Pain 114 (2005) 118–130 www.elsevier.

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Sensory and motor effects of experimental muscle pain in patients with lateral epicondylalgia and controls with delayed onset muscle soreness
Helen Slatera,b, Lars Arendt-Nielsena, Anthony Wrightb, Thomas Graven-Nielsena,*
a

Laboratory for Experimental Pain Research, Center for Sensory-Motor Interaction, Aalborg University, Fredrik Bajers Vej 7D, 9220 Aalborg E, Denmark b School of Physiotherapy, Curtin University of Technology, Perth, WA, Australia Received 1 July 2004; received in revised form 22 November 2004; accepted 2 December 2004

Abstract This study compares the effect of experimental muscle pain on deep tissue sensitivity and force attenuation in the wrist extensors of patients with lateral epicondylalgia (nZ20), and healthy controls (nZ20) with experimentally induced sensori-motor characteristics simulating lateral epicondylalgia. Delayed onset muscle soreness (DOMS) in wrist extensors of healthy controls was induced by eccentric exercise in one arm 24 h prior to injection (Day 0). Saline-induced pain intensity (visual analogue scale, VAS), distribution, and quality were assessed quantitatively in both arms for both groups. Pressure pain thresholds (PPT) were assessed at three different sites in the wrist extensors. Maximal grip force and wrist extension force were recorded. In response to saline-induced pain in the extensor carpi radialis brevis, regardless of arm, the patient group demonstrated a significantly quicker pain onset (P!0.01), mapped larger pain areas and more referred pain areas, compared to healthy controls (P!0.03). Pain persisted significantly longer in the sore arm of the patient group, compared with all other arms (P!0.02). Patients demonstrated significant bilateral hyperalgesia at extensor carpi radialis brevis during and post salineinduced pain compared to pre-injection and healthy controls (P!0.04). The sore arm in patients and the DOMS arms in healthy subjects showed significantly reduced maximal force (P!0.0001), at all Day 1 times compared with the control arms. In patients, the bilateral increase in deep tissue sensitivity and enlarged referred pain areas during saline-induced pain might suggest involvement of central sensitisation. q 2004 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
Keywords: Experimental muscle pain; Hyperalgesia; Referred pain; Peripheral sensitisation; Central sensitisation; Lateral epicondylalgia; Delayed onset muscle soreness (DOMS)

1. Introduction Lateral epicondylalgia patients present with pain and mechanical hyperalgesia at the common extensor origin, pain radiating into the dorsal forearm and hand and force attenuation of the wrist extensors (Haker, 1993; Pienimaki et al., 2002a,b; Stratford et al., 1993; Vicenzino et al., 1996, 1998). While the aetiology of lateral epicondylalgia remains unclear, evidence of a tissue-based pathology includes degenerative changes at the common extensor origin consistent with tendinopathy (Khan et al., 1999); altered recruitment and timing patterns contributing to repetitive microtrauma of the extensor carpi radialis brevis (Bauer and
* Corresponding author. Tel.: C45 96 35 9832; fax: C45 98 15 4008. E-mail address: tgn@smi.auc.dk (T. Graven-Nielsen).

Murray, 1999; Riek et al., 1999); intrinsic muscle pathology (Lieber et al., 1997; Ljung et al., 1999a,b) and increased substance P immunoreactivity (Ljung et al., 2004; Uchio et al., 2002). Tissue-based pathology alone does not appear sufficient to explain the chronic nature of lateral epicondylalgia, or reports of referred pain (Leffler et al., 2000) and evidence of hyperalgesia (Vicenzino et al., 1998; Wright et al., 1992, 1994). In response to initial tissue injury, the process of sensitisation of peripheral nociceptive apparatus results in a lowering of the normally high mechanical threshold for nociceptors (Graven-Nielsen and Mense, 2001). In patients with lateral epicondylalgia, the clinical correlate of this peripheral sensitisation could be seen as local pain and deep tissue tenderness associated with repeated load and movement of damaged tissues. Additionally, sensitised

0304-3959/$20.00 q 2004 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.pain.2004.12.003

