Increased postural stiffness during challenging postural tasks in patients with knee osteoarthritis with high pain sensitization

BACKGROUND

Postural stability is affected in knee osteoarthritis patients who present with pain but the link to pain sensitization is unclear.

METHODS

Patients with knee osteoarthritis completed the Knee Injury and Osteoarthritis Outcome Score and pressure pain thresholds were assessed bilaterally at the knee, lower leg and forearm prior to standing quietly (1 min) on a force platform in four conditions: Firm surface with open eyes, firm surface with closed eyes, soft surface with open eyes, and soft surface with closed eyes. Pain intensity during standing was assessed via numerical rating scale. Postural stability was assessed by the range, velocity, and standard deviation of the Center of Pressure (CoP) extracted from the force platform. The means of three repeated measures per standing condition were analysed. High-sensitization and low-sensitization groups were defined based on bilateral pressure pain thresholds from leg and arm.

FINDINGS

Fifty-six patients were included. Compared with the low-sensitization group, the high-sensitization group demonstrated 1) smaller pressure pain thresholds at the knee (P < 0.05) although the Knee Injury and Osteoarthritis Outcome Score and pain intensity were not significantly different between groups, and 2) smaller range of the CoP in the anterior-posterior direction during the soft surface with closed eyes condition (P < 0.05).

INTERPRETATION

Smaller CoP range suggest that patients with more widespread pain sensitivity have increased postural stiffness compared with the low-sensitization group. The greater stiffness found in high-sensitization patients under sensory restrictions (closed eyes and reduced proprioception) might relate to restricted integration of sensory information due to widespread pain sensitization.

Surface EMG Crosstalk Evaluated from Experimental Recordings and Simulated Signals

Objectives: Surface EMG crosstalk is the EMG signal detected over a non-active muscle and generated by a nearby muscle. The aim of this study was to analyze the sources of crosstalk signals in surface EMG recordings and to discuss methods proposed in the literature for crosstalk quantification and reduction.

Methods: The study is based on both simulated and experimental signals. The simulated signals are generated by a structure based surface EMG signal model. Signals were recorded with both intramuscular and surface electrodes and single motor unit surface potentials were extracted with the spike triggered averaging approach. Moreover, surface EMG signals were recorded from electrically stimulated muscles.

Results: From the simulation and experimental analysis it was clear that the main determinants of crosstalk are non-propagating signal components, generated by the extinction of the intracellular action potentials at the tendons. Thus, crosstalk signals have a different shape with respect to the signals detected over the active muscle and contain high frequency components.

Conclusions: Since crosstalk has signal components different from those dominant in case of detection from near sources, commonly used methods to quantify and reduce crosstalk, such as the cross-correlation coefficient and high-pass temporal filtering, are not reliable. Selectivity of detection systems must be discussed separately as selectivity with respect to propagating and non-propagating signal components. The knowledge about the origin of crosstalk signal constitutes the basis for crosstalk interpretation, quantification, and reduction.

Paradoxical differences in pain ratings of the same stimulus intensity

Aims

Stimulus intensity used for assessing temporal summation of pain (TSP) is commonly set at the participants’ pain tolerance. Yet pain ratings during TSP rarely reach that initial pain tolerance pain rating. This study aimed to explore the differences between baseline pain tolerance assessed by cuff algometry and subsequent pain ratings of the same stimulus intensity, and the reliability of these ratings over 2 sessions.

Methods

In two sessions, separated by one week, 24 healthy, pain-free males had their pressure pain detection (PDT) and tolerance threshold (PTT) recorded using a staircase inflation paradigm (5 kPa increments, 1sec-ON:4sec-OFF) with a cuff algometry system. The pain intensity was assessed during cuff stimulation using an electronic visual analogue scale (VAS, 0–10 cm). Three different inflation paradigms were then performed, using the PTT level as stimulation intensity, and a 1-s duration for each stimulus: PEAKS: 3 inflations at 0.17 Hz, SLOW: 10 inflations at 0.01 Hz, FAST: 10 inflations at 0.5 Hz). Approximately 5-min was kept between the staircase assessment and the first stimulation paradigm, and between each of the 3 inflation paradigms. The PTT and first inflation VAS rating from each paradigm was extracted.

Results

The VAS rating of PTT pressure was higher in the staircase (VAS: 8.5±2.1 cm) than the first PPT stimulus in any other paradigm (PEAKS: 5.4±2.0; SLOW: 4.6±2.1; FAST: 4.0±2.3, P < 0.05). VAS ratings were also lower in each subsequent paradigm (i.e. PEAKS > SLOW > FAST, P < 0.05). Intra-class coefficients demonstrated excellent reliability for each paradigm (all ICC > 0.79) between sessions.

Conclusions

PTT, as assessed with the staircase inflation paradigm, was rated more painful during baseline assessment than when the identical stimulus profile (PPT intensity for 1-s) was applied afterwards and this finding is considered reliable.

Fixed or adapted conditioning intensity for repeated conditioned pain modulation

Aims

Conditioned pain modulation (CPM) is used to assess descending pain modulation through a test stimulation (TS) and a conditioning stimulation (CS). Due to potential carry-over effects, sequential CPM paradigms might alter the intensity of the CS, which potentially can alter the CPM-effect. This study aimed to investigate the difference between a fixed and adaptive CS intensity on CPM-effect.

Methods

On the dominant leg of 20 healthy subjects the cuff pressure detection threshold (PDT) was recorded as TS and the pain tolerance threshold (PTT) was assessed on the non-dominant leg for estimating the CS. The difference in PDT before and during CS defined the CPM-effect. The CPM-effect was assessed four times using a CS with intensities of 70% of baseline PTT (fixed) or 70% of PTT measured throughout the session (adaptive). Pain intensity of the conditioning stimulus was assessed on a numeric rating scale (NRS). Data were analyzed with repeated-measures ANOVA.

Results

No difference was found comparing the four PDTs assessed before CSs for the fixed and the adaptive paradigms. The CS pressure intensity for the adaptive paradigm was increasing during the four repeated assessments (P < 0.01). The pain intensity was similar during the fixed (NRS: 5.8±0.5) and the adjusted paradigm (NRS: 6.0±0.4). The CPM-effect was higher using the fixed condition compared with the adaptive condition (P < 0.05).

Conclusions

The current study found that sequential CPM paradigms using a fixed conditioning stimulus produced an increased CPM-effect compared with adaptive and increasing conditioning intensities.

