Specific thalamic nuclei function as novel 'nociceptive discriminators' in the endogenous control of nociception in rats.

Recently, we hypothesized that supraspinal structures may have important functions in discriminating between noxious mechanically and heat mediated nociception through distinct functions: facilitation and inhibition. In this study, conducted in conscious rats, we explored the role of different thalamic nuclei: the mediodorsal (MD) nucleus, the central medial (CM) nucleus, the submedius (SM) nucleus, the ventralmedial (VM) nucleus and the ventral posterolateral (VPL) nucleus, in the descending control of secondary and contralateral mechanical hyperalgesia and heat hypoalgesia occurring in intramuscularly hypertonic (HT, 5.8%) saline-induced muscle nociception. We found that the MD nuclei participated in the descending facilitation of mechanical hyperalgesia, and that the VM nuclei were specifically involved in the descending inhibition of heat hypoalgesia. Neither descending facilitation nor descending inhibition was affected after electrolytic lesion of the thalamic CM, SM, and VPL nuclei. This descending facilitatory and inhibitory modulation of nociception was strengthened by glutamate, and weakened by GABA, microinjected into the thalamic MD and VM nuclei. It is suggested that (1) thalamic MD nucleus and VM nucleus form two distinct endogenous systems in the control of noxious mechanically and heat evoked responses, and (2) the strengthening of descending inhibition and the weakening of descending facilitation by means of up regulation and down regulation of appropriate receptor expression in the VM and MD nuclei may provide a new strategic policy in treating pathological pain.

Stability of long term facilitation and expression of zif268 and Arc in the spinal cord dorsal horn is modulated by conditioning stimulation within the physiological frequency range of primary afferent fibers.

Long term facilitation (LTF) of C-fiber-evoked firing of wide dynamic range neurons in the spinal dorsal horn in response to conditioning stimulation (CS) of afferent fibers is a widely studied cellular model of spinal nociceptive sensitization. Although 100 Hz CS of primary afferent fibers is commonly used to induce spinal cord LTF, this frequency exceeds the physiological firing range. Here, we examined the effects of electrical stimulation of the sciatic nerve within the physiological frequency range on the magnitude and stability of the C-fiber-evoked responses of wide dynamic range neurons and the expression of immediate early genes (c-fos, zif268, and Arc) in anesthetized rats. Stimulation frequencies of 3, 30 and 100 Hz all induced facilitation of similar magnitude as recorded at 1 h post-CS. Strikingly, however, 3 Hz-induced potentiation of the C-fiber responses was decremental, whereas both 30 and 100 Hz stimulation resulted in stable, non-decremental facilitation over 3 h of recording. The number of dorsal horn neurons expressing c-fos, but not zif268 or Arc, was significantly elevated after 3 Hz CS and increased proportionally with stimulation rate. In contrast, a stable LTF of C-fiber responses was obtained at 30 and 100 Hz CS, and at these frequencies there was a sharp increase in zif268 expression and appearance of Arc-positive neurons. The results show that response facilitation can be induced by stimulation frequencies in the physiological range (3 and 30 Hz). Three hertz stimulation induced the early phase of LTF, but the responses were decremental. Arc and zif268, two genes previously coupled to LTP of synaptic transmission in the adult brain, are upregulated at the same frequencies that give stable LTF (30 and 100 Hz). This frequency-dependence is important for understanding how the afferent firing pattern affects neuronal plasticity and nociception in the spinal dorsal horn.

Ketamine blocks enhancement of spinal long-term potentiation in chronic opioid treated rats.

BACKGROUND: Long-term opioid treatment is associated with the development of hyperalgesia. In a rat model we wanted to study if chronic opioid treatment changed the induction and maintenance of spinal long-term potentiation (LTP), a form of hyperexcitability in the spinal cord. We also wanted to investigate if the clinically available NMDA receptor antagonist ketamine inhibited the effect of chronic opioid treatment on LTP. METHODS: The animals were randomized into four groups (saline, morphine 20 mg/kg/day, ketamine 20 mg/kg/day, morphine 20 mg/kg/day and ketamine 20 mg/kg/day). Drugs were given as continuous subcutaneous infusions by means of osmotic minipumps. After 7 days of treatment and during ongoing treatment single unit extracellular recordings were made from the lumbar deep dorsal horn under urethane anesthesia. Single electrical stimuli were applied to the sciatic nerve, and the C-fiber evoked responses of WDR neurons were recorded before and during 3 h following low frequency (3 Hz) electrical conditioning stimulation. RESULTS: The potentiation of C-fiber evoked responses by conditioning stimulation was significantly increased in the morphine-treated group compared to the saline group, while there was no significant difference between the saline, the ketamine and the morphine/ketamine groups. The potentiated responses in the morphine/ketamine group were significantly reduced compared to the morphine group (P=0.01). CONCLUSION: Our results indicate that animals treated with long-term opioid show amplification of stimulus-induced central sensitisation compared to opioid naïve animals. Ketamine inhibited the morphine-induced enhancement of LTP, supporting the role of ketamine in prevention of opioid induced hyperalgesia.