the effect of combined DOMS and saline-induced pain on deep tissue sensitivity was assessed. Stratford et al. other upper limb musculoskeletal disorders or neurological disorders. and compared with matched controls. Baseline VAS was described as the worst level of lateral elbow pain experienced in the 24 h preceding injection at Day 1.2. antidepressants) were excluded from the study. range 32–63 years).1 months 3. All subjects were requested to refrain from using analgesic or non-steroidal medications during the testing period. 1993. Widespread pain. gender and affected arm (either dominant or non-dominant) with patients. 1988) as a precaution against excessive intercarpal motion during the experimental exercise procedure. and no abnormal tenderness to palpation of the soft tissues in the extensor muscles of the forearm and wrist (Haker. or prior wrist extensor training. and controls demonstrate similar sensory manifestations and motor effects in response to saline-induced muscle pain as seen in patients with lateral epicondylalgia. deep tissue sensitivity and force attenuation than in the asymptomatic arm. frequency. analgesics. (2) In healthy subjects with DOMS. A bilateral upper limb physical examination. was performed. fractures or neurological disorders. Patients and healthy controls taking regular anticoagulant medication or medications known to influence pain sensitivity (e. However. subjects in both groups were asked to rate the worst level of lateral elbow pain experienced in the preceding 24 h using a 10 cm visual analogue scale (VAS) where 0 cm indicated ‘no pain’ and 10 cm ‘most pain . The specific hypotheses to be tested in this study are: (1) Saline-induced pain in the sore arm of patients with lateral epicondylalgia results in a more substantial increase in pain areas.g. 2. referred pain and changes in somatosensory sensitivity raise the index of suspicion that patients with lateral epicondylalgia may demonstrate alterations in the way in which the nervous system processes nociceptive and non-nociceptive information. or reduced muscle length. For the healthy controls. 1993). 1983).25 years.1. Materials and methods 2. At Day 1 prior to injection. 2. The aim of the current study was therefore to compare the sensory manifestations and motor effects during experimental muscle pain in patients with chronic lateral epicondylalgia and in healthy controls with acute experimentally induced pain simulating lateral epicondylalgia. and for both arms. Clinical tests of wrist stability were performed (Taleisnik. whiplash and osteoarthritis and might reflect central sensitisation (Arendt-Nielsen and Graven-Nielsen. Slater et al. Exclusion criteria included involvement of the contralateral arm. visual analogue scale. non-steroidals. Expansion of experimentally induced referred pain has been demonstrated in various musculoskeletal conditions such as fibromyalgia. that is. 1993. with the set of pre-exercise and post-exercise measures recorded for both the DOMS and control arms. The patient population was drawn from volunteers who responded to a newspaper article and radio interview discussing ‘tennis elbow’. 2003). range 34–65 years) and the healthy controls (mean age 47.45 years.. saline-induced muscle pain is associated with a more substantial increase in deep tissue sensitivity and force attenuation than in the control arm.2G0. nZ20) on entry into study Duration of current episode Baseline VAS Right arm dominant Right arm affected Recurrence Mechanism(s) of injury Insidious Tennis (increase volume. each of twenty subjects.4 cm nZ17 nZ17 nZ8 nZ4 nZ7 nZ4 nZ5 VAS. Subjects participated in three sessions (Day 0. Symptoms had to have persisted for at least 3 months and be unilateral. Study design For each group (patient and control). 1. pain associated with functional activities such as gripping and pain with resisted contraction of the wrist extensors or extensor carpi radialis brevis. pain on palpation over the lateral epicondyle and the associated common extensor myotendinous unit. Written informed consent was obtained prior to inclusion in the study. painting) 6. the role of central sensitisation in chronic lateral epicondylalgia has yet to be investigated. / Pain 114 (2005) 118–130 119 nociceptors also demonstrate an increased responsiveness to noxious stimuli that may be expressed clinically as a mechanical hyperalgesia at the attachment of the common extensor tendon to the lateral epicondyle. was performed at Day 0. a set of quantitative tests (pressure pain thresholds. 2003).5G1. Travell and Simons. There were 23–25 h between Day 0 and Day 1 sessions. with the same requirements as described for the unaffected arm in the patient group. participated in the study.. muscle soreness. changes in racquet) Trauma Overuse (keying. A profile of the clinical characteristics of the patient group is shown in Table 1. exercise to induce DOMS in the arm ‘matched’ to the patient’s sore arm. Subjects were then selected by satisfying the inclusion criteria for a clinical diagnosis of chronic lateral epicondylalgia. cervicothoracic spinal pathology. This combined experimental model has previously been shown to be an effective vehicle for simulating characteristics of lateral epicondylalgia (Slater et al. or with passive stretching of the wrist extensors (Haker. Day 1 and Day 7).H. Table 1 Clinical characteristics of patients (GSE. Subjects Two groups. The study was performed in accordance with the National Health and Medical Research Council guidelines and with the Helsinki Declaration. There were 10 males and 10 females in both the patient group (mean age 48. A comprehensive musculoskeletal physical examination was performed on both upper limbs to ensure that the unaffected arm had full pain free range of elbow and wrist motion. as indicated in Fig. In the healthy controls. maximal grip force and maximal wrist extension force) was performed and repeated at each time period. Subjects in the healthy controls were matched for age. Exclusion criteria for subjects in the healthy controls included a history of upper limb pain. The Human Research Ethics Committee at Curtin University of Technology had approved the study.