The size of pain referral patterns from a tonic painful mechanical stimulus is increased in women

Aims

The purpose of this study was to investigate potential gender differences in pain referral patterns induced by a tonic painful mechanical stimulus.

Methods

Forty-five healthy adults (22 women) participated in this study. Pressure pain thresholds (PPTs) were assessed at the infraspinatus, the brachioradialis and the gastrocnemius muscles on the dominant side, using handheld algometry. Following this, painful pressure at the infraspinatus muscle was induced using the algometer by rapidly increasing the pressure until it reached the level of 7 cm on VAS (PVAS7). This pressure was kept constant for 60s. Upon release, the subject was asked to indicate the area of the pressure-induced pain on a digital body chart. PPT values, PVAS7 and the pain area (number of pixels) were extracted for data analysis.

Results

No gender differences were found in PPT values (P >0.05). The pressure needed to reach 7 cm on the VAS was significantly lower in the female group (687.4±50.5 kPa) compared with males (971.0 ± 49.6 kPa; unpaired t-test: P < 0.05). The size of the pain area following PVAS7 stimulation for 60 s was significantly larger in the female group (12,578.5 ± 17,280.3 pixels) compared with the male group (6175.0 ± 9518.5 pixels; Mann–Whitney-U; P < 0.05).

Conclusions

Despite comparable PPT values, women demonstrated larger pain areas compared with men although the standardized painful stimulus which intensity was perceived similarly as 7 cm on the VAS scale in both groups. These findings suggest that there are gender-specific differences in pain distribution and referred pain but it is unclear through which mechanism they are mediated.

Several days of muscle hyperalgesia facilitates cortical somatosensory excitability

Background and aims

Maladaptive plasticity in neural circuits has been proposed in chronic musculoskeletal pain and has been discussed as a key component of the transition from acute to chronic pain. The induction of delayed onset muscle soreness (DOMS) in healthy individuals is one method that can be used to investigate the adaptations of neural circuits in response to several days of muscle hyperalgesia. The aim of this study was to determine the adaptations of the sensory cortex in response to muscle hyperalgesia induced by eccentric exercise of the wrist extensor muscles. It was hypothesized that muscle hyperalgesia would result in a facilitation of cortical somatosensory excitability, based on sensory evoked potentials evoked by electrical stimulation of the radial nerve.

Methods

Twelve healthy subjects performed eccentric exercise of the wrist extensors. Muscle soreness, pressure pain thresholds (PPTs) on the extensor carpi radialis (ECR) muscle, somatosensory evoked potentials (SEPs) based on 10 channel EEG recorded during electrical stimulation of the radial nerve were recorded before (Day0Pre), 2h (Day0Post), 2 days (Day2), and 6 days (Day6) after exercise.

Results

Compared to Day0Pre: (i) Muscle soreness increased at Day0Post and increased further at Day2 (both P < 0.05). (ii) Pressure pain thresholds decreased at Day2 (P < 0.05), (iii) the peak-to-peak N30-P45 and P45-N60 amplitude of the sensory evoked potential from the central-parietal recording sites were increased at Day2 (both P < 0.05); (iv) reduction in ECR PPTs was correlated with an increase of the post-central P45 wave.

Conclusions

These data demonstrate that hyperalgesia developing across several days is accompanied by an increase in sensory cortical excitability. In addition, sensory cortical adaptation followed a similar temporal profile to increased sensitivity to pressure (PPTs). This model may be relevant for further understanding neural adaptation in the transition from acute to chronic pain.

Blood flow after contraction and cuff occlusion is reduced in subjects with muscle soreness after eccentric exercise

Delayed onset muscle soreness (DOMS) occurs within 1-2 days after eccentric exercise, but the mechanism mediating hypersensitivity is unclear. This study hypothesized that eccentric exercise reduces the blood flow response following muscle contractions and cuff occlusion, which may result in accumulated algesic substances being a part of the sensitization in DOMS. Twelve healthy subjects (five women) performed dorsiflexion exercise (five sets of 10 repeated eccentric contractions) in one leg, while the contralateral leg was the control. The maximal voluntary contraction (MVC) of the tibialis anterior muscle was recorded. Blood flow was assessed by ultrasound Doppler on the anterior tibialis artery (ATA) and within the anterior tibialis muscle tissue before and immediately after 1-second MVC, 5-seconds MVC, and 5-minutes thigh cuff occlusion. Pressure pain thresholds (PPTs) were recorded on the tibialis anterior muscle. All measures were done bilaterally at day 0 (pre-exercise), day 2, and day 6 (post-exercise). Subjects scored the muscle soreness on a Likert scale for 6 days. Eccentric exercise increased Likert scores at day 1 and day 2 compared with day 0 (P<.001). Compared with pre-exercise (day 0), reduced PPT (~25%, P<.002), MVC (~22%, P<.002), ATA diameter (~8%, P<.002), ATA post-contraction/occlusion blood flow (~16%, P<.04), and intramuscular peak blood flow (~23%, P<.03) were found in the DOMS leg on day 2 but not in the control leg. These results showed that eccentric contractions decreased vessel diameter, impaired the blood flow response, and promoted hyperalgesia. Thus, the results suggest that the blood flow reduction may be involved in the increased pain response after eccentric exercise.

User-independent assessment of conditioning pain modulation by cuff pressure algometry

BACKGROUND

The use of conditioning pain modulation (CPM) is hampered by poor reproducibility and lack of user-independent paradigms. This study refined the CPM paradigm by applying user-independent cuff algometry.

METHODS

In 20 subjects, the CPM effect of conditioning with cuff stimulation on the arm was investigated by pain test stimuli on the contralateral leg before and in parallel with different cuff conditionings (10, 30, 60 kPa/60 s; 30, 60 kPa/10 s). As test stimulus, another cuff was inflated (1 kPa/s) until the subjects detected the pain tolerance threshold (PTT) during which the pain detection threshold (PDT) and the pressure at a pain intensity of 6 cm on a 10-cm visual analogue scale (PVAS6) were extracted. For comparison, pressure pain thresholds (PPTs) as test stimuli were recorded by the user-dependent handheld pressure algometry. Combinations of cuff locations for conditioning (pain intensity standardized) and contralateral test stimuli were additionally evaluated (leg-arm, leg-leg, arm-thigh). The test-retest reliability in two sessions 1 month apart was assessed in five CPM protocols.