Activation of spinal serotonin(2A/2C) receptors augments nociceptive responses in the rat.

The role of spinal 5-HT(2A/2C) receptors in the regulation of spinal nociceptive transmission was studied. The 5-HT(2A/2C) agonist (+/-)-1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane (DOI) and the antagonist ketanserin tartrate were administered intrathecally immediately before the formalin test. Activation of spinal 5-HT(2A/2C) receptors increased the pain-like behavioural response in both the early and late phases. The findings support the hypothesis that spinal 5-HT(2A/2C) receptors augment the spinal afferent nociceptive impulses induced by peripheral inflammation.

Different brain areas activated during imagery of painful and non-painful 'finger movements' in a subject with an amputated arm.

The purpose of the present study was to investigate differences in brain activation with functional magnetic resonance imaging (fMRI) during imagery of painful and non-painful 'finger movements' and 'hand positioning' in a subject with an amputated arm. The subject was a right-handed man in his mid-thirties who lost his right arm just above the elbow in a car-train accident. MRI was performed with a 1.5 T Siemens Vision Plus scanner. The basic design involved four conditions: imagining 'painful finger movements', 'non-painful finger movements', 'painful hand positioning', 'non-painful hand positioning'. Imagery of finger movements uniquely activated the contralateral primary motor cortex which contains the classic 'hand area'. The lateral part of the anterior cerebellar lobe was also activated during imagery of finger movements. Imagery of pain uniquely activated the somatosensory area, and areas in the left insula and bilaterally in the ventral posterior lateral nucleus of the thalamus. It is suggested that the insula and thalamus may involve neuronal pathways that are critical for mental processing of pain-related experiences, which may relate to a better understanding of the neurobiology of phantom limb pain.

Inhibition of spinal nociceptive responses after intramuscular injection of capsaicin involves activation of noradrenergic and opioid systems.

Extracellular recordings of wide dynamic range neurones in the dorsal horn driven by electrical stimulation of the sciatic nerve were performed in intact urethane-anaesthetized Sprague-Dawley rats. The electrically evoked neuronal responses were defined as A- and C-fibres responses according to latencies, and the effect of a deep nociceptive conditioning stimulus induced by 200 microg capsaicin (8-methyl-N-vanillyl-6-noneamide) injected into the contralateral gastrocnemius-soleus muscle was studied for at least 30 min. Independent of the size and location of the receptive field of the neurone under study, a clear inhibition of the neuronal responses was observed. The electrically evoked C-fibre responses were inhibited to 53% of baseline 15-30 min after injection of capsaicin. This inhibition was only slightly attenuated by 125 nmol of the alpha-adrenoceptor antagonist phentolamine or 250 nmol of the opioid receptor antagonist naloxone applied directly onto the spinal cord when the two compounds were administered separately 5 min before capsaicin. In contrast, when a mixture of the two compounds was given 5 min before capsaicin, the effect of capsaicin was completely abolished. These results indicate that activation of the capsaicin-sensitive afferents in the gastrocnemius-soleus muscle inhibits the electrically evoked C-fibre responses in the dorsal horn by activating noradrenergic and opioidergic inhibitory systems. Moreover, our data indicate that the activation of these two systems following injection of capsaicin has a sub-additive inhibitory effect on the wide dynamic range neurones in the spinal cord. We conclude that only one of these systems is sufficient for the inhibition to occur.

Effect of spinal morphine after long-term potentiation of wide dynamic range neurones in the rat.