subjects described the pain using the McGill Pain Questionnaire (MPQ) (Melzack. For each subject. The sequence of testing of arms was randomised. This allowed the maximal wrist extensor effort produced by each subject in . The arm was divided into five areas for classifying local and referred pain areas (Fig. 20 mm).8%) saline was injected over 40 s.3. The order of testing of arms was randomised. The site of injection for extensor carpi radialis brevis belly was identified using a technique described by Riek et al.4. The ultrasound imaging was performed with a 5–12 MHz linear probe using an ATL HDI 5000 (Bothell. 1975). extension set with polyethylene inner line) was connected from the syringe to the disposable needle (27G. A battery of quantitative tests was performed in both the ‘matched’ and control arm at pre-exercise and post-exercise.120 H. (2000). (E) distal to the proximal wrist carpus. A tube (IVAC G30303. Canada). TN). To avoid any direct contact with the posterior interroseus nerve. Ultrasound imaging was used in five subjects to confirm that this injection protocol for needle localisation was reliable and valid. maximal VAS (Painmax).0 ml of sterile hypertonic (5. quantitative measures were repeated. After the injection. time of pain onset and duration of pain were determined from the VAS recordings. This level of pain was defined as baseline VAS. In order to generate delayed onset muscle soreness. the protocol was repeated in the contralateral arm. (B) elbow joint to upper third of forearm including the injection site. quantitative measures were repeated in both arms for all subjects. The needle was removed at the completion of the injection. the Day 1 protocol was identical. with saline-induced pain provoked in the extensor carpi radialis brevis muscle of the DOMS and sore arms. Taiwan) and the area calculated in arbitrary units (Sigma-Scan. during the saline-induced pain period and 20 min post-pain. 1997). Wash. The Day 7 session involved a repeat of quantitative measures for both arms (in randomised order) in both groups. with a 10 ml plastic syringe (Graven-Nielsen et al. (2000). For both patients and controls. At pre-injection. Delayed onset muscle soreness DOMS was induced with repeated eccentric wrist extension contractions in the nominated ‘matched’ arm. The experimental protocol for healthy controls and patients is shown. To act as a control. The pain distribution experienced by each subject was mapped on a body chart. Areas were defined as: (A) proximal to the elbow joint. The needle tip was then identified with ultrasound imaging and in all cases was shown to be correctly located into the muscle belly of extensor carpi radialis brevis. Day 1 involved the identical protocol for both groups with injection of hypertonic saline into the extensor carpi radialis brevis muscle of first one arm (either the control or sore/exercised arm). Hixson. 2. Saline-induced pain intensity was scored continuously on a 10 cm electronic VAS where 0 cm indicated ‘no pain’ and 10 cm ‘most pain imaginable’. A bolus injection of 1. model 770. Referred pain was defined as pain outside the injection area.. Quantitative measures were recorded for the tested arm at pre-injection. The exercise protocol was performed using the isokinetic mode of the KinCom dynamometer (Chattecx Corp. 2. the nerve was manually identified prior to injection. the extensor carpi radialis brevis of the contralateral arm in both groups was also injected with hypertonic saline (using the same injection paradigm). The pain circumference was later digitised (ACECAD D9000 Digitiser. the time between consecutive injections into the affected (sore or DOMS arm) and control arm was approximately 60 min. and the same Day 1 measures repeated in this arm. Saline-induced deep pain Hypertonic saline was infused using a computer-controlled pump (IVAC. (D) lower third of forearm. healthy controls were required to undertake the eccentric wrist extensor exercise protocol in the ‘matched’ arm 24 h prior to injection (Day 0). At Day 7. One investigator (HS) inserted a disposable needle vertically through the skin surface approximately 10 mm into the extensor carpi radialis brevis muscle belly according to the procedure described by Riek et al. The area under the VAS-time curve (Painauc). The VAS rating was sampled every 5 s by a computer. Pain areas were also classified from the body charts as local and/or referred. / Pain 114 (2005) 118–130 Fig. USA). Following a 30 min post-pain period. 1. including the hand. (C) mid third of the forearm. Words from the MPQ chosen by at least 30% of the subjects were used in data analysis. Jandel Scientific. during injection and post-injection. 2). Slater et al. USA). imaginable’.