RESULTS

In all protocols, the PDT, PVAS6 and PTT increased during conditioning compared with baseline (p < 0.05). The CPM effect (i.e. conditioning minus baseline) for PVAS6, PTT and PPT increased for increasing conditioning intensities (p < 0.05). The CPM effects were not significantly different for changes in conditioning durations or conditioning/test stimulus locations. In two sessions, the CPM effects for PVAS6 and PTT assessed after 60 s of conditioning on the leg/thigh showed the highest intra-class correlations (0.47-0.73), where they were 0.04-0.6 for PPTs.

CONCLUSIONS

The user-independent cuff algometry is reliable for CPM assessment and for supra-pain threshold test stimuli better than the user-dependent technology.

SIGNIFICANCE

A user-independent CPM technique where the conditioning is controlled by one cuff stimulation, and the test-stimulus is provided by another cuff stimulation. This study shows that cuff algometry is reliable for CPM assessment.

Acute bilateral experimental neck pain: Reorganise axioscapular and trunk muscle activity during slow resisted arm movements

Aims

Neck pain is frequent and many develop on-going neck pain after the initial onset. Studies on clinical neck pain suggested that altered axioscapular muscle activity may be an important factor in on-going neck pain. This study investigates the effect of bilateral experimental neck pain on axioscapular muscle activity during standardised resisted arm movements.

Methods

25 healthy participants were recruited for this single blinded cross-over study. Experimental pain was induced by bilateral injection of hypertonic saline into the splenius capitis muscle. Isotonic saline was used as a control. Pain intensity was recorded using an electronic visual analogue scale (VAS; 0-10 cm). Participants performed standardised arm movements, from a seated position, while wearing 1 kg wrist weights. Six arm abduction movements (30° to frontal plane, 3 per side) were performed to an angle of 140°. Each movement consisted of two 3 s phases (up/down) and was separated by a 6 s break, before moving the opposite arm. Surface electromyography (EMG) was recoded from 8 bilateral muscles. Recordings were done before, immediately after, and 5 min after the experimental pain. Root-mean-square (RMS) of the EMG signals were extracted for each muscle and averaged for the 3 trials. Data was compared between sides and no differences were identified after which data was pooled for further analysis.

Results

During the painful condition for the slow upward movement, a reduced RMS-EMG activity was found for the ipsilateral upper trapezius (P< 0.01). In addition, increased RMS-EMG was found bilaterally for the erector spinae muscle (P< 0.01).

Conclusion

Bilateral experimental neck reorganise axioscapular and trunk muscle activity during resisted, slow upward movement. The results of this supports previous studies on neck pain patients suggesting neck pain is linked to axioscapular function and underpins the necessity to include the shoulder girdle in assessment and rehabilitation of neck pain patients.

Interaction between ultraviolet B-induced cutaneous hyperalgesia and nerve growth factor-induced muscle hyperalgesia

BACKGROUNDS AND OBJECTIVES

Clinical observations indicate that cutaneous hyperalgesia may arise from pain located in deep structures. The objective of this study was to investigate whether combined sensitization of deep and superficial somatic tissues facilitates skin hyperalgesia.

METHODS

The interaction between muscle and cutaneous hyperalgesia was investigated in 16 healthy volunteers. Skin sensitization was induced unilaterally on the same randomly selected part of the body by ultraviolet B (UVB) irradiation above the upper trapezius and low back muscles. The next day, muscle hyperalgesia was induced bilaterally in low back muscles by injections of nerve growth factor (NGF). Thus, 1 day after irradiation there was skin sensitization, whereas after 2 days both skin and muscle sensitizations were present. Cutaneous blood flow, pin-prick thresholds, pressure pain thresholds (PPTs), temporal summation to repetitive painful pressure stimulation, and stimulus-response functions of graded pressure stimulations and pain intensity were assessed within the irradiated skin area and in the surrounding area before and 1, 2 and 3 days after irradiation.

RESULTS

Comparing baseline with 1 day after irradiation, UVB and UVB+NGF locations demonstrated: (1) Increased superficial blood flow inside the irradiated area (p < 0.01); (2) Reduced pin-prick (p < 0.01) and PPTs (p < 0.05) within the irradiated area and in the surrounding area; (3) Left-shifted pressure stimulus-response function within the irradiated area (p < 0.01); (4) Facilitated temporal summation inside the irradiated area (p < 0.01).

CONCLUSIONS

Using skin and deep tissue pain sensitization models simultaneously, no significant synergistic effects were found within the 3-day investigation suggesting little integration between the two phenomena in this period.

Motor Cortex Reorganization and Impaired Function in the Transition to Sustained Muscle Pain

Primary motor cortical (M1) adaptation has not been investigated in the transition to sustained muscle pain. Daily injection of nerve growth factor (NGF) induces hyperalgesia reminiscent of musculoskeletal pain and provides a novel model to study M1 in response to progressively developing muscle soreness. Twelve healthy individuals were injected with NGF into right extensor carpi radialis brevis (ECRB) on Days 0 and 2 and with hypertonic saline on Day 4. Quantitative sensory and motor testing and assessment of M1 organization and function using transcranial magnetic stimulation were performed prior to injection on Days 0, 2, and 4 and again on Day 14. Pain and disability increased at Day 2 and increased further at Day 4. Reorganization of M1 was evident at Day 4 and was characterized by increased map excitability. These changes were accompanied by reduced intracortical inhibition and increased intracortical facilitation. Interhemispheric inhibition was reduced from the "affected" to the "unaffected" hemisphere on Day 4, and this was associated with increased pressure sensitivity in left ECRB. These data provide the first evidence of M1 adaptation in the transition to sustained muscle pain and have relevance for the development of therapies that seek to target M1 in musculoskeletal pain.

Decreased muscle strength is associated with impaired long-term functional outcome after intramedullary nailing of femoral shaft fracture

PURPOSE

To examine the long-term outcome after intramedullary nailing of femoral diaphysial fractures measured as disease-specific patient reported function, walking ability, muscle strength, pain and quality of life (QOL).

METHODS

Cross-sectional study. Retrospective review and follow-up with clinical examination of 48 patients treated with intramedullary nailing after femoral shaft fracture between 2007 and 2010. The patients underwent a clinical examination and assessment of walking ability, maximal muscle strength during knee flexion and extension and hip abduction. Hip disability and Osteoarthritis Outcome Score (HOOS) and questionnaire evaluating QOL (Eq5D-5L) were completed by patients.

