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.

Reg-2 expression in dorsal root ganglion neurons after adjuvant-induced monoarthritis.

Reg-2 is a secreted protein that is expressed de novo in motoneurons, sympathetic neurons, and dorsal root ganglion (DRG) neurons after nerve injury and which can act as a Schwann cell mitogen. We now show that Reg-2 is also upregulated by DRG neurons in inflammation with a very unusual expression pattern. In a rat model of monoarthritis, Reg-2 immunoreactivity was detected in DRG neurons at 1 day, peaked at 3 days (in 11.6% of DRG neurons), and was still present at 10 days (in 5%). Expression was almost exclusively in the population of DRG neurons that expresses the purinoceptor P2X(3) and binding sites for the lectin Griffonia simplicifolia IB4, and which is known to respond to glial cell line-derived neurotrophic factor (GDNF). Immunoreactivity was present in DRG cell bodies and central terminals in the dorsal horn of the spinal cord. In contrast, very little expression was seen in the nerve growth factor (NGF) responsive and substance P expressing population. However intrathecal delivery of GDNF did not induce Reg-2 expression, but leukemia inhibitory factor (LIF) had a dramatic effect, inducing Reg-2 immunoreactivity in 39% of DRG neurons and 62% of P2X(3) cells. Changes in inflammation have previously been observed predominantly in the neuropeptide expressing, NGF responsive, DRG neurons. Our results show that changes also take place in the IB4 population, possibly driven by members of the LIF family of neuropoietic cytokines. In addition, the presence of Reg-2 in central axon terminals implicates Reg-2 as a possible modulator of second order dorsal horn cells.

Comparison of vibration perception thresholds in individuals with diffuse upper limb pain and carpal tunnel syndrome.

The study objective was to compare vibration perception and patterns of blood flow in outpatients with diffuse upper limb pain disorder (ULPD), carpal tunnel syndrome (CTS) and age and sex matched healthy controls. Vibration perception and discrimination thresholds were compared in subjects with ULPD (n=27), CTS (n=27) and healthy matched controls (n=54). Vibration measurements were taken bilaterally at three sites: (a) over the dorsum of the second and (b) fifth metacarpals and (c) the palmar aspect of the first and second metacarpals, corresponding to the innervation territories of the radial, ulnar and median nerves, respectively. Non-invasive assessments of peripheral blood flow were also performed in both limbs. When compared to healthy controls, subjects with ULPD had widespread elevation of vibration thresholds both ipsilateral and contralateral to the symptomatic limb. Subjects with CTS had similarly elevated vibration thresholds at sites both adjacent to and distant from the site of peripheral nerve injury. The responses to cold pressor testing of the upper limbs were physiologically normal in both the CTS and ULPD patient groups. Furthermore, there were no significant differences in the haemodynamic responses between the patient groups. The global elevation of vibration thresholds in subjects with both ULPD and CTS is consistent with altered central nervous system mechanisms, common to both conditions, which may be either adaptive to or maintaining the perception of pain.

The effect of substance P on nitric oxide release in a rheumatoid arthritis model.

OBJECTIVE: The inflammatory mediator substance P (SP) acts principally through the neurokinin (NK1) receptor. We assessed the influence of SP on production of NO and its possible role in the pathogenesis of rheumatoid arthritis (RA). METHODS: The effect of SP (0.1-100 nM) on concentrations of the NO metabolite, nitrite, produced by synovial fibroblasts from RA patients was studied. For comparison, the effects of TNF-alpha (0.57 pM-5.7 nM) and IL-1beta (0.57 pM-5.7 nM) were also studied. In parallel studies, footpad inflammation was induced in NK1 receptor knock-out (KO) and wild-type (WT) mice, and swelling and NO metabolite levels were measured. RESULTS: In cultured synoviocytes, SP, TNF-alpha and IL-1beta induced significantly increased nitrite concentrations. Consistent with a role for NO in SP-mediated inflammatory reactions, the plasma NO metabolite level in WT mice was significantly increased at 3 days following an injection of 10 mg/ml Mycobacterium tuberculosis, but there was no significant change in NK1 KO mice. These results were paralleled by the changes in footpad swelling in WT mice compared to NK1 KO mice. CONCLUSION: SP, like TNF-alpha and IL-1beta, induces NO in both rheumatoid synoviocytes and experimental models of inflammation. Treatments directed against SP may have important and hitherto unrecognised anti-inflammatory effects.

