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REGIONAL ANESTHESIA AND PAIN MANAGEMENT

The Effects of Ketamine on the Temporal Summation (Wind-Up) of the R_III Nociceptive Flexion Reflex and Pain in Humans

Frédéric Guirimand, MD, PhD^*,, Xavier Dupont, MD, Louis Brasseur, MD^*,, Marcel Chauvin, MD, and Didier Bouhassira, MD, PhD^*,

*Centre d’Evaluation et de Traitement de la Douleur and Service d’Anesthésie-Réanimation Chirurgicale, Hôpital Ambroise Paré, Boulogne; and INSERM U-161, Paris, France

Address correspondence and reprint requests to Didier Bouhassira, MD, PhD, INSERM U-161, 2, rue d’Alésia, 75014 Paris, France. Address e-mail to bouhassira{at}broca.inserm.fr

	Abstract

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Animal studies have suggested that the temporal summation of nociceptive inputs might play a significant role in the development of central sensitization (i.e., hyperexcitability of central nociceptive neurons) and hyperalgesia via the activation of N-methyl-D-aspartate receptors. To further analyze these processes in humans, we evaluated the effects of small systemic doses of ketamine on the temporal summation (i.e., wind-up) of both the nociceptive flexion (R_III) reflex and sensations of pain in six healthy volunteers. The R_III reflex was recorded from the biceps femoris and was elicited by electrical stimulation of the sural nerve. First, the recruitment (stimulus/response) curve for the reflex was built using stimuli up to the pain tolerance threshold (applied once every 6 s). A series of 15 stimuli was then applied once a second at an intensity of 1.2 times the reflex threshold. These procedures were performed both before and after the randomized IV injection of either 0.15 mg/kg ketamine or a placebo. The R_III reflex threshold and its recruitment curve were not significantly altered after the injection of ketamine or placebo. By contrast, the significant increases (i.e., wind-up) in both the reflex responses and the sensations of pain observed during the higher frequency stimulation were significantly reduced after the administration of ketamine, but not placebo. This method might be useful for quantifying and analyzing the wind-up phenomenon and, thus, for studying the neurophysiological and pharmacological mechanisms underlying hyperalgesia in humans.

Implications: The wind-up phenomenon (i.e., the progressive increase of the responses induced by repetitive nociceptive stimuli) was characterized in humans by using electrophysiological recordings of the nociceptive flexion reflex. We showed that, as in animals, this phenomenon, which might represent an elementary form of the central sensitization involved in various painful syndromes, depends on the activation of N-methyl-D-aspartate receptors, because it was selectively reduced after the administration of ketamine.

	Introduction

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Hyperalgesia and allodynia are common clinical conditions characterized by perturbations in the relationship between a peripheral stimulus and the sensation of pain. A better understanding of the physiological and pharmacological mechanisms underlying these painful conditions might promote the development of new analgesic drugs. Many experimental studies have suggested that changes at both the periphery and secondary mechanisms in the central nervous system, such as central sensitization, are involved in the development of hyperalgesia/allodynia (1–3). Central sensitization corresponds to a state of hyperexcitability of central (notably spinal) nociceptive neurons induced by persistent or tonic nociceptive peripheral inputs (4,5).

The temporal summation of nociceptive inputs might play a significant role in the development of central sensitization and hyperalgesia. In animals, the repeated application of nociceptive stimuli at a fixed intensity and a relatively high frequency (i.e., >0.3 Hz) results in a progressive increase in the responses of spinal nociceptive neurons and reflexes (6–8). During the last few years, numerous experimental studies have been devoted to this "wind-up" phenomenon, as it may represent an elementary form of central sensitization. One of the main arguments to suggest such a relationship between these phenomena is that both wind-up (9,10) and central sensitization involve the activation of N-methyl-D-aspartate (NMDA) receptors (11,12).

Consistent with these findings, psychophysical experiments in humans have demonstrated that the temporal summation resulting from repetitive nociceptive stimuli results in a similar increase in the sensation of pain (13,14). This effect might be related to the wind-up of nociceptive responses described in animals because it is observed with similar frequencies of stimulation and is reduced after the administration of NMDA receptor antagonists such as ketamine or dextromethorphan (15–17). Thus, it is thought that NMDA-mediated mechanisms similar to those described in animals also function in humans and might lead to central sensitization under pathological conditions. Such a state of hyperexcitability of central nociceptive neurons might explain why, in some patients, non-nociceptive stimuli can induce pain (i.e., allodynia), whereas in others, normal nociceptive stimuli can induce abnormally large responses (i.e., hyperalgesia). In accordance with this hypothesis, several clinical studies have indicated that the administration of NMDA receptor antagonists is particularly effective in reducing evoked pain in patients suffering from neuropathic pain (18–21) or inflammatory pain from the region surrounding a surgical incision (22).