The subject’s upper limb was positioned in pronation and elbow extension. Leeds. (B) elbow joint to upper third of forearm including the injection site. the healthy controls to be ‘matched’ by the dynamometer during the eccentric phase.6. The pressure was increased at a rate of 30 kPa/s until the subject detected the pain threshold.. The wrist position was preset at 258 wrist extension and not less than 508 wrist flexion. A minimum force of 20 N was necessary in order to trigger an eccentric contraction. Slater et al. (D) lower third of forearm. range 0–500 N. This forearm rest could be adjusted in height and length to allow appropriate alignment of the wrist joint with the KinCom axis of rotation. and were found as the mean of 3 trials. and the radial head laterally. Each subject’s maximal eccentric effort was marked on the screen initially and subjects asked to try and maintain this level of force for as long as possible. Areas were defined as: (A) proximal to the elbow joint. PPT was calculated as the mean of 3 trials with a 30 s interval between repetitions. A hand attachment was designed to provide fixation of the wrist joint close to the axis of movement of the KinCom. 2. with 1 defining a light soreness and 6 indicating severe muscle soreness (Slater et al. and the DOMS arm in the healthy controls (3) and their control arm (4). including the hand. with each bout separated by a minute rest interval (Slater et al. This allowed an extensive through-range eccentric exercise without the associated risk of end range joint or soft tissue injury. 2. The wrist was positioned in pronation and wrist extension (208) with the 3rd knuckle abutting the centre of the hand attachment. To allow familiarisation. The duration of each cycle of eccentric contraction/ passive recovery was set at 4 s contraction with a second of passive recovery.0 cm2. (E) distal to the proximal wrist carpus.H. 1989) specifically modified for the upper limb. The arm was divided into five areas for assessing local and referred pain (5). the belly of the extensor carpi radialis brevis muscle. A visual display of successive efforts was also provided on the computer screen and subjects were encouraged to use this as feedback to assist them in maintaining the desired eccentric effort throughout the exercise period. 2003). Subject’s maximal eccentric effort was determined as the force at which the subject could no longer prevent movement initiation of wrist extension. Subjects were positioned in sitting with the pronated forearm stabilised on a padded forearm rest attached to a seat. Soreness was also assessed in patients although they did not undertake the exercise protocol. subjects were required to complete a warm-up on the KinCom. Peak values determined the maximal grip force. Subjects completed a Likert scale of muscle soreness (High et al. Wrist extension force was recorded via a force gauge (AFG. Subsequent marks were made on the screen at each successive bout to match the best eccentric effort if the effort had dropped considerably. The exercise protocol was designed to passively extend the wrist at a speed of 1008/s and to cause flexion of the wrist at a speed of 258/s when the subject exerted a wrist extensor torque (eccentric wrist extension). Assessment of deep tissue sensitivity Pressure pain thresholds (PPT) were recorded using an electronic algometer (Somedic AB. The total exercise period was 25 min. (C) mid third of the forearm. / Pain 114 (2005) 118–130 121 Fig. Subjects were instructed to maximally resist the dynamometer’s movement from wrist extension to wrist flexion.... The transducer was mounted on a flat platform and placed on a table to the side of the plinth. England).5. UK). Sweden) with a stimulation area of 1.. 2003). Three sites were assessed: the common extensor origin at the lateral epicondyle. 2. Assessment of grip force and wrist extension force Grip force was assessed using an electronic digital dynanometer (MIE Medical Research Ltd. Mecmesin Ltd. The magnitude of the maximal eccentric effort was marked on the computer screen. A specifically designed padded hand attachment was connected to the underside of the force gauge. with 5 bouts each of 5 min duration (60 repetitions per bout). The height of the hand attachment and force transducer was adjustable to allow for variations in hand sizes. Mean (nZ20) VAS profiles and the associated areas of pain for injections of hypertonic saline into extensor carpi radialis brevis muscle of the sore arm (1) in the patient group and their control arm (2). prior to the eccentric exercise protocol. Subjects were instructed to maximally extend the wrist by pushing the dorsal surface of the hand onto the padded .

F2.001).001) and compared with both arms for healthy subjects (SNK: P!0. The patient group displayed a quicker pain onset than healthy controls. maximal.003).001. F2.01). 3. ECRB.** 206 (18)*. was used for analysis of VAS data. When significant this was followed by parametric Student–Newman–Keuls (SNK) post-hoc tests. P!0. with factors group (between-group: ‘patient’ and ‘healthy controls’) and arm (repeated: ‘sore/DOMS’ and ‘control’). maximal grip force and maximal wrist extension force.0 (0.2. Additionally. AU. The control arm in the patient group was also weaker than the control arm in healthy subjects (SNK: PZ0. 2.38Z7. The symptomatic arm in the patient group demonstrated more muscle soreness compared with all other arms (F1. grip force (N) Max. .1.2. maximal grip force and maximal wrist extension force of pre-injection (Day 1) measures in the patient group compared with pre-exercise (Day 0) measures in normal controls Variables Patient group Sore arm PPT-CEO (kPa) PPT-ECRB (kPa) PPT-RH (kPa) Muscle soreness (AU) Max.4. 3. compared with pre-exercise and post-exercise (SNK: P!0.7. Spearman’s correlation coefficient (R) was used to describe correlations between parameters.38Z16.38Z6.02). wrist extension force (N) 257 (34)*.2.6.1. Deep tissue sensitivity The patient group demonstrated a significant hyperalgesia to pressure at common extensor origin in both sore and control arms compared with healthy controls (Table 2. Max.2.005).001). 3. 2-way and 3-way repeated measures mixed model ANOVA were used. regardless of arm (F1. F1. P!0. P!0. extensor carpi radialis brevis. muscle soreness.3. For analysis of PPT.4.38Z4. Saline-induced deep pain Injection of hypertonic saline into the extensor carpi radialis brevis muscle on Day 1 induced different pain profiles in the two groups (Table 4.** 56 (8)*. with repeated measures (factors ‘time’ and ‘arm’) and a between-group factor (‘patient’ and ‘healthy controls’). tables and figures. Baseline assessments 3. and were found as the mean of 3 trials. Fig. RH.0 (0. Results 3.1. the DOMS arm was weaker in both force measures compared with the control arm at post-exercise and pre-injection (SNK: P!0. *P! 0.** 228 (37) 284 (32) 2.002).3.122 H.38Z6.4. Maximal grip force and maximal wrist extension force As shown in Table 2.001).001).1. P!0.3. pressure pain threshold.1 (0.0) 317 (19) 117 (4) Control arm 464 (48) 306 (46) 332 (29) 0. Statistical analysis Mean and standard error (SE) values are given in the text. nZ20) for pressure pain thresholds. Table 2). Slater et al. Muscle pain and soreness 3.38Z15. / Pain 114 (2005) 118–130 surface of the hand attachment.05 (SNK) compared with healthy controls comparable arm. Peak values determined the maximal extension force.1.38Z16. For both groups.7.38Z49. Effects of exercise on deep tissue sensitivity There was a bilateral decrease in PPT at the common extensor origin at pre-injection (Table 3. there were group differences for maximal grip force (F1. P!0.0) 311 (22) 114 (7) PPT. Patients had significantly weaker maximal grip force and wrist extension Table 2 Mean values (SE. Muscle soreness was different between arms (Table 3. P!0. common extensor origin.** Control arm 357 (45)* 239 (30) 291 (39) 0.001) and maximal wrist extension force (F1.001) and compared with the control arm (SNK: P!0. CEO. Subjects were requested to perform maximal contractions for each motor task.001). The height of the device was noted for each subject to ensure reliable measures. pre-exercise (SNK: P!0.1.2.001). Maximal force for grip and wrist extension was significantly decreased in the exercised arm at pre-injection compared with pre-exercise and post-exercise (SNK: P!0. 2).3. Eccentric exercise did not significantly alter pre-injection PPT at the extensor carpi radialis brevis.02). P!0. **P!0.05.2.1) 303 (23) 87 (9)* Healthy controls Pre-DOMS arm 384 (38)** 257 (28) 331 (33) 0. A 2-way mixed model analysis of variance (ANOVA). the PPT at the common extensor origin in the sore arm and arms allocated for DOMS was lower than for the control arms (F1. 3.38Z40. radial head. A majority of measurements associated with PPTs and VAS data met the requirements of a normal distribution as determined by the Shapiro–Wilk normality test. P!0.003). force in their sore arm compared with their contralateral arm (SNK: P!0. F2.05 (SNK) compared with the contralateral control arm. Effects of eccentric exercise in the healthy controls 3. with substantially longer pain duration 3.38Z9. Significance was accepted at P!0. arbitrary units.0 (0. with the exercised arm demonstrating an increase in soreness at pre-injection (Day 1) compared with post-exercise.1. Effect of exercise on maximal grip force and maximal wrist extension force Maximal grip force and maximal wrist extension force differed between the exercised and control arms (Table 3. Saline-induced pain duration varied between groups (ANOVA: F1.6. P!0.04).3)*. P!0.