A rat model of bone cancer pain.

This study describes the first known model of bone cancer pain in the rat. Sprague-Dawley rats receiving intra-tibial injections of syngeneic MRMT-1 rat mammary gland carcinoma cells developed behavioural signs indicative of pain, including: mechanical allodynia, difference of weight bearing between hind paws and mechanical hyperalgesia. The development of the bone tumour and structural damage to the bone was monitored by radiological analysis, quantitative measurement of mineral content and histology. Intra-tibial injections of 3 x 10(3) or 3 x 10(4) syngeneic MRMT-1 cells produced a rapidly expanding tumour within the boundaries of the tibia, causing severe remodelling of the bone. Radiographs showed extensive damage to the cortical bone and the trabeculae by day 10-14 after inoculation of 3 x 10(3) MRMT-1 cells, and by day 20, the damage was threatening the integrity of the tibial bone. While both mineral content and mineral density decreased significantly in the cancerous bone, osteoclast numbers in the peritumoural compact bone remained unchanged. However, tartarate-resistant acid phosphatase staining revealed a large number of polykariotic cells, resembling those of osteoclasts within the tumour. No tumour growth was observed after the injection of heat-killed MRMT-1 cells. Intra-tibial injections of 3 x 10(3) or 3 x 10(4) MRMT-1 cells, heat-killed cells or vehicle did not show changes in body weight and core temperature over 19-20 days. The general activity of animals after injection with live or heat-killed MRMT-1 cells was higher than that of the control group, however, the activity of the MRMT-1 treated group declined during the progress of the disease. Rats receiving intra-tibial injections of MRMT-1 cells displayed the gradual development of mechanical allodynia and mechanical hyperalgesia/reduced weight bearing on the affected limb, beginning on day 12-14 or 10-12 following injection of 3 x 10(3) or 3 x 10(4) cells, respectively. These symptoms were not observed in rats receiving heat-killed cells or vehicle. Behavioural data suggest a reasonable time window for evaluation of anti-nociceptive agents between day 14 and 20 after cancer cell inoculation in this model. Acute treatment with morphine (1-3mg/kg, subcutanously (s.c.)) produced a dose-dependent reduction in the response frequency of hind paw withdrawal to von Frey filament stimulation 17 or 19 days following intra-tibial injections of 3 x 10(3) MRMT-1 cells. A significant reduction in the difference in hind limb weight bearing was also observed. Acute treatment with celebrex (10-30 mg/kg, s.c.) did not affect mechanical allodynia or difference in weight bearing in rats 20 days following treatment with 3 x 10(3) MRMT-1 cells. Although the pathophysiology of cancer pain is largely unknown, significant enhancement of glial fibrillary acidic protein (GFAP) staining in the corresponding segments of the ipsilateral spinal cord highlights the possible involvement of astrocytes. In summary, the induction of bone cancer in the rat by the syngeneic MRMT-1 mammary tumour cell line provides a valid pre-clinical model for pain associated with bone metastases. Significant mechanical hyperalgesia and allodynia develops in association with the progression of the tumour in the bone marrow cavity, while the general condition of the animal remains satisfactory. While acute treatment with morphine has some analgesic effect on hind limb sparing the selective COX-2 inhibitor, celebrex, has no influence on the pain-related behavioural changes in this model.

The neurogenic contribution to synovial leucocyte infiltration and other outcome measures in a guinea pig model of arthritis.

A neurogenic contribution to joint inflammation has been demonstrated in rat adjuvant arthritis, however as inflammatory mechanisms vary between species it is unclear whether these observations can be applied more generally. The aim of this study was to assess the neurogenic contribution to cellular infiltration and other outcome measures in a guinea pig model of arthritis. Compared to arthritic controls, animals pre-treated with capsaicin at doses sufficient to reduce sensory activity exhibited a significant attenuation of both mechanical and thermal hyperalgesia. Measures of inflammation, including swelling and radiological scores were also improved. Furthermore, capsaicin selectively reduced synovial T cell infiltration whereas no difference was seen with respect to synovial macrophages. These observations confirm a neurogenic component in guinea pig arthritis and indicate a selective sensory influence on T cell activity within the chronically inflamed joint. As T cells are strongly implicated in the pathogenesis of rheumatic disease, such an influence may serve to explain some of the clinical features observed in these disorders.