We sought to provide a useful psychophysiological index for quantifying the wind-up phenomenon and analyzing its mechanisms in humans. We compared the effects of small systemic doses of ketamine or a placebo, administered in a double-blinded, cross-over design, on the temporal summation of the nociceptive flexion (R_III) reflex and the sensation of pain in normal volunteers. The R_III reflex is a polysynaptic spinal reflex that can be easily elicited by electrical stimulation of a sensory nerve, such as the sural nerve, and recorded from a flexor muscle, such as the biceps femoris in the ipsilateral limb. This reflex is a useful tool for objectively studying the spinal mechanisms of nociception in humans because its threshold and amplitude are closely related to those of the concomitant pain evoked by electrical stimulation (23). In addition to investigating the selective action of ketamine on temporal summation, we also evaluated its effects on the recruitment (i.e., stimulus/response) curve for the R_III reflex up to the pain tolerance threshold.

	Methods

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Experiments were performed, with local ethics committee approval, on six healthy volunteers (men 25–40 yr old). The participants were carefully briefed on the experimental procedure, and they gave their informed, written consent.

The R_III reflex was evoked and recorded using a completely computerized system (Notocord Systems, Croissy, France), using techniques previously described and validated (23). In brief, the sural nerve was stimulated electrically using a pair of surface electrodes placed 2 cm apart on the degreased skin overlying the nerve within its retromalleolar path. Each electrical stimulus consisted of a train of five rectangular pulses, each of 1-ms duration, delivered over a 12-ms period, from a constant current stimulator. Electromyographic responses were recorded from the ipsilateral biceps femoris muscle via a pair of surface electrodes placed 2 cm apart on the skin over the muscle. The R_III reflex responses were identified as multiphasic waves appearing 90–180 ms after the onset of the stimuli. By restricting the study to responses within this time, it is possible to avoid the tactile (R_II) reflex, which can occur between 50 and 70 ms, or artifacts produced by involuntary movements, which can be observed as early as 250–300 ms after the stimulus. Each reflex response was amplified, digitized, full wave-rectified, and integrated. The resulting integrals were used to quantify the R_III response.

The six volunteers underwent experiments on two occasions separated by an interval of 7 days. On each occasion, two experimental sequences were performed: one before (control period) and one 5 min after the IV administration (over a 1-min period) of 0.15 mg/kg ketamine or a placebo (saline). This dose was chosen based on the results of previous clinical studies (18, 19) and pilot experiments. The injections were administered in a double-blinded and randomized fashion. Each sequence consisted of 1) constructing the recruitment curve for the reflex as a function of stimulus intensity, which was increased progressively up to the tolerance threshold at a frequency of 0.17 Hz (i.e., 10 stimuli/min); 2) adjusting the stimulus intensity to 1.2 times the reflex threshold and checking the stability of the recordings and reflex responses over a 2-min period (with the stimuli at a frequency of 0.17 Hz); 3) applying a series of 15 such stimuli (i.e., 1.2 times threshold) at 1 Hz. The subjects were asked to use a 100-mm visual analog scale (VAS) graduated from 0 (no pain) to 100 (worst possible pain) to rate both the sensation evoked by the first stimulus in this series and the maximal pain produced by any of the stimuli. The stimulation frequency was chosen based on pilot experiments, which had shown that the magnitude of the wind-up of the reflex was much less at lower frequencies (e.g., 0.5 Hz), whereas higher frequencies (e.g., 1.5 or 2 Hz) resulted in fusion of successive responses, which hampered the analysis of each individual response. Similarly, with respect to the stimulus intensity, higher stimulus intensities (e.g., 1.4–1.5 times the threshold) induced intolerable increases in the sensations of pain and motor artifacts during the stimulation sequences.

Data are expressed as means ± SEM. The reflex threshold was defined as the intersection of the linear regression line for the R_III stimulus/response relationship with the abscissa. The tolerance threshold was the maximal intensity on the recruitment curve. To allow analysis of group data, each reflex response was expressed as a percentage of the maximal response observed during the control recruitment curve (i.e., before the injection). Recruitment curves were normalized between 0 and 30 mA such that when the tolerance threshold was <30 mA, the last value obtained for the reflex was assigned to all the higher intensities in the series. Temporal summation was analyzed by expressing each response during the sequence of 15 stimuli at 1 Hz as a percentage of the first response. Wilcoxon’s signed ranks test was used for comparison of paired data. The areas under the mean recruitment curves and the mean wind-up curves were calculated and used to compare the effects of the placebo and ketamine by using of repeated-measures analysis of variance. The influence of treatment order (placebo-ketamine or ketamine-placebo) and period (first or second stage) were also tested. Results were considered significant at P < 0.05.

