosis of chronic pain requires information about the psychological characteristics of the patient and how emotional and higher cognitive functions influence the perception of pain.

Effect of medial bulboreticular and raphe nuclear lesions on the excitation and modulation of supraspinal nocifensive behaviors in the cat

Six cats were trained to eat while partially restrained and while thermal pulse stimuli (43-60 degrees C, 5 s duration) were delivered to the upper hindlimbs. Food and stimulus delivery were under programmed electronic control. The probability and latency of 3 natural, unlearned nocifensive behaviors were electronically registered: interruption of eating or of exploring for food, hindlimb movement and vocalization. Preoperatively, all cats showed significant increases in the probability of two or more behaviors as stimulus temperature increased. Each cat also showed a significant food-induced suppression of one or more of these behaviors. Thermocoagulation lesions limited to the giganto- and magnocellular fields of the medial medullary reticular formation (4 cats) produced a decrease in nocifensive responsiveness. Larger lesions within the same area but with extension into the postpyramidal raphe nuclei, resulted in increased nocifensive responsiveness (2 cats). No lesion affected response latency or the food-induced modulation of nocifensive behavior. The results support the hypothesis that supraspinally organized nocifensive responses are: (1) tonically facilitated by neural activity originating in or passing through the medial bulboreticular formation; (2) tonically suppressed by midline raphe spinal neurons; and (3) phasically modulated by suprabulbar neural mechanisms that are related to changes in behavioral state.

Cocaine: evidence for supraspinal, dopamine-mediated, non-opiate analgesia

Cocaine (25 mg/kg i.p.) produces analgesia in the rat within 5 min and for a duration of 90 min as determined by the formalin test or for 30 min as determined by the hot plate test. Cocaine analgesia is unaffected by doses of naloxone that are sufficient to attenuate morphine analgesia in both tests. Chlorpromazine (3 mg/kg i.p.), SCH 23390 (100 micrograms/kg i.p.; a D1 dopamine receptor antagonist), and eticlopride (75 micrograms/kg i.p.; a D2 dopamine receptor antagonist) each attenuate cocaine analgesia in both tests at doses that alone do not affect performance in either test. Measurements of blood pressure and heart rate indicate that cocaine analgesia is not due to the activation of baroreceptor reflex afferents. We conclude that cocaine is a supraspinally acting, dopamine-mediated, non-opiate analgesic in the rat.

Modulation of the spontaneous and evoked discharges of ventral posterior thalamic neurons during shifts in arousal

The responses of 154 ventral posterior thalamic neurons to a variety of somatic stimuli and to electrical stimulation of the midbrain spinal lemniscus were recorded in the awake squirrel monkey during varying states of arousal. Many VP (42/93) neurons showed changes in somatosensory responsiveness which correlated with shifts in arousal. Arousal related modulation (ARM) of somatic responses were not selective for any specific stimulus modality. Most cells (N = 36) responded maximally during quiet waking with responses significantly reduced during drowsiness or periods of waking movement. Other neurons (N = 5) responded maximally during drowsiness, and gave decreased responses as the level of arousal increased. Similar changes were seen for neurons driven by spinal lemniscal (SL) stimulation. All changes in evoked responses were independent of prestimulus background discharge frequency. At least one site of ARM takes place at the level of the VP thalamus.

Supraspinal nocifensive responses of cats: spinal cord pathways, monoamines, and modulation

These experiments were conducted to determine (1) whether dorsal and ventral ascending spinal pathways can each mediate unlearned supraspinal nocifensive responses of cats to noxious thermal stimuli and (2) whether interrupting the spinal projection of supraspinal monoaminergic neurons alters the excitability and natural modulation of these responses. In partially restrained cats, thermal pulses (greater than or equal to 47 degrees C) delivered to the hindlimbs of intact cats or rostral to lesions of the thoracic spinal cord elicited abrupt body movements and interruption of eating (or of exploring for) liquified food. These electronically monitored responses automatically terminated the stimulus. Natural modulation of responsiveness was produced by delivering food and thermal stimuli simultaneously; this reduced response probability by an average of 41%. Complete transection of the thoracic spinal cord eliminated both thermally elicited responses and orienting responses to noxious and tactile mechanical stimulation of the hindlimbs. Ventral bilateral thoracic spinal cord lesions that spared only the dorsal funiculus and portions of the dorsolateral funiculus (three cats) significantly reduced orienting responses to all mechanical hindlimb stimuli and reduced, but did not eliminate, movement and interrupt responses to noxious thermal hindlimb stimuli. Response latency was unaffected. Food-induced response suppression persisted although lumbar spinal cord concentrations of serotonin (5HT) and norepinephrine (NE) were markedly reduced. A bilateral lesion of the dorsal funiculi and dorsal portions of the dorsolateral funiculi (one cat) also reduced nocifensive responsiveness, but only the NE concentration in lumbar spinal cord was reduced significantly relative to a matched cervical sample. In contrast, deep bilateral lesions of the dorsolateral funiculi (two cats) produced an increase in the probability of movement and interrupt responses without affecting either response latency or food-induced response suppression. Lumbar spinal cord concentrations of NE and, in one cat, 5HT were reduced. We conclude that (1) the dorsal and ventral spinal funiculi are each sufficient to initiate and necessary to maintain normal supraspinally organized nocifensive behavior in the cat; (2) descending monoaminergic pathways are not necessary for the phasic modulation of these responses; and (3) the tonic excitability, but not the phasic modulation, of these responses is determined in part by fibers in the dorsolateral funiculus.

