Ruth Defrin

Characterization of chronic pain and somatosensory function in spinal cord injury subjects.

&NA; The pathophysiology of the chronic pain following spinal cord injury (SCI) is unclear. In order to study its underlying mechanism we characterized the neurological profile of SCI subjects with (SCIP) and without (SCINP) chronic pain. Characterization comprised of thermal threshold testing for warmth, cold and heat pain and tactile sensibility testing of touch, graphesthesia and identification of speed of movement of touch stimuli on the skin. In addition, spontaneously painful areas were mapped in SCIP and evoked pathological pain – allodynia, hyperpathia and wind‐up pain evaluated for both groups. Both SCIP and SCINP showed similar reductions in both thermal and tactile sensations. In both groups thermal sensations were significantly more impaired than tactile sensations. Chronic pain was present only in skin areas below the lesion with impaired or absent temperature and heat‐pain sensibilities. Conversely, all the thermally impaired skin areas in SCIP were painful while painfree areas in the same subjects were normal. In contrast, chronic pain could be found in skin areas without any impairment in tactile sensibilities. Allodynia could only be elicited in SCIP and a significantly higher incidence of pathologically evoked pain (i.e. hyperpathia and wind‐up pain) was seen in the chronic pain areas compared to SCINP. We conclude that damage to the spinothalamic tract (STT) is a necessary condition for the occurrence of chronic pain following SCI. However, STT lesion is not a sufficient condition since it could also be found in SCINP. The abnormal evoked pain seen in SCIP is probably due to neuronal hyperexcitability in these subjects. The fact that apparently identical sensory impairments manifest as chronic pain and hyperexcitability in one subject but not in another implies that either genetic predisposition or subtle differences in the nature of spinal injury determine the emergence of chronic pain following SCI.

Quantitative testing of pain perception in subjects with PTSD--implications for the mechanism of the coexistence between PTSD and chronic pain.

&NA; Post‐traumatic stress disorder (PTSD) often co‐occurs with chronic pain. Neither the underlying mechanism of this comorbidity nor the nature of pain perception among subjects with PTSD is well defined. This study is the first systematic and quantitative evaluation of pain perception and chronic pain in subjects with PTSD. The study group consisted of 32 outpatients with combat‐ and terror‐related PTSD, 29 outpatients with anxiety disorder and 20 healthy controls. Quantitative somatosensory testing included the measurement of warm, cold, light touch and heat‐pain thresholds and responses to acute suprathreshold heat and mechanical stimuli. Chronic pain was characterized, and levels of PTSD and anxiety symptomatology were assessed by self‐report questionnaires. Subjects with PTSD exhibited higher rates of chronic pain, more intense chronic pain and more painful body regions compared with the other two groups. PTSD severity correlated with chronic pain severity. Thresholds of subjects with PTSD were significantly higher than those of subjects with anxiety and healthy controls, but they perceived suprathreshold stimuli as being much more intense than the other two groups. These results suggest that subjects with PTSD exhibit an intense and widespread chronic pain and a unique sensory profile of hyposensitivity to pain accompanied by hyper‐reactivity to suprathreshold noxious stimuli. These features may be attributed to the manner with which PTSD subjects emotionally interpret and respond to painful stimuli. Alternatively, but not mutually exclusive, the findings may reflect altered sensory processing among these subjects.

International Spinal Cord Injury Pain Classification: part I. Background and description

Study design:Discussion of issues and development of consensus.Objective:Present the background, purpose, development process, format and definitions of the International Spinal Cord Injury Pain (ISCIP) Classification.Methods:An international group of spinal cord injury (SCI) and pain experts deliberated over 2 days, and then via e-mail communication developed a consensus classification of pain after SCI. The classification was reviewed by members of several professional organizations and their feedback was incorporated. The classification then underwent validation by an international group of clinicians with minimal exposure to the classification, using case study vignettes. Based upon the results of this study, further revisions were made to the ISCIP Classification.Results:An overall structure and terminology has been developed and partially validated as a merger of and improvement on previously published SCI pain classifications, combined with basic definitions proposed by the International Association for the Study of Pain and pain characteristics described in published empiric studies of pain. The classification is designed to be comprehensive and to include pains that are directly related to the SCI pathology as well as pains that are common after SCI but are not necessarily mechanistically related to the SCI itself.Conclusions:The format and definitions presented should help experienced and non-experienced clinicians as well as clinical researchers classify pain after SCI.

The characteristics of chronic central pain after traumatic brain injury.