Differential role of neurokinin receptors in human lymphocyte and monocyte chemotaxis.

The precise nature of neurokin receptor involvement in human immune cell chemotaxis is unclear. This study therefore sought to directly compare the chemotactic effects of neurokinins on human T lymphocytes and monocytes. Substance P was found to have a similar dose-dependent chemotactic action on T lymphocyte and monocyte populations. In contrast, T lymphocytes were found to be more responsive than monocytes both to the highly selective NK-1 agonist, [Sar(9)Met O(2)(11)]-substance P, and also to the NK-2 selective agonist, beta-alanine neurokinin A((4-10)). Consistent with these findings, substance P-induced chemotaxis of both T lymphocyte and monocytes was attenuated by the selective NK-1 antagonist LY303870. However, the selective NK-2 antagonist MEN 10,376 was only effective in inhibiting the T lymphocyte response. The study confirms that neurokinins have chemotactic actions on immune cells and indicates important functional differences between human T lymphocyte and monocyte responses. This provides a potential mechanism by which the nervous system can selectively influence cellular recruitment in inflammatory disease.

Assay of topically administered ibuprofen using a model of post-injury hypersensitivity. A randomised, double-blind, placebo-controlled study.

OBJECTIVE: To develop a reliable assay for quantifying the analgesic efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) using a model that is accepted as a paradigm of clinical pain. SUBJECTS: Fifteen normal subjects, all of whom were volunteers from medical school staff, took part in the study. METHODS: Capsaicin (20 microl) in solution (0.03 mg/ml) was applied to the volar surface of the forearm, and the skin was maintained at a constant temperature using a thermal stimulator. The magnitude of the surrounding area of mechanical allodynia to a brush stimulus (i.e. a clinical correlate of tenderness to touch) was assessed. Under double-blind, placebo-controlled conditions, the test was repeated using skin previously treated with ibuprofen gel or placebo. RESULTS: A close linear relationship was observed between skin temperature over a range of 30 degrees C to 40 degrees C and the area of capsaicin-induced allodynia. Ibuprofen gel significantly reduced (P < 0.004) the area of touch-evoked allodynia at a constant skin temperature of 40 degrees C. CONCLUSIONS: The thermal-facilitated adaptation of the capsaicin model described in this study represents an inexpensive and reliable assay for the effects of topical formulations of NSAID upon mechanical sensitivity. As such, it is a potential alternative to many clinical studies in which inherent confounding and bias can preclude a meaningful conclusion.

Activation of the transcription factor NF-kappaB in the rat air pouch model of inflammation.

OBJECTIVE: To investigate the activation of NF-kappaB in the carrageenan rat air pouch model of inflammation in a time course experiment, and the effect of dexamethasone on NF-kappaB activation. METHODS: Air pouch tissue treated with carrageenan (inflamed tissue) was obtained from rats killed at days 1, 2, 3, 6, 14, 21, 28 and 35 after carrageenan challenge. Tissue was also taken from non-carrageenan treated pouches (non-inflamed tissue) at day 3, and from inflamed tissues treated with dexamethasone. Tissue sections were wax embedded and stained with an "activity specific" monoclonal antibody raised against the nuclear localisation signal (NLS) of the p65 sub-unit of NF-kappaB. RESULTS: Cells containing activated NF-kappaB were detected in the intimal and sub-intimal regions of the air pouches as early as day 1. There was a significant increase in cells staining for activated NF-kappaB as the inflammation progressed. Initially cells staining were more prominent in the intimal versus sub-intimal region (p<0.001 for day 1) and at later time points the pattern was reversed (p<0.001 for day 6). There was a significant reduction in the number of cells staining for activated NF-kappaB in tissue taken from dexamethasone treated rats, compared with inflamed pouches alone (p<0.001). At no time point was positive staining for activated NF-kappaB observed in blood vessels. CONCLUSIONS: Activated NF-kappaB is present in the inflamed air pouch and the activation is associated with the inflammatory response to carrageenan. Treatment with dexamethasone resulted in reduced numbers of cells staining for activated NF-kappaB.