114Z3. RH.8 (0.6) 5.05 (SNK) compared with post-exercise and pre-exercise.9 (0.93 (0. #P!0.30 (0. The saline-induced pain descriptors most commonly used were ‘intense’ and ‘aching’ (Table 4). **P!0. maximal grip force and maximal wrist extension force in normal controls Day 0.78 (0.19) 40 35 30 30 Control arm 2612. radial head.4.0 (53. The magnitude of this hyperalgesic effect was greater in the patient group than in healthy controls.05 (0.7) 0. P!0.67 (1. 3.05) 276 (19)*. the decrease in PPT at post-pain was greater in the sore arm and DOMS arms than in the control arms (SNK: P!0. while ‘sharp’ and ‘throbbing’ were chosen by patients and by healthy controls but only for the DOMS arm.00) 1.00 (0.16 (0. and in the sore arms compared with the control arms. During saline-induced pain in the sore and DOMS arms. the PPT at the extensor carpi radialis brevis in the patient group was hyperalgesic to pressure during saline-induced pain and post-pain (SNK: P!0.44) 35 30 35 30 Healthy controls DOMS arm 2663.20) 0. and arm and time (F3.21)* Area C 2.38)*.7) 0.9)* 0. / Pain 114 (2005) 118–130 Table 3 Effects of exercise on mean (SE.10) 1.00) 240 (17)** 304 (22) 77 (7)** 107 (7) 325 (31)* 359 (39)* 234 (33) 261 (38) 331 (36) 298 (26) 3.38Z 5.4 (578.00) Control arm 0.5 (0.11 (0. F1. Additionally.** 101 (7)# emanating from the injection site and more referred areas of pain in the distal forearm compared with healthy controls (Table 4.02.4) 606.24) 0. for the sore and DOMS arms. Referred pain was defined as pain outside the injection area.6 (317.17) Area B 1. P!0. arbitrary units *P!0. AU.5 (0.43 (0. Slater et al.** 302 (20) 81 (5)*. Regardless of arm.27) 0. Fig.H.32 (0.8)*# Total pain area (AU) 5. C. Additionally.** 0. 3). SNK: P!0. pre-injection 123 384 (38) 464 (48) 257 (28) 306 (46) 331 (33) 332 (29) 392(38) 409 (38) 257 (29) 259 (41) 332 (35) 319 (29) 1.17)* 1.02).67 (0.15) 0.05 (SNK) compared with control arm. CEO.3 (67. nZ20) pressure pain thresholds. The effect of saline-induced pain on deep tissue sensitivity The extensor carpi radialis brevis in the sore arm and DOMS arms demonstrated a pronounced mechanical hyperalgesia post-pain in both groups.114Z3. 2).4) 14.2.6) 21.23) 1.03).18) Area E 0.5) 22. elbow joint to upper third of forearm including the injection site. experienced by patients in their sore arm. The statistical bases for these findings are interactions between group and time for PPT at extensor carpi radialis brevis (F3.14 (0.4 (0.47 (0.4) 3.21 (0.00 (0.3 (2.3) Painonset (s) 17. common extensor origin. E.47 (0.3.0 (1.35)** 0. PZ0. Patients selected the word ‘radiating’ as a pain descriptor. . mid third of the forearm.24) 40 30 *P!0. ECRB.01).35 (0. pressure pain threshold.6) 3. All subjects reported a localised pain response around the ECRB muscle belly (Fig. B.3 (0.79 (0. #P!0.05 (SNK) compared with pre-exercise only. saline-induced referred pain was described at the common extensor origin (nZ4 per group). muscle soreness.78 (0.00 (0.64 (0. the patient group mapped significantly larger areas of saline-induced pain (Table 4.7) Painauc (cm s) Painmax (cm) 7. and compared with pre-injection values.55 (0. distal to the proximal wrist carpus.004).05 (SNK) compared with contralateral control arm.7 (258.33)* 0.05 (SNK) compared with healthy controls. proximal to the elbow joint.9)* 669. extensor carpi radialis brevis. Muscle soreness (AU) DOMS arm 0.5) 6. pre-exercise Deep tissue soreness PPT-CEO (kPa) DOMS arm Control arm PPT-ECRB (kPa) DOMS arm Control arm PPT-RH (kPa) DOMS arm Control arm Day 0.29) 0.6)* Pain area (AU) Area A 0.6 (0. including the hand.19) 0.24 (0. Compared to healthy controls.20 (0.31)* Area D 0.02).3.20) Pain descriptors (% of subjects) Intense 50 Aching 50 Radiating 35 Sharp 40 Throbbing 35 Control arm 2829.3 (1.20 (0.8 (65. D.05). lower third of forearm.001). nZ20) VAS parameters and pain areas after hypertonic saline injection into the extensor carpi radialis brevis muscle of patients and normal controls VAS data Patient group Sore arm 3251.21) 0.3. post-exercise Day 1.7)* Painduration (s) 889.4) 585. Pain areas were classified into five categories: A.00 (0.8 (1.3 (56. In the sore and DOMS arms. Patients experienced more widespread pain Table 4 Mean (SE.8 (0. and during salineinduced pain only in patients.00) Maximal grip force (N) DOMS arm 317 (19) Control arm 311 (22) Maximal wrist extension force (N) DOMS arm 117 (4) Control arm 114 (7) PPT. this hyperalgesia persisted at post-pain compared with pre-injection and Day 7 (SNK: P!0.9) 7.4) 6. compared with the contralateral control arm and compared with both arms of the healthy subjects (SNK: P!0.6 (302.