Physiological identification of afferent fibers and postsynaptic sensory neurons in the spinal cord of the intact, awake cat

A method was developed to record from spinal cord cells in the awake, intact, partially restrained cat. Units were classified as afferent fibers or postsynaptic cells based on their ability to follow 100-Hz peripheral stimulation, the duration and configuration of the action potential waveform, and the number of spikes evoked by a single electrical pulse. These criteria are supported by independent observations of the location of the recording site, size of the receptive field, and adequate stimulus. Of 84 cutaneously activated units, 29 were classified as afferent fibers, 28 as postsynaptic cells, and 27 were not classified. No cutaneously activated unit was spontaneously active. In contrast, all 28 units (7 postsynaptic and 21 not classified) responding to joint position or movement were spontaneously active (5 to 40 Hz). No unit responded to both cutaneous and proprioceptive inputs. Evidence for convergence of cutaneous input from different types of receptors was limited to five postsynaptic neurons that responded to hair movement and to stimuli applied to the skin; two of these cells responded differentially to noxious pinch. Two of 24 postsynaptic cutaneous units ceased responding to electrical cutaneous stimuli when the cat was eating. The responses of 29 primary afferent fibers were not altered by the behavior of the cat. These results suggest that, in the awake cat (i) criteria based on neuronal responsiveness and action potential waveform can be used to distinguish adequately between afferent fibers and postsynaptic cells; and (ii) there is a tonic inhibitory control, greater than in the anesthetized or spinally transected cat, that varies with behavioral state and is directed primarily at spinal neurons receiving cutaneous input.

The effect of systemic cocaine on spinal nociceptive reflex activity in the rat

In the anesthetized rat, cocaine (25 mg/kg i.p.), enhanced the frequency potentiation of nociceptively evoked polysynaptic discharges but did not affect the polysynaptic reflex discharge to single nociceptive stimuli or the habituation of this reflex to repetitive pinch stimuli. The non-nociceptive, short-latency reflex discharge was suppressed for 10-15 min after cocaine administration. The neurogenic extravasation response to antidromic cutaneous C-fiber stimulation was unaffected by cocaine. These findings suggest that systemic cocaine, in doses analgesic for the rat, does not suppress spinal nociceptive reflexes.

Differential effects of chronic partial myelotomies on monoamine levels in cat spinal cord

The concentrations of 5-hydroxytryptamine (5-HT), norepinephrine (NE) and dopamine (DA) were measured in samples of lumbar and cervical spinal cords from 6 cats with chronic (over 2 months) lesions of the thoracic spinal cord and from 7 unoperated cats. Lesions confined to the dorsal thoracic spinal cord significantly lowered lumbar concentrations of NE, but not 5-HT, compared with control lumbar or matched paired cervical samples. Both NE and 5-HT were significantly reduced by dorsal or ventral lesions that involved tissue ventral to the central canal. Only the largest lesion could be shown to reduce lumbar DA concentration.

Corticofugal influences of S1 cortex on ventrobasal thalamic neurons in the awake rat

Corticofugal influences on the responses of 39 ventrobasal (VB) thalamic neurons to repetitive stimuli were studied in awake rats by focally suppressing the evoked and spontaneous electrocortical activity of the primary (S1) somatosensory cortex with magnesium or lidocaine plus magnesium. Suppression of the S1 cortex reduced the number of spikes discharged by 19 (66%) of 29 VB units in response to each of 25 electrical stimuli delivered to the medial lemniscus; 9 units were unaffected and 1 showed an increased response to 1-10 Hz stimuli. The responses of 6 (38%) of 16 VB units to electrical somatic stimuli were also reduced following S1 cortical suppression; 9 units were unaffected and 1 showed an increased response to 20-40 Hz stimuli. A comparison of the reduced responsiveness of 5 units studied during medial lemniscal and somatic stimulation did not reveal any additional response attenuation attributable to subthalamic corticofugal influences. We conclude that, in the awake rat, somatosensory transmission to VB thalamic neurons is primarily facilitated by S1 corticothalamic neurons.

A microprocessor device for the real-time detection of synchronized alpha and spindle activity in the EEG

A microprocessor based device is described which permits the real-time detection of synchronized EEG activity within the frequency range of the alpha rhythm or sleep spindles. This device offers a reliable, inexpensive method for EEG analysis according to flexible, user selectable parameters. It can be used either on-line or off-line and provides information as to the occurrence and duration of alpha-spindle EEG activity.