What are the mechanisms of regional musculoskeletal pain?

Pain is a subjective experience that is unique to the individual. Although pain is usually associated with tissue injury or inflammation, it is strongly influenced by changes within the nervous system as well as by psychological and social factors. This review focuses on those 'nociceptive' mechanisms which contribute to pain and demonstates how an appreciation of underlying molecular and cellular mechanisms can lead to improved diagnosis and treatment.

Effect of capsaicin on substance P and nerve growth factor in adjuvant arthritic rats.

We have investigated the effect of capsaicin pretreatment (50 mg kg(-1) s.c.) on substance P, preprotachykinin (PPT) mRNA, and nerve growth factor (NGF), plus its high-affinity receptor, trkA, in adult rats with adjuvant arthritis. Twenty one days after induction of adjuvant arthritis, sciatic nerve levels of substance P were significantly increased whilst there was a small but non-significant increase in gamma-PPT mRNA and substance P in L4/L5 dorsal root ganglia (DRG). NGF levels in sciatic nerve and foot skin as well as DRG trkA mRNA were unaltered after 21 days arthritis suggesting that NGF may not play a role in chronic inflammation. Capsaicin treatment of naive rats significantly reduced substance P in all tissues and NGF levels in the sciatic nerve. In contrast, gamma-PPT mRNA and trkA mRNA expression in DRG were significantly increased after capsaicin treatment. The nervous and skin tissues used in this study were harvested from the same rats in which we had previously shown that capsaicin pretreatment significantly attenuated the severity of arthritis (Cruwys, S.C., Garrett, N.E. and Kidd, B.L., Sensory denervation with capsaicin attenuates inflammation and nociception in arthritic rats, Neurosci. Lett., 193 (1995) 205-207). Arthritis in capsaicin-treated rats had no effect on substance P or NGF levels in any tissue when compared with capsaicin-treated control rats, suggesting that pharmacological impairment of the sensory nervous system can reduce the severity of inflammatory joint disease.

Characterisation of capsaicin-induced mechanical hyperalgesia as a marker for altered nociceptive processing in patients with rheumatoid arthritis.

Rheumatoid arthritis (RA) is characterised by pain and tenderness not only over inflamed or damaged joints, but also over apparently normal tissues. Experimental models suggest that these features results from changes of sensitivity within both peripheral and central neurones, but direct evidence from human disease is lacking. At present, most clinical studies have evaluated overall pain experience rather than activity within components of the nociceptive pathway. Therefore, the aim of this study was to assess the use of a capsaicin-based technique to quantify changes of neuronal sensitivity in patients with RA. First 20 microliters of capsaicin in solution (0.03 mg/ml) was applied topically for 30 min to apparently normal skin on the forearm of control subjects and patients with RA. The subsequent development of mechanical hyperalgesia to pinprick stimuli was then measured at various time points using a 74.4-mN von Frey hair. The relationship between the area of hyperalgesia and a number of clinical measures was determined. Capsaicin-induced mechanical hyperalgesia was found to decline with age in normal subjects (r = 0.47, P < 0.01). The development of hypearlgesia had a similar time course in normal subjects and patients with RA. The maximum area of hyperalgesia, however, was substantially larger in 35 RA patients; 254.3 +/- 20.7 cm2, compared with 35 normal controls; 109 +/- 7.5 cm2 (P < 0.001). An association was apparent between hyperalgesic area and a composite score of joint tenderness (r = 0.47, P < 0.01), but not with overall pain score or a systemic marker of inflammation. These results provide evidence for enhanced sensitisation of a population of sensory fibres in RA. Peripheral sensory activity over the forearms of rheumatoid patients has previously been shown to be normal and the results suggest the presence of enhanced central mechanisms in this disorder. The correlation between capsaicin-induced hyperalgesia and joint tenderness in the RA patients implies that joint symptoms arise partially as a result of central, and not exclusively peripheral, factors. The study supports the use of capsaicin-based techniques to explore nociceptive mechanisms in clinical disorders characterised by chronic pain.