	Results

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The results indicate that the administration of a small systemic dose of ketamine, which did not significantly alter the recruitment curve for the R_III reflex, did selectively depress the progressive increase (i.e., wind-up) of both the reflex and the sensation of pain associated with the repeated application of nociceptive stimuli at a fixed intensity.

Effects of Ketamine on the Recruitment Curve of the Nociceptive Flexion Reflex
The recruitment curves of the reflex obtained with low-frequency electrical stimuli (i.e., 0.17 Hz) did not differ significantly between the two control periods and were not significantly altered after the injection of ketamine or placebo (Figure 1). The mean R_III reflex thresholds were 9.3 ± 1.4 and 9.1 ± 1.5 mA (not significant) in the first and second control periods, respectively, and were not significantly different after the administration of ketamine or placebo (9.5 ± 1.6 and 8.9 ± 1.3 mA). The mean tolerance thresholds (i.e., the maximal stimulus intensities on the recruitment curves) were 22.5 ± 4.1 and 25.3 ± 5.3 mA during the first and second control periods, respectively, and were not significantly different after the injection of ketamine or placebo (23.2 ± 2.6 and 24.6 ± 3.1 mA).

View larger version (12K): [in this window] [in a new window]   Figure 1. The recruitment curves for the RIII reflex were not significantly different before (control) and after the systemic injection of ketamine (A) or placebo (B). Each reflex response is expressed as a percentage of the maximal response obtained when building the control curve.

View larger version (24K): [in this window] [in a new window]   Figure 2. Individual example of the effects of ketamine on the wind-up of the RIII reflex (for clarity of presentation, only the first 8 responses in the series of 15 are illustrated). During the control period (left side), a progressive increase in the reflex was observed. This wind-up was strongly reduced after the systemic injection of ketamine (right side).

View larger version (17K): [in this window] [in a new window]   Figure 3. Cumulative results showing the effects of ketamine (A) or placebo (B) on the wind-up of the RIII reflex. Each reflex response was expressed as a percentage of the first response in the series.

The sequence (placebo-ketamine or ketamine-placebo) and the period (first or second session) did not influence the results.

Side Effects
All the subjects reported one or several side effects after ketamine administration. These included sedation (one of six), illusions (two of six), paraesthesia in the limbs (one of six), increased sensitivity to light and sound (two of six), unpleasant dreams (one of six), and dizziness (one of six). The side effects were maximal 1–3 min after the injection.

	Discussion

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The present data from humans indicate that the temporal summation of inputs from nociceptive stimuli results in a parallel increase in both the R_III reflex and the sensation of pain and that this wind-up phenomenon involves the activation of NMDA receptors, as it is selectively decreased after the administration of ketamine.

Our electrophysiological results are in keeping with those of Arendt-Nielsen et al. (17), who showed that the "temporal summation threshold" for the R_III reflex (i.e., the threshold of the reflex induced by the application of five electrical stimuli at 2 Hz) was significantly increased during an infusion of ketamine. However, these effects were not selective because the dose injected (a bolus of 0.5 mg/kg followed by an infusion of 9 µg · kg^-1 · min^-1) also induced a reduction in the responses to suprathreshold mechanical and electrical stimuli. By contrast, the smaller dose of ketamine we used (0.15 mg/kg) did not induce general analgesic effects. This was shown by the absence of a significant alteration in the stimulus/response curves for the reflex. One major problem associated with the use of ketamine is its numerous side effects. Although we used a very small systemic dose, all the subjects reported some side effects; consequently, the study was not completely blind. However, because of the selectivity of action of ketamine on the wind-up phenomenon, it is unlikely that the present results were due entirely to nonspecific effects.