During salineinduced pain. Pressure pain thresholds were assessed at extensor carpi radialis brevis (ECRB). P!0. although this hypoalgesia was evident at the common extensor origin in the sore arm of the patient group. injection and postinjection) and Day 7. P!0. compared with pre-injection there was a hypoalgesic response at common extensor origin during saline-induced pain. At Day 1. the sore and DOMS arms demonstrated a lower PPT than the control arms (F1.6.05). .014. Fig. P!0. but demonstrated a generalised hypoalgesia for all arms during pain and Day 7. The PPT at ECRB in patients demonstrated a significant decrease in both arms during saline-induced pain and post-pain compared with pre-injection and healthy controls (*SNK.39. Collectively.124 H.005. injection of hypertonic saline into the extensor carpi radialis brevis muscle was done in both the sore and control arms for both groups. nZ20) pressure pain thresholds for the sore and DOMS arms and the control arm for both groups Day 1 (pre-injection.02).001).3. Overall.38Z4. 3. P!0. Mean (CSE. Slater et al. higher clinical pain intensities and longer pain duration were associated with a greater decrease in PPT at extensor carpi radialis brevis (RO0. The PPT at radial head was not significantly changed in response to any factor. The PPT at CEO in the patient’s sore arm was hyperalgesic pre-injection compared with all other arms (***SNK.04). / Pain 114 (2005) 118–130 Fig.05). The PPT at ECRB in the sore and DOMS arm was significantly lower compared with pre-injection and compared with the control arms (# SNK. P!0. SNK: P!0. 3). Patients and healthy subjects demonstrated differences in pressure pain sensitivity at the common extensor origin in response to saline-induced pain (F1. which was still evident at Day 7 (F3.114Z3. compared with pre-injection values (** SNK. P!0.05). P!0.03). common extensor origin (CEO) and radial head (RH). P!0.38Z12. the PPT remained significantly lower than all other arms (SNK: P!0.05).