Effect of streptozotocin-diabetes on knee joint inflammation-induced changes in substance P and nerve growth factor in the rat.

Given the involvement of the sensory nervous system in the aetiology of neurogenic inflammation, we have investigated the effect of experimental diabetes and any associated sensory nerve dysfunction on the development of complete Freund's adjuvant-induced inflammation in the rat knee. Twenty-four hours after induction of inflammation in non-diabetic rats, gamma-preprotachykinin mRNA expression was increased in the L4/L5 dorsal root ganglia. Substance P levels were increased in dorsal root ganglia and sciatic nerve whilst synovial levels of substance P were significantly decreased. Nerve growth factor, which regulates expression of gamma-preprotachykinin mRNA, was significantly increased in synovium and sciatic nerve after induction of inflammation. After 24 weeks of streptozotocin-diabetes, there was a non-significant reduction in gamma-preprotachykinin mRNA expression whilst substance P levels in dorsal root ganglia, sciatic nerve and synovium and nerve growth factor levels in the sciatic nerve were significantly decreased. Conversely, synovial levels of nerve growth factor were significantly increased. Injection of complete Freund's adjuvant into the knee of diabetic rats produced diminished joint swelling compared to that observed in non-diabetic rats. Substance P levels were unaltered compared to non-arthritic diabetic rats whilst nerve growth factor levels were significantly increased in synovium and sciatic nerve suggesting an uncoupling of substance P from nerve growth factor control in the inflammatory response in diabetic rats. The results show a significant reduction in the inflammatory response in rats with chronic streptozotocin-diabetes. Deficits in gamma-preprotachykinin mRNA expression and substance P and the altered levels of nerve growth factor indicate sensory neuronal dysfunction may play a major role in this abnormal response.

Neurogenic influences on contralateral responses during experimental rat monoarthritis.

Many inflammatory conditions show topographically precise symmetrical responses. In this study we assessed vascular and cellular responses of apparently normal knees following induction of monoarthritis on the opposite side. A strictly localised monoarthritis was induced in the right knee of experimental animals using intra-articular latex spheres. In both knee joints bradykinin-induced plasma extravasation was significantly enhanced increasing from 0.52 +/- 0.07 micrograms/ml Evans blue to 0.99 +/- 0.07 micrograms/ml and 0.88 +/- 0.1 micrograms/ml in the injected and uninjected, contralateral, knees respectively (P < 0.05). A bilateral increase in cellularity was also apparent with cell counts in the uninjected, and apparently normal, knee increasing from 512 +/- 42 cells/mm2 to a maximum of 812 +/- 125 cells/mm2 on day 10 (P < 0.05). Immunohistological analysis demonstrated that the infiltrating cells in both the ipsilateral and contralateral joints were predominantly macrophages. Cell counts were not increased in the other peripheral joints. Levels of the sensory neuropeptide substance P were significantly elevated in both the ipsilateral and contralateral dorsal root ganglia and prior inhibition of small unmyelinated nerve activity inhibited the cellular infiltrate on the contralateral side, suggesting that the effect was mediated, at least partially, by a specific neurogenic pathway. The data suggests the presence of a neurogenic mechanism able to induce a topographically precise response. This may serve to upregulate the cellular defences of at-risk tissues following a potentially damaging stimulus at another site.

Sensory denervation with capsaicin attenuates inflammation and nociception in arthritic rats.

The relatively few studies that have investigated the effects of the nervous system on chronic joint disease have reported conflicting results. We have reassessed the effects of capsaicin on experimental polyarthritis with particular reference to the relationship between changes in nociception and changes in process and outcome measures of disease activity. Capsaicin pretreatment significantly attenuated both joint swelling and disease outcome as determined by quantitative radiology and histology. There was a close correlation between process measures of inflammation and mechanical hyperalgesia in both the untreated and capsaicin treated arthritic groups. The results confirm a suppression of inflammation by capsaicin and imply that the nociceptive and pro-inflammatory (neurogenic inflammation) activities of capsaicin-sensitive fibres are closely linked such that stimuli which cause pain will also induce neurogenic inflammation and vice versa.