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. 1997 Oct;56(10):601–607. doi: 10.1136/ard.56.10.601

Reduced cortical responses to noxious heat in patients with rheumatoid arthritis

A Jones 1, S Derbyshire 1
PMCID: PMC1752267  PMID: 9389221

Abstract

OBJECTIVES—To test the hypothesis that patients with chronic inflammatory pain develop adaptive cortical responses to noxious stimulation characterised by reduced anterior cingulate responses.
METHODS—Positron emission tomography was used to measure changes in regional cerebral blood flow (rCBF) in response to an acute experimental pain stimulus in six patients with rheumatoid arthritis (RA) in comparison to six age and sex matched controls. A standardised and reproducible non-painful and painful phasic heat stimulus was delivered by a thermal probe to the back of the right hand during six two minute periods during which time rCBF measurements were made. The effects of non-painful heat were subtracted from those of painful heat to weight the analysis towards the non-discriminatory or `suffering' components of pain processing. Significance maps of pain processing were generated and compared in each group and contrasted with results obtained in a group of patients with atypical facial pain (AFP) that have been previously published.
RESULTS—The RA patients showed remarkably damped cortical and subcortical responses to pain compared with the control group. Significant differences between the two groups were observed in the prefrontal (BA 10) and anterior cingulate (BA 24 ) and cingulofrontal transition cortical (BA 32) areas. The reduced anterior cingulate responses to standardised heat pain were compared with the increased cingulate responses seen in patients with psychogenically maintained pain (AFP) who had both lower pain tolerance and mood than the RA group.
CONCLUSIONS—Major cortical adaptive responses to standardised noxious heat can be measured and contrasted in patients with different types of chronic pain. The different pattern of cingulate and frontal cortical responses in the patients with inflammatory and non-nociceptive pain suggest that different mechanisms are operating, possibly at a thalamocortical level. Implications for treatment strategies for chronic pain are discussed.



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Figure 1  .

Figure 1  

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Schema of components of processes leading to handicap and the different components of disease related behaviour that may contribute to it.

Figure 2  .

Figure 2  

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Subsignificant responses to the suffering components of experimental heat pain in a group of six patients with RA pain. After correction for global blood flow changes the data for the group were pooled and fitted to a standardised stereotactic template. Significant increases in rCBF as a result of the non-discriminatory (suffering) components of the pain response were assessed by subtracting the effect of non-painful heat stimulation from painful heat stimulation. At the top are transverse images of the brain after stereotaxic normalisation, with the distances from the AC-PC (anterior commissure-posterior commissure) plane indicated. (A) Anatomical features obtained by averaging all blood flow scans from the six female patients. (B) Arithmetical difference between adjusted mean blood flows for painful hot and non-painful hot stimuli. (C) The SPM (t) values derived from the formal pixel by pixel comparison of the adjusted mean blood flows and variances for each of the two conditions. The colour scale is arbitrary from low values to high, represented from mauve/blue, green, yellow, red to white respectively. Threshold significance is indicated by the lower left pixel for each plane and therefore only white is significant at a p<0.001 (Z threshold 3.09). Orientation: top is the front of the brain (rostral) and bottom is the back (caudal). Left is left. Arrows identify some of the subsignificant responses in left insula cortex, medial prefrontal cortex, (BA9) and anterior cingulate cortex (BA 24).

Selected References

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