RESULTS

Fourty-eight patients agreed to participate. Mean time for follow-up was 4.7 years. The mean HOOS scores were 84.9 (Pain), 86.6 (ADL), 85.0 (Symptoms), 72.6 (QOL), and 69.1 (Sport). The mean muscle strength of knee flexion with the injured leg (226.0 N) was significantly lower then knee flexion with the non-injured leg (259.5 N, P < 0.0001). Likewise for knee extension (335.2 vs 406.4 N, P < 0.001) and hip abduction (129.2 vs 156.0 N, P < 0.001). Significant association between HOOS and an increase in the difference in muscle strength were observed as well as between worse HOOS outcome and increasing body mass index.

CONCLUSION

This study showed that decreased muscle strength for knee flexion, knee extension and hip abduction was associated with worse long-term functional outcome measured with a disease-specific questionnaire (HOOS) after intramedullary nailing of femoral shaft fracture.

Normalization of widespread hyperesthesia and facilitated spatial summation of deep-tissue pain in knee osteoarthritis patients after knee replacement

OBJECTIVE

The modest association between radiographic joint damage and pain in osteoarthritis (OA) has led to the suggestion of facilitated central pain processing. This study evaluated the importance of ongoing tissue pathology in the maintenance of enhanced central pain processing.

METHODS

Pain assessment was performed on 48 patients with symptomatic knee OA and 21 sex- and age-matched pain-free healthy control subjects. Twenty of the OA patients subsequently underwent total knee replacement surgery and were reassessed. Pressure-pain thresholds (PPTs) were recorded using a pressure algometer (both over and distant from the knee) and a double-chamber inflatable cuff mounted around the calf. Spatial summation was assessed by relating PPTs using the dual- and single-chamber cuff. Conditioned pain modulation (CPM) was assessed by recording the increase in PPT in response to experimental arm pain.

RESULTS

PPTs at the knee and at sites away from the knee were reduced in OA patients as compared with healthy pain-free control subjects (P < 0.0001). Cuff PPTs were decreased in OA patients as compared with the healthy controls (P < 0.05), who also exhibited a greater degree of spatial summation (P < 0.05). Whereas an elevation of PPTs was noted in the healthy controls in response to experimental arm pain (P < 0.0001), no such CPM was observed in the OA patients. Following joint replacement in the OA patients, there was a reduction in the widespread mechanical hyperesthesia, along with normalization of spatial summation ratios and restoration of CPM.

CONCLUSION

The widespread hyperesthesia and enhanced spatial summation observed in OA patients imply sensitized central pain mechanisms together with the loss of CPM. Normalization of the results following joint replacement implies that these central pain processes are maintained by peripheral input.

Exercise and conditioned pain modulation have different effects on cuff pressure pain tolerance in humans

Background/aims

Exercise and experimental pain is known to cause an acute decrease of the pain sensitivity. Assessment of pain inhibitory mechanisms is often done by paradigms of exercise and experimental pain in both healthy subjects and pain patients. It is currently unknown whether pain and different types of exercise has similar effects on pain sensitivity. The aim of the present study was to investigate the effects of experimental pain and different types of exercise on deep tissue pain tolerance in healthy subjects.

Methods

On two separate days fifty-four healthy subjects (23 females, 33.8 ± 15.0 years) were assigned in random order to cold pressor tests (ice water at 1–2°C; 120 s duration) for the dominant hand and foot, bicycling exercises (100 W and 200 W; 20 min duration), and isometric contraction exercises (30% and 60% of maximal voluntary contraction, MVC; 180 s duration) of the dominant quadriceps and biceps brachii muscles. Before, immediately after, and 10 min after cold pressor tests and exercises, pressure pain tolerance (PTT) were assessed with computerized cuff-algometry at the non-dominant lower-leg and upper arm. Subjects reaching maximum stimulation intensity at baseline were excluded from the analysis. PTTs were analysed with repeated measures ANOVA and multiple comparisons.

Results

Immediately and 10 min after the cold pressor test in the dominant hand and foot significantly increased PTTs were found at the non-dominant upper arm and lower leg (P < 0.05). Both intensities of dominant biceps brachii isometric contractions produced a significant increase in the PTT at the non-dominant lower leg immediately after and 10 min after contractions (P < 0.05). After the 30% dominant quadriceps isometric contraction the PTT at the non-dominant lower leg was significantly increased (P < 0.05).

Conclusion

Cold pressor pain produced a contralateral and extrasegmental increase in deep tissue pain tolerance. Isometric arm exercise produced an extrasegmental increase in pain tolerance, whereas isometric leg contractions produced a contralateral effect. Aerobic exercise had no effect on pain tolerance. Thus, exercise and pain related inhibitory effects were not comparable.

Acknowledgment/disclosures

H.B. Madsen was supported by grants from the philanthropic foundation TrygFonden (7-11-0990), The Danish Rheumatism Association 8R95-A1871), The Research Foundation of the Danish Physiotherapy Association and The Fund for Physiotherapy in Private Practice.

A simple test of muscle coactivation estimation using electromyography

In numerous motor tasks, muscles around a joint act coactively to generate opposite torques. A variety of indexes based on electromyography signals have been presented in the literature to quantify muscle coactivation. However, it is not known how to estimate it reliably using such indexes. The goal of this study was to test the reliability of the estimation of muscle coactivation using electromyography. Isometric coactivation was obtained at various muscle activation levels. For this task, any coactivation measurement/index should present the maximal score (100% of coactivation). Two coactivation indexes were applied. In the first, the antagonistic muscle activity (the lower electromyographic signal between two muscles that generate opposite joint torques) is divided by the mean between the agonistic and antagonistic muscle activations. In the second, the ratio between antagonistic and agonistic muscle activation is calculated. Moreover, we computed these indexes considering different electromyographic amplitude normalization procedures. It was found that the first algorithm, with all signals normalized by their respective maximal voluntary coactivation, generates the index closest to the true value (100%), reaching 92 ± 6%. In contrast, the coactivation index value was 82 ± 12% when the second algorithm was applied and the electromyographic signal was not normalized (P < 0.04). The new finding of the present study is that muscle coactivation is more reliably estimated if the EMG signals are normalized by their respective maximal voluntary contraction obtained during maximal coactivation prior to dividing the antagonistic muscle activity by the mean between the agonistic and antagonistic muscle activations.