Saline-induced pain.. At Day 1. P!0. healthy subjects demonstrated reduced maximal wrist extension in their DOMS arms compared with their control arm at all Day 1 times. a greater number of referred pain areas and pressure hyperalgesia at the muscular part (extensor carpi radialis brevis) of the common extensor myotendinous unit. P!0. 5. Maximal wrist extension force was different between group and arms at Day 1 and Day 7 (Fig.05). The sore and DOMS arms for both groups were weaker than the control arms at all times (F 3. Compared with day 7. This finding may suggest a pre-existing .03. nZ20) muscle soreness for the sore and DOMS arms and the control arm for both groups Day 1 (24 h after eccentric exercise: preinjection.1. Wright et al. Regardless of time. is shown.0. Muscle soreness and VAS area were positively correlated in the sore and DOMS arms (RZ0.114Z10. SNK: P!0. injection and post injection) and Day 7. but not at Day 7 (SNK: P!0.. 4. In response to saline-induced pain. the duration of clinical pain (in weeks of lateral epicondylalgia or DOMS) and baseline VAS were correlated with saline-induced VAS Painauc area. but was also evident in the contralateral (aymptomatic) arm. SNK: P!0. Mean (CSE. / Pain 114 (2005) 118–130 125 Fig. Correlation between clinical parameters and experimental data In the sore and DOMS arms. 3. hypertonic saline was injected into the extensor carpi radialis brevis muscle in both the sore and DOMS arms and control arms for both groups.7.005).04).007). 1993. A significant increase in muscle soreness compared with pre-injection (*SNK. the patient group demonstrated more reduced maximal wrist extension force in their sore arm compared with their control arm and compared with both the DOMS and control arms of the healthy subjects (SNK: P!0. 4. 1992. Similar to the patients’ sore arms.001). except in the patient’s sore arm. consistent with previous experimental findings in patients with lateral epicondylalgia (Haker. At all Day 1 times.001). F3.05). 3.005). maximal grip force and maximal wrist extension force Changes in maximal grip force in response to salineinduced pain differed between arms for patients and healthy controls (F1. maximal grip force was significantly lower at pre-injection.114Z3. Slater et al.001). P!0.5. muscle soreness was influenced according to group and arm (F3.4.001). The patient group experienced an increase in muscle soreness in the sore arm during saline-induced pain and post-pain compared with pre-injection (SNK: P!0. pain duration and mapped pain area (Table 5).0. 5.1. during saline-induced pain and post-pain (SNK: P!0. SNK: P! 0. Muscle soreness had decreased significantly at Day 7 compared with pre-injection for all arms. 1994).03) in the sore arm and DOMS arms only. 4. The decrease in PPT at extensor carpi radialis brevis during and post saline-induced pain was also correlated with clinical pain duration but only in the sore and DOMS arms.H. the levels of muscle soreness were greater in the sore and DOMS arms than for control arms (Fig. P! 0. The evidence of this was more rapid pain onset.114Z6.001). Vicenzino et al. P!0. Compared with pre-injection. P!0. 4. 2001. during saline-induced pain muscle soreness increased in the control arms of both patients and healthy subjects (SNK: P!0.001).05) and compared with the control arms (# SNK.38Z8. more widespread pain. P! 0. The patient’s sore arm demonstrated significantly weaker grip force than all other arms (Fig.31. Group differences A pressure hyperalgesia at the attachment of the common extensor origin to the lateral epicondyle was most pronounced in the sore arm of the patient group. longer pain duration. Discussion In the current study patients with lateral epicondylalgia demonstrated bilateral hyperalgesia to saline-induced muscle pain as compared to matched healthy controls.

. While not excluding central sensitisation. Similar findings have been previously . except an unexpected decrease in PPT at the common extensor origin in the ‘matched’ arm (17 from 20 of which were right dominant) at pre-exercise.05). Greenspan and McGillis. 2004. Changes in pressure pain sensitivity in the arms of the healthy controls were specific for site with a pressure hyperalgesia at the common extensor origin. Pauli et al. nZ20) maximal grip and maximal wrist extension force for the sore arm and exercised arm and the control arm for both groups Day 1 (pre-injection. A significant decrease in force compared with compared to all other arms (*SNK. 1992. this finding may suggest a degree of peripheral sensitisation secondary to repeated PPT measurement. Delayed onset muscle soreness in the healthy controls Muscle soreness was maximal in the DOMS arms 24 h post-exercise. 2003). and compared with Day 7 (# SNK. although this effect was not seen at the other PPT sites.. with the greatest deficit in the affected arm. Jensen et al. Wright et al. compared with control arms (**SNK.. P!0.126 H. / Pain 114 (2005) 118–130 Fig.. Slater et al. It is plausible that the decreased PPT at the common extensor origin in the ‘matched’ healthy controls may relate to a higher frequency of daily loading of the right common extensor tendon–bone junction associated with right hand dominance. P!0.2.05). No subjects reported muscle pain at rest. injection and post-injection) and Day 7. Maximal wrist extension force was bilaterally attenuated in the patient group.. (subliminal) degree of pressure hypersensitivity in the patient group. Maquet et al. Both force parameters were most substantially reduced in the patient’s sore arm. 1995) and increased pain thresholds on the right side compared to left (Brennum et al. At Day 1.. in press. Bilateral compromise of motor performance in patients with chronic unilateral lateral epicondylalgia has been reported previously (Pienimaki et al. Data on handedness and its effect on pressure pain sensitivity in healthy subjects are conflicting since no side differences (Fischer. Healthy controls demonstrated no side-toside quantitative differences in any baseline parameter. Rolke et al. 1989. however both the exercised and control arm were similarly affected.. an important feature of DOMS (Weerakkody et al. 1997). Mean (CSE.05). 1987. 4. 1994. 1999) have been reported. 5. injection of hypertonic saline into the extensor carpi radialis brevis (ECRB) muscle belly was done in both the sore and exercised arm and control arms for both groups. P!0.