Abstract Central pain following traumatic brain injury (TBI) has not been studied in depth. Our purpose was to conduct a systematic study of patients with TBI suffering from chronic central pain, and to describe the characteristics of the central pain. Groups were TBI patients with (TBIP) and without central pain (TBINP) and healthy controls. TBI patients with other pain mechanisms were excluded from the study. Participants underwent quantitative somatosensory testing in the painful and pain‐free body regions. Thresholds for warmth, cold, heat‐pain, touch and graphesthesia were measured and pathologically evoked pain (allodynia, hyperpathia and wind‐up pain) evaluated. Chronic pain was mapped and characterized. Chronic pain developed at a relatively late onset (6.6 ± 9 months) was almost exclusively unilateral and reported as pricking, throbbing and burning. Although both TBIP and TBINP exhibited a significant reduction in thermal and tactile sensations compared to controls, thermal sensations in the painful regions of TBIP were significantly more impaired than pain‐free regions in the same patients (p < 0.01) and in TBINP (p < 0.01). Painful regions also exhibited very high rates of allodynia, hyperpathia and exaggerated wind‐up. The characteristics of the chronic pain resembled those of other central pain patients although TBIP displayed several unique features. The sensory profile indicated that damage to the pain and temperature systems is a necessary but not sufficient condition for the development of chronic central pain following TBI. Neuronal hyperexcitability may be a contributing factor to the chronic pain.

Segmental noxious versus innocuous electrical stimulation for chronic pain relief and the effect of fading sensation during treatment

It is not clear whether segmental innocuous stimulation has a stronger analgesic effect than segmental noxious stimulation for chronic pain and whether the fading of current sensation during treatment interferes with the analgesic effect, as suggested by the gate control theory. Electrical stimulation (by way of Interferential Current) applied at the pain area (segmental) was administered to 4 groups of patients with osteoarthritis (OA) knee pain. Two groups were administered with noxious stimulation (30% above pain threshold) and two with innocuous stimulation (30% below pain threshold). In each group half of the patients received a fixed current intensity while the other half raised the intensity continuously during treatment whenever fading of sensation was perceived. Group 5 and 6 received sham stimulation and no treatment, respectively. The outcome measures were: chronic pain intensity, morning stiffness, range of motion (ROM), pain threshold and % pain reduction. Both noxious and innocuous stimulation significantly decreased chronic pain (P<0.001) and morning stiffness (P<0.01) and significantly increased pain threshold (P<0.001) and ROM (P<0.001) compared with the control groups. Nevertheless, noxious stimulation decreased pain intensity (P<0.05) and increased pain threshold (P<0.001) significantly more than innocuous stimulation. No differences in treatment outcomes were found between adjusted and unadjusted stimulation. (a) Interferential current is very effective for chronic OA knee pain, (b) segmental noxious stimulation produces a stronger analgesic effect than segmental innocuous stimulation, (c) the fading of sensation during treatment, does not decrease the analgesic effect. Possible mechanisms explaining the findings are discussed.

A quantitative somatosensory testing of pain threshold in individuals with mental retardation

&NA; The commonly held view, mainly based on behavioral observations, is that individuals with mental retardation (MR) have a decreased sensitivity to pain. However, the sensitivity to noxious stimuli was not systematically measured in these individuals. For this purpose we developed an experimental protocol with which we trained individuals with mild MR (unspecified MR and Downs syndrome) in heat‐pain threshold (HPT) measurement on the hand, and then performed the measurement using both the method of limits (MLI) which relies on reaction time (RT) and the method of levels (MLE) which is RT‐free. This allowed for an indirect assessment of the RT and conduction velocity (CV) of these individuals. We found that HPT in individuals with unspecified MR (41.23±1.86 °C) and Downs syndrome (40.96±2.93 °C) was significantly lower than that of controls (42.86±2.42 °C) when measured with the MLE (P<0.05). With the MLI no significant differences in HPT were found between the groups. However, the RT and CV values of individuals with unspecified MR and Downs syndrome were significantly lower compared to controls (e.g. mean RT of 1.86 and 2.55 compared to 1.2 s, respectively, P<0.01). From this work it would appear that individuals with MR are not only pain‐sensitive, but also more sensitive to heat‐pain than normal. It is suggested that computerized quantitative testing of pain threshold is feasible in individuals with MR preferably by using RT‐free methods (e.g. the MLE) due to the low RT and CV values exhibited by them.

The nature and course of sensory changes following spinal cord injury: predictive properties and implications on the mechanism of central pain

Central pain below the injury level after spinal cord injury is excruciating, chronic and resistive to treatment. Animal studies suggest that pretreatment may prevent central pain, but to date there are no measures to predict its development. Our aim was to monitor changes in the sensory profile below the lesion prior to the development of below-level central pain in order to search for a parameter that could predict its risk and to further explore its pathophysiology. Thirty patients with spinal cord injury and 27 healthy controls underwent measurement of warm, cold, heat-pain and touch thresholds as well as graphaesthesia, allodynia, hyperpathia and wind-up pain in intact region and in the shin and feet (below level). Patients were tested at 2-4 weeks, 1-2.5 months and 2.5-6 months after the injury or until central pain had developed. At the end of the follow-up, 46% of patients developed below-level central pain. During the testing periods, individuals who eventually developed central pain had higher thermal thresholds than those who did not and displayed high rates of abnormal sensations (allodynia and hyperpathia), which gradually increased with time until central pain developed. Logistic regressions revealed that the best predictor for the risk of below-level central pain was allodynia in the foot in the second testing session with a 77% probability (90.9% confidence). The results suggest that neuronal hyperexcitability, which may develop consequent to damage to spinothalamic tracts, precedes central pain. Furthermore, it appears that below-level central pain develops after a substantial build-up of hyperexcitability. To the best of our knowledge, this is the first systematic report establishing that neuronal hyperexcitability precedes central pain. Predicting the risk for central pain can be utilized to initiate early treatment in order to prevent its development.