BACKGROUND: Studies have shown that long-term increase in the excitability of single wide dynamic range neurones in the spinal dorsal horn of rats may be induced after tetanic stimulation to the sciatic nerve. This sensory event is possibly an in vivo counterpart of long-term potentiation, described in the brain. This study investigated whether this phenomenon occurs in the halothane-anesthetized rat and whether the antinociceptive effects of spinally administered morphine are altered when tested on the enhanced activity. METHODS: Single unit extracellular recordings were made in three different groups of halothane-anesthetized rats (n = 6 in each group). In group 1, the evoked neuronal responses of wide dynamic range neurones by a single electrical stimulus to the peripheral nerve were recorded every 4 min, for 1 h before (baseline) and for 3 h after brief high-frequency conditioning stimulation of the sciatic nerve. In group 2, morphine was applied onto the spinal cord after long-term potentiation had been established. Increasing concentrations of morphine were added until the C fiber-evoked responses were abolished; this was followed by naloxone reversal. In group 3, the same protocol as in group 2 was used except a waiting period substituted for the electrical conditioning. RESULTS: The C fiber-evoked responses were significantly increased (P < 0.001) after conditioning compared with baseline and those in control animals. Further, significantly higher concentrations of morphine (P = 0.008) were needed to abolish the C fiber-evoked responses in tetanized animals than in control animals. Naloxone reversed the effects of morphine to the predrug potentiated baseline in group 2, showing that opioids do not block the maintenance of spinal long-term potentiation. CONCLUSIONS: Long-term potentiation of C fiber-evoked responses also can be induced in halothane-anesthetized rats, and morphine seems to have less potency during such conditions. These data suggest that long-term potentiation-like mechanisms may underlie some forms of hyperalgesia associated with a reduced effect of morphine.

Recording of long-term potentiation in single dorsal horn neurons in vivo in the rat.

We have published several reports on long-term potentiation (LTP) in single spinal wide dynamic range (WDR) neurons (responding to both innocuous and noxious stimuli) in urethane-anaesthetised rats. The protocol presented here, with single unit recordings of dorsal horn neurons before and after a nociceptive conditioning stimulation, may be useful in many electrophysiological studies of plastic changes in the spinal cord, such as LTP. We invite others to use this protocol for the study of spinal plasticity. Findings using this technique may be relevant for the understanding of changes in nociceptive transmission, induction of central sensitisation and maybe even in mechanisms of pathological pain and chronic pain states. We describe modified and alternative protocols for the study of LTP mechanisms under different conditions in intact and in spinalised animals, and after natural noxious stimuli. We present a novel method minimising peripheral influence of afferent input induced by antidromic neurogenic inflammation or inflammatory changes following a natural noxious stimulation. This is made possible by dissection of the sciatic nerve at two separate locations and local anaesthetic block distal to the stimulation site.

Inhibition of evoked C-fibre responses in the dorsal horn after contralateral intramuscular injection of capsaicin involves activation of descending pathways.

In this study extracellular recordings of nociceptive dorsal horn neurones driven by electrical stimulation of the sciatic nerve were performed in intact urethane-anaesthetized Sprague-Dawley rats. Spikes 0-40, 40-250 and 250-800 ms after stimulus were defined as A- and C-fibre responses and post-discharge, respectively, and the effect of 200 microg capsaicin (8-methyl-N-vanillyl-6-noneamide) injected into the contralateral gastrocnemius-soleus muscle was investigated. In most cells tested, regardless of the size or location of their receptive fields, the injection of capsaicin caused a clear inhibition of the electrically evoked C-fibre responses. In animals with intact descending pathways the mean C-fibre response was inhibited to 51% of baseline 15 min after injection of capsaicin. In contrast, when capsaicin was given during cold block of the spinal cord between the brainstem and the site of recording in the dorsal horn, the same response was inhibited to 91% of baseline. A significant interaction between cold block and capsaicin was detected. We conclude that stimulation of capsaicin-sensitive afferents in the deep tissue in the hind limb can inhibit the electrically evoked C-fibre responses in the dorsal horn by activating inhibitory descending projections from higher centres. The model presented here may be an important tool for further investigations of the endogenous descending antinociceptive system.

The medullary dorsal reticular nucleus facilitates pain behaviour induced by formalin in the rat.

The influence of the dorsal reticular nucleus (DRt) on pain behaviour during the formalin test was studied in the rat by lesioning the nucleus through local application of electrical current or quinolinic acid. Animals in which the DRt was lesioned ipsilaterally to the paw injected with formalin spent less time in focused (licking, biting or scratching the injected paw) and total (focused pain behaviour plus protection of the injected paw during movements) pain behaviour, and showed paw-jerks less frequently than non-lesioned animals in both phases 1 and 2 of the test. Animals in which the DRt was lesioned contralaterally to the injected paw presented a decrease in total pain behaviour and number of paw-jerks only during phase 2. The number of superficial (laminae I-II) and deep (laminae III-VI) spinal dorsal horn cells expressing the c-fos proto-oncogene 2 h after subcutaneous injection of formalin was reduced by 34% and 50%, respectively, in animals with an ipsilateral DRt lesion as compared to non-lesioned rats. No differences in c-fos expression were observed after lesioning the DRt contralateral to the formalin injection. The results indicate that the DRt is involved in the facilitation of nociception during the formalin test by enhancing the response capacity of dorsal horn neurons to noxious stimulation. It is suggested that the pronociceptive action of the DRt is mediated by the reciprocal connections it establishes with the spinal dorsal horn.