Wind-up of nociceptive responses has been well characterized in animals. It has been demonstrated in spinal dorsal and ventral horn neurons, both in vivo and in vitro, after stimulation of thin myelinated A or unmyelinated C fibers (6–10,24), as well as in nociceptive reflexes (25–27). Intracellular recordings have shown that, in contrast to what happens after activation of Aß fibers, the activation of thin afferent fibers induces excitatory postsynaptic potentials in dorsal horn nociceptive neurons, which can last several hundreds of milliseconds (28). Thus, the application of repetitive stimuli at a relatively rapid frequency (i.e., >0.3 Hz) can induce an increasing and cumulative depolarization, resulting in an increase in the number of action potentials evoked by each stimulus. This slow depolarization is due to the co-release of excitatory amino acids (EAA), such as glutamate, and neuropeptides, such as substance P (29) by nociceptive primary afferents. The release of EAA in the spinal dorsal horn and the activation of NMDA receptors seem to play a major role in wind-up, because it is selectively reduced by NMDA receptor antagonists (9,10). However, the action of EAA is probably modulated by neuropeptides (29). In addition, recent in vitro experiments suggest that other mechanisms, notably those mediated by L-type Ca²⁺ currents, may also have a significant role in these processes (30).

The fact that wind-up is mediated through NMDA receptors has lead to the proposition that it may represent an intermediate step in the development of central sensitization. Central sensitization of dorsal horn nociceptive neurons is characterized by a reduction in their threshold for activation, an increase in their spontaneous activity and responses to noxious peripheral stimuli, and an expansion of their receptive fields. This phenomenon has been observed in models of tissue or nerve injury and is thought to represent a pathophysiological mechanism for various acute and chronic pain syndromes (1–5). The increased release of EAA in the spinal cord due to the tonic or persistent activation of nociceptive afferents under pathological conditions (e.g., inflammatory processes) could be sufficient to lead to an activation of NMDA receptors, which is capable of inducing long-term alterations in neuronal properties. Such modifications are mediated by the intracellular influx of Ca²⁺ and the activation of protein kinase C and NO synthase and could result in a state of hyperexcitability or central sensitization of nociceptive neurons. In accordance with this hypothesis, behavioral signs of hyperalgesia can be reduced by NMDA antagonists (3–5).

However, despite these apparent similarities, there are significant discrepancies between the electrophysiological results concerning wind-up and the behavioral indices suggestive of hyperalgesia in animals (31). One major difference is that, in contrast to hyperalgesia, which may last for minutes, hours, or days, wind-up subsides within several seconds. The present results confirm that hyperalgesia induced by wind-up does not outlast the period of high-frequency stimulation. In addition, it is likely that much more complex alterations are also induced by the temporal summation of nociceptive inputs, because this can also activate descending inhibitory controls that counteract the facilitatory processes in the spinal cord (26,27). Finally, it has been reported that wind-up does not induce all the characteristics of central sensitization of dorsal horn neurons (32). Although wind-up alone cannot trigger complete, long-lasting central sensitization, these phenomena have some common characteristics, such as the ability to induce hyperalgesia or to be reduced by NMDA antagonists. This reinforces the interest in wind-up as a useful model for physiological of pharmacological studies.

In keeping with previous psychophysical studies, we observed that the temporal summation of the nociceptive reflex was associated with a parallel increase in sensations of pain. Unfortunately, because of the relatively high frequency of stimulation, it was not possible to rate the sensations evoked by each stimulus in the series and, thus, to correlate precisely the increase in reflexes and sensations. Most of the subjects reported a progressive increase in the spread and duration of the painful sensations during the stimulation sequence, which also hampered analysis of the sensations elicited by each stimulus. A similar effect of temporal summation on pain has been observed with nociceptive thermal, mechanical, and electrical stimuli (13,14). It parallels the wind-up phenomenon observed in animals because it is frequency-dependent and is selectively reduced by NMDA receptor antagonists such as ketamine or dextromethorphan (15–17). Thus, it is likely that central mechanisms similar to those proposed in animals also exist in humans. Although central sensitization has not been directly demonstrated in humans, several lines of evidence suggest that the secondary hyperalgesia induced by experimental burn injury or the local application of chemical irritants, as well as brush-induced allodynia in patients with nerve injuries (33,34), are dependent on central mechanisms. In addition, ketamine can reduce the secondary hyperalgesia induced experimentally (35). Finally, several studies suggest that NMDA receptor antagonists are clinically effective and exert effects predominantly on evoked pains (i.e., allodynia and hyperalgesia) associated with nerve or tissue injuries (18–21). Unfortunately, the use of these drugs is hampered by their psychotomimetic side effects.

These clinical results encourage a search for new molecules with more favorable tolerance profiles. The present data suggest that the R_III reflex might be a useful tool for pharmacological studies, particularly for objectively evaluating the effects of such molecules in humans. Such a methodology could also be used to analyze the effects of temporal summation and the alterations in the spinal processing of pain under various pathological conditions.

	Acknowledgments

 
This work was supported by L’Institut National de la Santé et de la Recherche Médicale (clinical research network).

We thank Dr. S. W. Cadden for advice in the preparation and correction of the manuscript.

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