Quantification of local and referred pain in humans induced by intramuscular electrical stimulation

The basic knowledge related to referred muscle pain is limited. To study referred pain, an experimental model using intramuscular electrical stimulation has been developed. Four experiments were performed: (1) the thresholds for eliciting local (LPT) and referred pain (RPT) were determined; (2) stimulus-response functions relating stimulus intensity, pain intensity ratings and size of pain areas were determined; (3) inter- and intrasession variabilities were assessed; and (4) prolonged stimulations were given with a duration of 10 min to evaluate temporal aspects of the referred muscle pain. Intramuscular electrical stimulation of the tibialis anterior muscle elicited pain at the stimulation site in 94% of the subjects, and referred pain in 78% of the subjects. Referred pain was located in the anterior part of the ankle. The mean RPT was 72% higher than the mean LPT (p<0.01). Correlation was found between stimulus intensity, sensory/pain rating scores and size of pain areas (0.74< or =r< or =0.98,p<0.04). Size of pain areas and sensation/pain rating scores were correlated (0.86< or =r< or =0.97, p<0.01). Intersession variability showed that the LPTs were not significantly different (p>0.16), but the RPTs were disparate (p<0.02). Intrasession values revealed a significant difference between the five LPTs, RPTs, local and referred pain rating scores. The size of the local and referred pain areas remained constant. Prolonged stimulation at 150% of RPT showed that the onset (the first occurrence of pain) of referred pain occurred significantly later (43 s +/- 80 s) than at the local pain site (p<0.03). This study showed that local and referred muscle pain can be elicited by intramuscular electrical stimulation, and indicated that temporal and spatial summation may be involved in the elicitation of referred muscle pain.

Referred pain is dependent on sensory input from the periphery: A psychophysical study

Muscle pain can be characterized by local pain and pain referred to distant somatic structures with concomitant cutaneous and deep somatosensory changes. The mechanisms responsible for referred muscle pain are poorly understood. The aim of this study was to study the origin of experimentally-induced referred muscle pain by anaesthetizing the skin overlying the referred pain area and to quantify deep somatosensory changes in the area. Fourteen healthy subjects (mean age = 25.1 years, range 22-34 years) were included in a placebo controlled study consisting of two sessions separated by 1 week. Two stimulation needles were inserted into the right anterior tibial muscle. Electrical stimuli (1Q Hz) were delivered by a computer-controlled constant current stimulator. The intensity required to generate referred pain was determined and the circumference of the referred pain area was marked. At the centre of the area, pressure pain threshold and pinprick perception threshold were determined. Either an anaesthetic cream (EMLA, Astra AB, Sweden) or a placebo cream (Astra AB, Sweden) covered by an occlusive dressing was applied to the marked referred pain area for 90 min. Afterwards, a 600-s stimulation at 150% of the referred pain threshold was induced while the VAS score of referred pain was recorded continuously. Pressure pain threshold and pinprick perception threshold were determined before, during and 5 min after the prolonged stimulation. A significantly lower referred pain visual analogue scale (VAS) score was recorded during the interval from 50 to 150s (p=0.04). The area under the referred pain VAS score vs time curve tended to be lower (22.7%) with the application of skin anaesthetic (p=0.07). The mean referred pain threshold and the mean referred pain area did not differ significantly between the two sessions (p>0.6). No difference was found in pressure pain threshold between the two treatments or between the four recordings during each session (p>0.8). Pinprick perception threshold increased significantly after EML application (p<0.04). Decreased referred pain intensity with application of anaesthetic cream at the referred pain site indicates that referred muscle pain depends on input from the periphery (skin) in humans.

Spatial dependency of trapezius muscle activity during repetitive shoulder flexion

The purpose of this study was to explore changes in spatial muscle activation within the three divisions of the trapezius muscle during a dynamic, cyclic task of the upper limb. Surface EMG signals were detected from thirteen healthy subjects from the upper, middle and lower divisions of the trapezius muscle at multiple electrode sites in the cephalad-caudal direction during a repetitive shoulder flexion task. Initial values and rate of change of average rectified value (ARV) and of instantaneous mean power spectral frequency (iMNF) were estimated at 45 degrees , 90 degrees and 120 degrees of shoulder flexion throughout the 5-min task. The location of the electrodes had a significant effect on initial EMG ARV for both the upper and middle division of the trapezius muscle (P<0.05). Both the rate of change and normalized rate of change of ARV were greatest for the most cranial muscle fibers of the upper division (P<0.05). Initial values and rates of change of iMNF were also affected by electrode location for the upper and lower divisions of the trapezius muscle (P<0.05). These results demonstrate that muscle activity and its changes over time depend on position within the three divisions of the trapezius muscle during a dynamic, cyclic task of the upper limb. This suggests non-uniform muscle fiber distribution and/or recruitment. The results also highlight the importance of multiple recording sites when investigating trapezius muscle function in dynamic tasks.

Muscle pain induces task-dependent changes in cervical agonist/antagonist activity

This study examined the effect of experimental neck muscle pain on the EMG-force relationship of cervical agonist and antagonist muscles. Surface EMG signals were detected from the sternomastoid, splenius capitis, and upper trapezius muscles bilaterally from 14 healthy subjects during cervical flexion and extension contractions of linearly increasing force from 0 to 60% of the maximum voluntary contraction (MVC). Measurements were performed before and after injection of 0.5 ml hypertonic and isotonic saline into either the sternomastoid or splenius capitis in two experimental sessions. EMG average rectified value (ARV) of the sternomastoid, splenius capitis, and upper trapezius muscles and the muscle fiber conduction velocity (CV) of the sternomastoid muscle were estimated at 5% MVC force increments. During cervical flexion with injection of hypertonic saline in sternomastoid, ARV of sternomastoid was lower on the side of pain in the force range 25-60% MVC (P < 0.05) and was associated with a bilateral reduction of splenius capitis and upper trapezius ARV (P < 0.01). During cervical extension, injection of hypertonic saline in splenius capitis resulted in lower estimates of splenius capitis ARV on the painful side from 45 to 60% MVC (P < 0.05), which was associated with a bilateral increase in upper trapezius ARV estimates from 50 to 60% MVC (P < 0.001). However, no significant change was identified for estimates of sternomastoid ARV. Experimentally induced neck muscle pain resulted in task-dependent changes in cervical agonist/antagonist activity without modifications in muscle fiber CV.