Enhanced pain modulation among triathletes: A possible explanation for their exceptional capabilities

Summary This article presents the features of pain perception and pain modulation among athletes of extreme sport compared with controls. The results may explain the unique capabilities of these athletes to persevere in extreme efforts and may shed light on the chronic effects of endurance sport on the pain system. Abstract Triathletes and ironman triathletes engage in an extremely intense sport that involves hours of considerable pain, as well as physical and psychological stress, every day. The basic pain modulation properties of these athletes has not been established and therefore it is not clear whether they present with unique features that enable them to engage in such efforts. The aim was to investigate the existence of possible alterations in pain perception and modulation of triathletes, as well as possible underlying factors. Participants were 19 triathletes and 17 non‐athletes who underwent measurement of pain threshold, pain tolerance, suprathreshold perceived pain intensity, temporal summation of pain, and conditioned pain modulation (CPM). Participants also completed the fear of pain and the pain catastrophizing questionnaires, and rated the amount of perceived stress. Triathletes exhibited higher pain tolerance (P < .0001), lower pain ratings (P < .001), and lower fear of pain values (P < .05) than controls. The magnitude of CPM was significantly greater in triathletes (P < .05), and negatively correlated with fear of pain (P < .05) and with perceived mental stress during training and competition (P < .05). The results suggest that triathletes exhibit greater pain tolerance and more efficient pain modulation than controls, which may underlie their perseverance in extreme physical efforts and pain during training/competitions. This capability may be enhanced or mediated by psychological factors, enabling better coping with fear of pain and mental stress.

Spatial summation of heat pain: a reassessment.

&NA; Heat pain threshold is commonly considered to be an ‘absolute’ value, which is not dependent on the area stimulated. In contrast, suprathreshold heat pain sensation has been shown to be highly dependent on the area stimulated, with considerable spatial summation demonstrated both within and between dermatomes. The present study sought to reevaluate two major issues: (a) Whether nociceptive thresholds are, indeed, independent of stimulation area. (b) Whether the spatial summation of suprathreshold heat pain sensation is independent of threshold changes. Using noxious heat we evaluated nociceptive thresholds and perceived pain intensity for contact areas of 0.25, 2.25, 6.25 and 15.36 cm2. Our results show that considerable spatial summation of heat pain thresholds is obtained and an apparent spatial summation of perceived intensity can also be observed. However, these apparent changes in perceived pain intensity can be accounted for completely by the changes in noxious heat thresholds. Furthermore, when using a stimulus configuration in which stimulation area was increased without changing nociceptive threshold, no spatial summation of perceived pain intensity was seen. Our results suggest that the spatial summation of perceived heat pain intensity can be attributed to reduced heat pain threshold. Furthermore, our findings stress the importance of determining pain thresholds in studies examining the psychophysics of suprathreshold noxious stimuli.

The evaluation of acute pain in individuals with cognitive impairment: A differential effect of the level of impairment

Abstract The present study investigated whether the level of cognitive impairment (CI) affects acute pain behavior and how it is manifested. Participants were 159 individuals (mean age 42 ± 12), 121 with CI (divided into four groups according to the level of CI: mild, moderate, severe, profound) and 38 with normal cognition (controls). The behavior of the participants before and during acute pain (influenza vaccination) was coded by two raters with the Facial Action Coding System (FACS – scores facial reactions to pain) and the Non‐Communicating Children’s Pain Checklist (NCCPC‐R – scores both facial and general body reactions). Individuals with severe–profound CI exhibited elevated FACS and NCCPC‐R values at baseline compared with all other groups (p < 0.01). Both FACS and NCCPC‐R scores of individuals with mild–moderate CI and controls increased significantly during vaccination (p < 0.001). In contrast, individuals with severe–profound CI exhibited high rates of “freezing reaction” (stillness) during vaccination, manifested mainly in the face and therefore resulting in elevation of only NCCPC‐R scores but not of FACS’s. The results suggest that the level of CI affects baseline as well as pain behavior and it is therefore necessary to choose an appropriate behavioral tool to measure pain in these individuals accordingly. For example, tools based on facial reactions alone might provide the false impression that individuals with severe–profound CI are insensitive to pain (due to freezing).