Expression of long-term potentiation in single wide dynamic range neurons in the rat is sensitive to blockade of glutamate receptors.

Plasticity in pain control systems may play an important role in clinical pain and some mechanisms of plasticity may be similar to those involved in learning. In this study we investigate the importance of alpha-amino-3-hydroxy-5-methylisoxazole-4-proprionic acid (AMPA) and N-methyl-D-aspartate (NMDA) receptors for the maintenance of long-term potentiation (LTP) in wide dynamic range (WDR) neurons. Doses of 6-nitro-7-sulphomoylbenzoylquinoxaline-2,3-dione disodium (NBQX) and D-Q-amino-5-phosphonopentanoic acid (D-AP5) equipotent in reducing C-fiber mediated responses in controls, reduced the established LTP by about 50 and 80%, respectively. The drug effect lasted less than 1 h in controls. After induction of LTP, NBQX caused a reversible reduction of the potentiation. D-AP5, however, caused a stronger attenuation of the LTP, outlasting the effect of the drug in controls. We suggest that both pre-emptive analgesia preventing LTP induction and an early reduction of the excitation of neurons is important for the inhibition of LTP and central sensitization. Thus, it is possible that an early antinociceptive treatment preventing an excessive excitation of neurons in the dorsal horn may be of importance in preventing longlasting and pathological pain states.

Long term potentiation of single WDR neurons in spinalized rats.

We report long-term potentiation (LTP) in single spinal wide dynamic range (WDR) neurons in urethane-anaesthetized spinalized rats with a complete neuromuscular blockade. Peripheral influences were excluded by a complete lidocaine block distal to the stimulation site on the sciatic nerve. As previously shown A-beta fibre evoked responses were not increased by the tetanic stimulation when there was a neuromuscular blockade during the experiment. Spinalization, excluding influences from supraspinal structures, increased all firing responses, and the LTP of C-fibre evoked responses when calculated in number of action potentials compared to intact animals and to previous studies. Furthermore, an LTP of the post discharge was observed after spinalization. An LTP of the post discharge has previously not been reported. Therefore, we conclude that LTP in the dorsal horn normally seems to be inhibited by descending pathways.

Behavioural effects of LTP-inducing sciatic nerve stimulation in the rat.

A short-lasting tetanic sciatic nerve stimulation that previously has been shown to be nociceptive only during the stimulation, induces long-term potentiation (LTP) of nociceptive evoked responses in wide dynamic range neurons in the dorsal horn of rats. The LTP may contribute to the process of central sensitization. We have shown that the tetanic conditioning stimulation with muscular contractions induces LTP of both Abeta- and C-fibre evoked responses. However, the same stimulation during muscular paralysis induces LTP only of C-fibre evoked responses. In the present study, we investigated the effects of this conditioning stimulation with or without muscular paralysis in behavioural tests in rats. Conditioning stimulation with muscular contractions caused a significant reduction of weight borne on the stimulated side, suggesting muscular soreness and peripheral sensitization. Conditioning stimulation during neuromuscular paralysis, which only has given LTP of C-fibre evoked responses in intact animals, caused no change in the weight borne on the stimulated side, suggesting less or even absence of allodynia. However, in these animals the response temperature in the hot plate test was increased both on the stimulated and on the contralateral side compared to sham-operated rats. In view of our recent results indicating that a descending inhibition reduces the expression of LTP in dorsal horn cells, and the suggestion by others that long-term descending inhibition may override a segmental facilitation, it is suggested that an increased long-lasting endogenous nociceptive inhibition is induced after LTP-inducing stimulation. This is an interesting parallel to stimulation-induced analgesia in humans. Copyright 1999 European Federation of Chapters of the International Association for the Study of Pain.

[Pain in neonates]. / Smerter hos nyfødte.

Recent research has lead to the conclusion that neonates and premature children do experience pain when undergoing painful procedures and that they should receive appropriate analgesics. It has earlier been argued that opioids should not be given to neonates because of their potentially dangerous adverse effects, e.g. respiratory depression and drug dependence. New reports emphasise the beneficial effects of proper analgesic treatment prior to surgery. Studies show that early pain experiences could have severe long-term effects, including altered sensitivity to pain. These effects appear to be different in neonates born at term compared to premature children.

AMPA and NMDA receptor-dependent spinal LTP after nociceptive tetanic stimulation.