Patterns of experimentally induced pain in pericranial muscles

Nociceptive mechanisms in the craniofacial muscle tissue are poorly understood. The pain pattern in individual pericranial muscles has not been described before. Experimental muscle pain was induced by standardized infusions of 0.2 ml 1 m hypertonic saline into six craniofacial muscles (masseter, anterior temporalis, posterior temporalis, trapezius, splenius capitis and sternocleidomastoid) in 20 healthy subjects. The pressure pain thresholds (PPTs) were determined before and after infusions. The subjects continuously reported intensity of saline-induced pain on an electronic visual analogue scale (VAS) and the perceived area of pain was drawn on anatomical maps. The pain areas were measured and the localization determined by a new centre-of-gravity method. The PPTs were lowest on the sternocleidomastoid muscle (anova: P<0.001), but the saline-evoked VAS pain scored highest following injection into the masseter muscle (anova: P<0.05). The centre-of-gravity measures demonstrated significantly different localization of the pain areas (anova: P<0.001). The trigeminally vs. the cervically innervated muscles had significantly different patterns of spread and referral of pain according to trigeminally vs. cervically innervated dermatomes (P<0.005). In conclusion, there appear to be characteristic pain patterns and pain sensitivity in different craniofacial muscles in healthy volunteers, which may be of importance for further research on different craniofacial pain conditions.

Experimental skin pain and muscle pain induce distinct changes in human trigeminal motoneuronal excitability

Seeking information on the physiological properties of the trigeminal motoneuronal pool we investigated changes in the excitability of trigeminal motor system induced by two types of experimental pain (muscle and skin). In one session, we studied the effect of muscle pain induced by hypertonic saline infusion into the masseter muscle on the recovery cycle of the heteronymous H-reflex in the temporalis muscle and the homonymous silent period (SP) in the masseter muscle, both elicited by stimulation of the masseteric nerve in ten-healthy subjects. In another session, we studied the effect of laser stimuli applied to the perioral region, at conditioning intervals from 20 to 160 ms, on the temporalis H-reflex and masseter SP in nine healthy subjects. Whereas laser-induced skin pain significantly inhibited the temporalis H-reflex and facilitated the masseter SP (P < 0.01), muscle pain left the time course of the temporalis H-reflex and masseter SP unchanged (P > 0.05). The timing of temporalis H-reflex suppression and masseter-SP enhancement induced by laser stimuli indicates that facial skin nociceptors inhibit trigeminal motoneurones via multysynaptic reflex pathways. Hypertonic saline, a stimulus that predominantly activates group III and IV afferents, left both variables reflecting trigeminal motoneuron excitability unchanged. Due to the differences between the two experimental models, we cannot conclude that such inhibitory reflex pathway does not exist from muscle nociceptors to trigeminal motoneurones.

Activity patterns of wrist extensor muscles during wrist extensions and deviations

Wrist extensor muscles are prone to certain focal musculoskeletal disorders for which the activation pattern of the extensor carpi radialis (ECR) and ulnaris (ECU) muscles may be important risk factors. Surface and intramuscular EMG of these muscles were recorded during isometric low-force wrist extension in semipronation and pronation as well as for ulnar/radial deviation, and were analyzed using root mean square (RMS) and decomposition methods. Despite shorter ECR length at semipronation, higher amplitudes of intramuscular EMG and of motor unit action potentials (MUAPs) were found in pronation than in semipronation. However, these changes were not detectable in the surface EMG. Higher ECR activity levels were also found during wrist extension compared to ulnar/radial deviation, and differences in the motor unit (MU) properties were found during ulnar deviation compared to radial deviation and extension. Remarkably, the MUAPs of ECR were almost twice as large as those of the ECU. Overall, the ECR muscle did not respond as predicted from biomechanical considerations, and in general activity level was higher than expected. This may partly explain why the tendon of the ECR often is associated with lateral epicondylitis.

Experimental muscle pain increases trapezius muscle activity during sustained isometric contractions of arm muscles

OBJECTIVE

In the present study, the influence of experimental muscle pain on muscle co-ordination and fatigue development during sustained isometric elbow flexion was investigated.

METHODS

Conventional surface electromyography (EMG) was recorded from the biceps brachii, brachioradialis, deltoideus and trapezius muscle during isometric elbow flexion at 40% maximum force. Single motor unit (MU) conduction velocity in the biceps brachii was assessed using a high spatial resolution surface EMG technique. Measurements were performed on 15 healthy subjects before, during and after (1) injection of hypertonic (pain condition) and (2) isotonic saline (control) into the biceps brachii. The pain intensity was assessed on a 10 cm visual analogue scale.

RESULTS

The experimental results showed in both experimental sessions a fatigue-related increase of the root mean square value of EMG (222+/-164% of the baseline), and a decrease of the median frequency (118+/-16% of the baseline) in all investigated muscles. A maximum pain level of in average 3.2 cm on the visual analogue scale was reached after injection of hypertonic saline during contraction. Differences between painful and control condition were seen in an increased trapezius activity (230+/-141%) during pain. The global EMG activity of the brachioradialis and biceps brachii was unaffected by experimental muscle pain in line with unaffected single MU conduction velocity in the biceps brachii. Differences in endurance time (mean 89.3 and 102.3 s, pain and control, respectively) were not significant.

CONCLUSIONS/SIGNIFICANCE

The findings suggest that upper extremity pain could be a possible source for overloading the trapezius muscle and as such is an important factor in occupational settings.

[Assessment of muscle pain and hyperalgesia. Experimental and clinical findings]

AIM

It is evident that muscle hyperalgesia and referred pain have an important role in chronic musculoskeletal pain. More knowledge of the basic mechanisms involved and better methods of assessing muscle pain in clinical practice are needed so that treatment regimens can be revised and improved.

METHODS

Methods of quantitative sensory testing of muscle pain and associated phenomena are described. These methods make it possible to evaluate manifestations of muscle pain in a standardised way both in patients suffering from musculoskeletal pain and in healthy volunteers.

RESULTS

Elevated muscle sensitivity becomes manifest as (1) pain evoked by a normally non-noxious stimulus (allodynia), (2) abnormally intense pain evoked by noxious stimuli (hyperalgesia), or (3) unusually large areas of referred pain with associated somatosensory changes. These changes can occur as increased somatosensory sensitivity of deep somatic tissues or of the skin in areas of pain referral. Some manifestations of sensitisation in chronic musculoskeletal pain patients, such as expansion of the areas of referred muscle pain, can be explained by the extra segmental spread of central sensitisation seen in animal experiments.