connections with dorsal horn neurons (Mense. Sorensen et al. triggered pain more quickly and pain persisted for substantially longer in the sore arm compared with the control arm and compared with healthy controls.. 1992). myofascial temporomandibular pain disorders (Maixner et al. 1992. 2002). 1998. 2001a). the mechanisms possibly involving the unmasking of latent synaptic connections associated with the expansion of receptive fields and the generation of novel receptive fields in dorsal horn neurones (Hoheisel et al. Slater et al. Svensson et al.4.310 RZ0. 2001b.. 4.. DOMS.. delayed onset muscle soreness. Spearman (R) correlations shown are significant at P!0. due to the overlapping of excitatory fields. 2001. Once afferent fibres are facilitated. quiescent or latent synapses become operational.. 2003). and observed in other models of DOMS (Bajaj et al. Previously. Weerakkody et al. ECRB..404 – RZ0. Patients reported more widespread pain and more areas of pain referral compared with healthy controls. Johansen et al. duration and mapped pain areas. extensor carpi radialis brevis. Svensson et al.. 2002).. Duration of pain was defined as weeks of the current episode of lateral epicondylalgia or DOMS (1/7 week). possibly reflecting time-dependent development of central sensitisation. 1994). 1993). Cleak and Eston. 2000. 1995.341 Baseline VAS – 127 RZ0.05.. both these sites receive innervation from the radial nerve and are contained within the same myotome (Bonica. An imbalance of descending pain modulation coupled with an increase in endogenous pain facilitation. Staud et al. During saline-induced pain..318 PPT. Baseline VAS was taken as the worst pain (10 cm scale) experienced in the symptomatic and ‘matched’ arms over the 24 h prior to hypertonic saline injection at Day 1. The saline-induced hyperalgesia increased further at 20 min post-pain in both arms for the patient group and also developed in healthy subject’s DOMS arm. In this way. reported using the same experimental protocol (Slater et al. Saline-induced muscle pain and referred pain Injection of hypertonic saline into extensor carpi radialis brevis in the patient group. deep tissue hypoalgesia in extra segmental areas remote from a saline-induced pain locus has been demonstrated (Graven-Nielsen et al. Furthermore.352 RZ0. the spatial organisation of convergence means that a noxious stimulus can potentially activate a larger number of wide-dynamic-range neurons (Le Bars.505 RZ0.. pressure pain threshold.. 1999). 2001. In both groups. as suggested in other chronic pain states (Ren and Dubner. the more profound hyperalgesia seen during and after experimental muscle pain in the sore arm of the patient group may be further evidence of enhanced of neuronal excitability... the increased sensitivity in the sore arm at the common extensor origin could effectively ‘prime’ dorsal horn neurons. / Pain 114 (2005) 118–130 Table 5 Correlation coefficients for clinical data and experimental parameters in the sore arm of patients with lateral epicondylalgia and in the DOMS arm of normal controls (nZ20) Experimental parameters Clinical parameters Duration of clinical pain Decrease in PPT at ECRB during saline-induced pain Decrease in PPT at ECRB post saline-induced pain Saline-induced VAS area Saline-induced pain duration Mapped pain area RZ0. 1998. A number of interacting neurophysiologic mechanisms may explain this facilitated pain response including the awakening of previously subliminal or quiescent synaptic . could also lead to hyperalgesia.340 RZ0. thereby providing an effective mechanism for convergence of inputs and information transfer (Graven-Nielsen et al.. Furthermore.. Additionally. Combined with VAS data.485 RZ0. 2002). 1990). which then potentially receive convergent group III and IV afferents input from the extensor carpi radialis brevis. 2003). 4. clinical pain duration and baseline VAS were positively correlated with saline-induced pain area. 1999) suggesting recruitment of descending noxious inhibitory controls.. Deep tissue hyperalgesia and saline-induced muscle pain The findings of this study indicate hyperalgesia to salineinduced pain in patients with chronic lateral epicondylalgia and healthy controls with provoked DOMS. 1992). Paddon-Jones et al. 2000. 1997. a bilateral mechanical hyperalgesia at the extensor carpi radialis brevis developed within 5–10 min in the patient group and was most profound in the sore arm.. 2001) and osteoarthritis (Bajaj et al. the generalised hypoalgesia at the common extensor origin during saline-induced pain suggests facilitation of antinociceptive mechanisms. Previous experimental pain studies indicate that the nervous system is likely to be centrally sensitised in musculoskeletal conditions including whiplash (Curatolo et al. ¨ fibromyalgia (Graven-Nielsen. Hypervigilance is unlikely to be a plausible explanation for the bilateral hyperalgesia as this effect was isolated to the extensor carpi radialis brevis. The substantial attenuation in force measures in the exercised arm at pre-injection is consistent with the development of DOMS as previously demonstrated for this model (Slater et al. 1993. A similar time course of neuronal facilitation has been found experimentally in rats (Hu et al.H. 2001). 1998. 1987. While more pronounced in the sore arm these effects were also evident in the control arm suggesting a greater degree of central sensitisation in the patient group. Hoheisel et al. Expansion of receptive fields and unmasking of new receptive fields have previously been demonstrated in response to noxious muscle stimuli in animals (Cook et al.. Hu et al.. 1995. 2003).3.

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