LTP is often studied as a model of synaptic plasticity. Plasticity in pain control systems may involve mechanisms similar to those involved in learning. We recently reported LTP of both the A beta and C-fibre evoked responses of single dorsal horn neurons after a tetanic stimulation of the sciatic nerve, lasting for at least 6 h. In the present paper we show that identical stimulation induced LTP only of the C-fibre evoked response after blockade of muscular contractions during the tetanus. The C-fibre evoked response increased significantly less after pretreatment with either the AMPA antagonist NBQX or the NMDA antagonist D-AP5 (mean increase 33%) than in untreated animals (105%, p < 0.001), indicating that both AMPA and NMDA receptor stimulation are involved in the induction of LTP.

[Group learning in medical education]. / Gruppebasert undervisning i medisinstudiet.

The implementation of group learning in medical education puts special demands on the participants, but also offers pedagogical benefits, which may be conductive to the efficient learning of facts, skills and attitudes. The group makes it possible to verify or modify the learned material, which is an important part of preparing for a career as a doctor. Students develop a dependence on others when solving problems in groups, whereas as clinicians they are often alone when confronted with problems demanding quick decisions. In this article we discuss some of the pedagogical principles involved in group learning and make suggestions on how to apply them to learning based on problem solving and other forms of group learning in the medical curriculum.

A dual effect of 5-HT1B receptor stimulation on nociceptive dorsal horn neurones in rats.

In this study the modulatory effects of 5-HT1B receptor activation on wide dynamic range neurones in the spinal cord were studied. Extracellular single unit recordings of dorsal horn neurones were performed in intact urethane-anaesthetized female Sprague-Dawley rats, and the receptive field distally on one hind paw was electrically stimulated with needle electrodes applied to the skin. The 5-HT1B receptor agonist, CP-93,129 (3-(1,2,5,6-tetrahydropyrid-4-yl)pyrrolo[3,2-b]pyrid-5-one), the 5-HT1A/B receptor antagonist cyanopindolol, and the 5-HT1A receptor antagonist WAY100635 (N-[2-[4-(2-methoxypheny])-1-piperazinyl]ethyl]-N-(2-pyridinyl) cyclohexanecarboxamide trihydrochloride), were applied directly onto the spinal cord, and single unit responses were counted separately for A beta-, A delta-, C-fibre responses and post-discharge according to the latencies. A dual effect of CP-93,129 was observed: 50 nmol CP-93,129 caused a clear inhibition of the A delta-fibre responses, whereas 50 and 150 nmol CP-93,129 produced a dose-dependent increase in post-discharge without affecting A beta- and C-fibre responses. Application of 50 nmol cyanopindolol or 50 nmol WAY 100635 alone did not affect neither the neuronal A-fibre nor the C-fibre responses, but when 50 nmol cyanopindolol was coadministered with 50 nmol CP-93,129 the effect of CP-93,129 alone was blocked: the A delta-fibre response was not inhibited and the post-discharge was not increased. In contrast, 50 nmol WAY100635 did not block the effect of 50 nmol CP-93,129 when the two drugs were coadministered. These results suggest that stimulation of the 5-HT1B receptors may have both pro- and antinociceptive effects on wide dynamic range neurones in the dorsal horn after repeated electrical stimulation.

Differential effects of activation of lumbar and thoracic 5-HT2A/2C receptors on nociception in rats.

The role of 5-HT2 receptors in nociceptive behaviour of rats was investigated using spinal administration of the 5-HT2A/2C receptor agonist (+/-)-2,5-dimethoxy-4-iodoamphetamine (DOI), the 5-HT2A/2C antagonist ketanserin and the glutamate receptor agonist NMDA. Nociceptive behaviour was scored after injections at upper thoracic or lumbosacral levels. DOI (0.1-10 mM, 15 microl) administered at the upper thoracic level induced pain-like behaviour in a dose-dependent manner and a long-lasting motor depression at the greatest dose. At the lumbosacral level a similar dose-dependent pain-like behaviour was observed, but it was less pronounced. Motor depression was not observed at any dose. Ketanserin injected before DOI blocked both nociceptive and motor effects. Stimulation of both NMDA and 5-HT2A/2C receptors had a mutually potentiating effect. The present results show that the effects of DOI were more pronounced at the upper thoracic than at the lumbosacral level. This is possibly caused by the difference in 5-HT2A/2C receptor density at the two levels. The motor depression induced by the greatest dose of DOI given at the upper thoracic level appears to mask the pain-like behaviour. The nociceptive behaviour seen after DOI injection is further increased following co-injection of NMDA.