CONCLUSIONS

An important part of the manifestations of pain in chronic musculoskeletal disorders may be due to peripheral and central sensitisation processes, which are also involved in the transition from acute to chronic pain. Knowledge of these processes has expanded enormously in recent years; it should be utilised when new intervention strategies are designed.

Effects of experimental muscle pain on mechanical properties of single motor units in human masseter

OBJECTIVE

Muscle pain is known to influence muscle activity but the details of its effects on the mechanical properties of single motor units (SMU) have not been described. We have recently reported a decreased firing rate of SMU in the human masseter muscle during painful contractions with a constant force output. Force output can be modulated by the SMU discharge rate in relation to the contractile properties of SMU. Therefore, the objective of the present study was to measure the mechanical properties of SMU in the masseter to clarify the mechanism which underlies the decrease in SMU firing rate during jaw-muscle pain.

METHODS

A spike-triggered averaging (STA) technique was used to determine the mechanical properties of low-threshold SMU in the masseter muscle recorded with fine wire electrodes during a voluntary isometric contraction. The twitch amplitude, contraction time, and half-relaxation time were determined from the averaged force records before and during experimental jaw-muscle pain induced by injection of 0.2 ml (100 microg/ml) capsaicin in 8 healthy subjects. Injections of 0.2 ml isotonic saline served as a non-painful control in 11 healthy subjects.

RESULTS

The twitch amplitude was significantly increased during capsaicin-evoked muscle pain (P<0.001) without significant changes of half-relaxation time and contraction time. No significant changes in SMU twitch properties were observed during the control injections.

CONCLUSIONS

Potentiation of twitch force could be a possible compensatory mechanism to maintain a constant force output during painful isometric contractions when SMU firing decreases. This finding therefore provides new information on the adaptation of motor function by muscle pain.

Surface EMG crosstalk evaluated from experimental recordings and simulated signals. Reflections on crosstalk interpretation, quantification and reduction

OBJECTIVES

Surface EMG crosstalk is the EMG signal detected over a non-active muscle and generated by a nearby muscle. The aim of this study was to analyze the sources of crosstalk signals in surface EMG recordings and to discuss methods proposed in the literature for crosstalk quantification and reduction.

METHODS

The study is based on both simulated and experimental signals. The simulated signals are generated by a structure based surface EMG signal model. Signals were recorded with both intramuscular and surface electrodes and single motor unit surface potentials were extracted with the spike triggered averaging approach. Moreover, surface EMG signals were recorded from electrically stimulated muscles.

RESULTS

From the simulation and experimental analysis it was clear that the main determinants of crosstalk are non-propagating signal components, generated by the extinction of the intracellular action potentials at the tendons. Thus, crosstalk signals have a different shape with respect to the signals detected over the active muscle and contain high frequency components.

CONCLUSIONS

Since crosstalk has signal components different from those dominant in case of detection from near sources, commonly used methods to quantify and reduce crosstalk, such as the cross-correlation coefficient and high-pass temporal filtering, are not reliable. Selectivity of detection systems must be discussed separately as selectivity with respect to propagating and non-propagating signal components. The knowledge about the origin of crosstalk signal constitutes the basis for crosstalk interpretation, quantification, and reduction.

Pharmacological modulation of experimental phasic and tonic muscle pain by morphine, alfentanil and ketamine in healthy volunteers

BACKGROUND

Muscle pain is a major clinical problem but the underlying mechanisms and its pharmacological modulation need further investigation. This study on 15 volunteers evaluates if two experimental muscle pain models are sensitive to micro -receptor agonists and to an N-methyl-D-aspartate (NMDA)-receptor antagonist.

METHODS

In the left tibialis anterior, intramuscular electrical (IMES) pain thresholds were determined for single (SPTmuscle) and five (RPTmuscle) repeated stimuli. Also pain to suprathreshold stimulation at 150% of RPTmuscle, 10 s, was assessed on a visual analog scale (VAS) as AUCimes (area under the VAS curve). In the right TA muscle, pain intensity on infusion of 0.5 ml of hypertonic saline, 5% (AUCsaline) and pain distribution indicated as local and referred were evaluated. Pain variables were assessed before, during and after intravenous infusions of morphine (10 microg x kg-1 min-1, 10 min), alfentanil (target-controlled infusion, plasma concentration; 60 ng ml-1, 60 min) and ketamine (10 microg x kg-1 min-1, 60 min). All data were normalized to baseline pain values (before drug infusions were initiated) and compared with placebo (midazolam, 2 microg x kg-1 min-1, 10 min).

RESULTS

SPTmuscle increased (log mean values +/- SD, mA) with morphine (0.11 +/- 0.17, P < 0.05), alfentanil (0.28 +/- 0.24, P < 0.001) and ketamine (0.19 +/- 0.18, P < 0.01) as compared with placebo (-0.03 +/- 0.12). Alfentanil and ketamine also increased RPTmuscle (0.25 +/- 0.21, P < 0.01 and 0.21 +/- 0.19, P < 0.05, respectively) as compared with placebo (0.00 +/- 0.17). Pain to IMES (AUCimes) was reduced (median values [25th-75th percentiles], cm x s) by alfentanil and ketamine (-19.7 [-14.6 - -29.6] and-12.8 [-8.3 - -27.8], P < 0.05, respectively) vs. placebo (-0.8 [1.6 - -12.3]). Similar drug effects were seen when pain to infusion of hypertonic saline (AUCsaline) was assessed (alfentanil:-388 [-99 - -677] and ketamine:-326 [-227 - -573], P < 0.05 compared with placebo: 150 [449--240]). Ketamine also reduced the size of the local pain area (-58.4 [-21.2 - -176.1], < 0.05) as compared with placebo (-0.4 [70.6 - -13.4]). The frequency of referred pain was also lower when ketamine was given (3/13, P < 0.05) vs. placebo (9/14).

CONCLUSION

The study demonstrates that experimental muscle pain induced in humans by electrical stimulation and infusion of hypertonic saline is sensitive to pharmacological modulation similar to preclinical animal tests and clinical trials. The data suggest that these models can be valuable tools in analgesic drug development.

Lumbar epidural fentanyl: segmental spread and effect on temporal summation and muscle pain

BACKGROUND

Despite extensive use, different aspects of the pharmacological action of epidural fentanyl have not been clarified. We applied a multi-modal sensory test procedure to investigate the effect of epidural fentanyl on segmental spread, temporal summation (as a measure for short-lasting central hyperexcitability) and muscle pain.

METHODS

Thirty patients received either placebo, 50 or 100 micro g single dose of fentanyl epidurally (L2-3), in a randomized, double-blind fashion. Heat pain tolerance thresholds at eight dermatomes from S1 to fifth cranial nerve (assessment of segmental spread), pain threshold to transcutaneous repeated electrical stimulation of the sural nerve (assessment of temporal summation) and pain intensity after injection of hypertonic saline into the tibialis anterior muscle (assessment of muscle pain) were recorded.

RESULTS

Fentanyl 100 micro g, but not 50 micro g, produced analgesia to heat stimulation only at L2. Surprisingly, no effect at S1 was detected. Both fentanyl doses significantly increased temporal summation threshold and decreased muscle pain intensity.

CONCLUSIONS

The findings suggest that a single lumbar epidural dose of fentanyl should be injected at the spinal interspace corresponding to the dermatomal site of pain. Increased effect on L2 compared with S1 suggests that drug effect on spinal nerve roots and binding to opioid receptors on the dorsal root ganglia may be more important than traditionally believed for the segmental effect of epidurally injected fentanyl. Epidural fentanyl increases temporal summation threshold and could therefore contribute to prevention and treatment of central hypersensitivity states. I.M. injection of hypertonic saline is a sensitive technique for detecting the analgesic action of epidural opioids.

Temporal summation of pain from skin, muscle and joint following nociceptive ultrasonic stimulation in humans

This study investigated the phenomenon of temporal summation in response to repetitive focused ultrasound stimulation of skin, muscle and joint in human volunteers. Stimulation was carried out using a custom-designed, focused ultrasonic stimulator with a resonant frequency of 1.66 MHz. A series of stand-off attachments were used to ensure that the focal region of the ultrasound beam projected either cutaneously, within the distal interphalangeal joint of the index finger, or within the first dorsal interosseous muscle. Stimulation was carried out using single pulses and trains of five pulses of different pulse durations (25 ms, 50 ms, 75 ms, 100 ms), and using single pulses and trains of five pulses (50 ms duration) at different frequencies (0.5 Hz, 1 Hz, 2 Hz, 3 Hz, 4 Hz, 5 Hz). Tactile perception thresholds, pain thresholds and summation pain thresholds were recorded. Temporal summation of pain could be elicited by stimulation of both skin, joint and muscle, although the influence of temporal summation appeared to be more pronounced for muscle stimulation. Muscle stimulation also required greater ultrasound intensity compared with joint and skin stimulation. Temporal summation could not be elicited by tactile, low-intensity stimulation. Focused ultrasound is a potent, noninvasive technique with which to investigate temporal summation from somatic structures. A number of factors may account for the higher intensities required to elicit pain in muscle and the increased rate of temporal summation. It is clear, however, that if temporal summation is more pronounced in muscle than other tissues then this may be an important factor contributing to pain in musculoskeletal syndromes.

Thermosensitivity of muscle: high-intensity thermal stimulation of muscle tissue induces muscle pain in humans

Small-calibre afferent units responding to thermal stimuli have previously been reported to exist in muscle. The question as to whether these receptors in humans mediate subjective thermal sensations from muscle remains unresolved. The aims of the present study were to determine in humans whether intramuscular injection of warm and cold isotonic saline elicits temperature sensations, muscle pain or any other sensations. In 15 subjects, no thermal sensations assessed on a temperature visual analogue scale (VAS) could be detected with intramuscular injections of isotonic saline (1.5 ml) into the anterior tibial muscle at temperatures ranging from 8 to 48 degrees C. The same subjects recorded strongly increasing scores on a temperature VAS when thermal stimuli in the same intensity range were applied to the skin overlying the muscle by a contact thermode. However, I.M. isotonic saline of 48 degrees C induced muscle pain with peak scores of 3.2 +/- 0.8 cm on a VAS scale ranging from 0 to 10 cm. Using the the McGill pain questionnaire a subgroup, of subjects qualitatively described the pain using the 'thermal hot' and 'dullness' word groups. Temperature measurements within the muscle during the stimulating injections showed that the time course of the pain sensation elicited by saline at 48 degrees C paralleled that of the intramuscular temperature and far outlasted the injection time. The present data show that high-intensity thermal stimulation of muscle is associated with muscle pain. High-threshold warm-sensitive receptors may mediate the pain following activation by temperatures of 48 degrees C or more. Taken together, the data indicate that thermosensation from a given volume of muscle is less potent than nociception.

Non-painful and painful surface and intramuscular electrical stimulation at the thenar and hypothenar sites: differential cerebral dynamics of early to late latency SEPs

Little is known about somatosensory evoked potentials (SEPs) from muscle stimulation compared to that from skin stimulation. The current study examined this issue in the full SEP spectrum (0-440 ms). The aims of the study were to (1) establish the dynamics of early to late latency SEPs from intramuscular stimulation in contrast to surface stimulation, (2) compare the effect of non-painful and painful stimuli on SEP latencies and amplitudes of the two methods, and (3) investigate to which extent these results can be shared between the median nerve innervated thenar site and ulnar nerve innervated hypothenar site. Stimuli were delivered (2 Hz) at a non-painful and a painful intensity above or within the thenar and hypothenar muscles of the hand. Maximas of the SEPs were extracted by a combination of global field power and visual inspection of the topographies. Amplitudes and latencies of the maximas were analysed by a two-way ANOVA with repeated measures. In the early phase (0-50 ms) the topographic patterns showed different dynamics between surface and intramuscular stimulation and in the late phase (100- 440 ms) prolonged latencies were found for intramuscular stimulation. Apart from this, similar topographic patterns and time sequences were obtained. Significant higher SEP amplitudes for most of the isolated components (C4'/P25, Fz/N35, C4'/P45, Fc2/N65, P4/P90, T4/N137, F3/P150, Cz/P240-P270) were found with surface stimulation compared to intramuscular stimulation. In contrast to surface stimulation, intramuscular stimulation at a stimulation frequency of 2 Hz did not result in a differentiation in amplitude for any of the isolated components. These results indicate differences in the early and late processing of sensory input from skin and muscle.