Hassan Azhdari-Zarmehri1, Saeed Semnanian2, Yaghoub Fathollahi2, Firouz Ghaderi Pakdel3. 1. Department of Physiology, School of Medical Sciences, Tarbiat Modares University, Tehran, Iran ; Department of Basic Sciences, Torbat Heydarieh University of Medical Sciences, Torbat Heydarieh, Iran. 2. Department of Physiology, School of Medical Sciences, Tarbiat Modares University, Tehran, Iran. 3. Department of Physiology, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran.
Abstract
OBJECTIVE: It is well known that intracerebroventricular (ICV) and supraspinal injections of orexin-A elicit analgesia, but the mechanism(s) of action remains unidentified. This study aims to characterize the effect of orexin-A on rostral ventromedial medulla (RVM) neurons which are involved in the descending nociception modulating pathway. MATERIALS AND METHODS: In this experimental study, we injected orexin-A or vehicle di- rectly into rats' ICV while the tail flick (TF) latencies were measured and the on- and off-cell firing activities were monitored for more than 60 minutes. RESULTS: In response to noxious stimuli on the tail, we observed increased firing rate of on-cells and a decreased association with the firing rate of off-cells and in neutral cells the firing rate was unchanged just prior to tail flicking. ICV injection of orexin-A decreased the spontaneous firing rate of on-cells (the type of RVM neurons believed to have facilitatory action on nociception). Furthermore, orexin-A increased firing rate of off-cells (the type of RVM neurons believed to have an inhibitory action on nocicep- tion). Orexin-A reduced the TF-related responses of on-cells and TF-related pause duration of off-cells. CONCLUSION: These results have shown that the analgesic effect produced by orexin-A may be induced by brainstem neurons. It is suggested that the orexinergic system from the hypothalamus to the RVM may have a potential role in modulation of nociceptive transmission.
OBJECTIVE: It is well known that intracerebroventricular (ICV) and supraspinal injections of orexin-A elicit analgesia, but the mechanism(s) of action remains unidentified. This study aims to characterize the effect of orexin-A on rostral ventromedial medulla (RVM) neurons which are involved in the descending nociception modulating pathway. MATERIALS AND METHODS: In this experimental study, we injected orexin-A or vehicle di- rectly into rats' ICV while the tail flick (TF) latencies were measured and the on- and off-cell firing activities were monitored for more than 60 minutes. RESULTS: In response to noxious stimuli on the tail, we observed increased firing rate of on-cells and a decreased association with the firing rate of off-cells and in neutral cells the firing rate was unchanged just prior to tail flicking. ICV injection of orexin-A decreased the spontaneous firing rate of on-cells (the type of RVM neurons believed to have facilitatory action on nociception). Furthermore, orexin-A increased firing rate of off-cells (the type of RVM neurons believed to have an inhibitory action on nocicep- tion). Orexin-A reduced the TF-related responses of on-cells and TF-related pause duration of off-cells. CONCLUSION: These results have shown that the analgesic effect produced by orexin-A may be induced by brainstem neurons. It is suggested that the orexinergic system from the hypothalamus to the RVM may have a potential role in modulation of nociceptive transmission.
The neuropeptide orexin (hypocretin) has been
simultaneously discovered by two independent
research teams (1, 2). The orexin-containing
neurons are located exclusively within the lateral
hypothalamus (2, 3), where they are believed to
be involved in pain modulation through the brain
stem (4, 5). Sakurai et al. (2) have also described
two orexin receptors coupled to G proteins. These
receptor subtypes are differentially localized in
the central nervous system, particularly in nuclei
involved in pain processing (6-8). Widespread
projections of orexin have been implicated in the
regulation of various brain and body functions
such as feeding (2), sleep (9, 10), stress-induced
analgesia (11, 12), reward and addiction (13-15).
Recently, it has been proposed that systemic injection
of orexin-A is involved in pain modulation
through orexin receptor 1 (16-19). A recent study
has reported an association with orexin-A induced analgesia at the level of the supraspinal and spinal
cord (20-22). A finding that intra-periaqueductal
gray matter (PAG) microinjection of orexin-A has
an analgesic effect in hot-plate and formalin tests
in rats confirms that PAG, as a supraspinal center,
is involved in orexin-A induced analgesia through
the orexin receptor 1 (20, 22). Additionally, rostral
ventromedial medulla (RVM) is involved in
the top-down pain-modulating system through the
first synapse in dorsal horn neurons (23) and innervated
by orexinergic fibers (3). Thus, RVM may
directly and/or indirectly (projection from PAG)
be an important site of action for orexin-induced
supraspinal antinociception. As described by
Fields and Heinricher (24), RVM neural response
to noxious stimulus applied on the tail or paw can
be divided into three distinct physiological groups:
off-, on-and neutral-cell.Although the effect of orexin-A on RVM neurons
is unclear, the responses these neurons to opioid induced-
analgesia are well known (23, 25). Therefore
this study researches the effects of intracerebroventricular
(ICV) injection of orexin-A on RVM neuronal
activity in rats.
Materials and Methods
In this experimental study, all experiments were
performed in accordance with the National Institutes
of Health Guide for the Care and Use of
Laboratory Animals (NIH Publication No. 80-23,
revised 1996) and approved by the Ethics Committee
of the School of Medical Sciences, Tarbiat
Modares University (TMU), Tehran, Iran. Adult
Sprague-Dawley rats (220-300 g at the beginning
of the experiments) were purchased from Razi Institute
(Hesarak Karaj, Iran). Animals were randomly
housed in groups of three rats per cage in
a temperature-controlled room under a 12 hour
light-dark cycle with lights on from 7:00 to 19:00.
Animals had access to food and water ad libitum.
For all experiments, we complied with the regulations
of local authorities for handling laboratory
animals.
Surgical procedure
The procedure for simultaneous extracellular single
unit recording and noxious response was adopted from
previous studies (23, 26). Animals were anesthetized
with sodium pentobarbital (60 mg/kg i.p., Sigma-Aldrich,
USA) and additional doses (10-15 mg/kg/h, iv)
were administered through a catheter that was inserted
into an external jugular vein with the intent to maintain
a level of light anesthesia (27, 28). Tracheal cannulation
was performed for spontaneous ventilation
after which the animals were placed into a stereotaxic
instrument (29, 30). Using a thermistor-controlled
heating pad (Bahrami Thermostat Pad, Kerman, Iran),
body temperature was maintained at 35.5-36.8˚C. A
guide cannula for ICV injections (23-gauge) was implanted
into a region 2 mm above the right lateral ventricle
using the following stereotaxic coordinates: 0.96
mm caudal to bregma, 2 mm laterally from midline,
and 1.8 mm ventrally from the level of the bregma.
The ICV cannula was anchored on the skull with a
stainless steel screw using dental cement. A 2 mm
hole was drilled in the skull above the RVM at the following
stereotaxic coordinates (31), 10.68-11.28 mm
posterior to the bregma, in midline and the dura was
reflected to allow insertion of a recording electrode.
Following surgery, the animals were maintained in a
lightly anesthetized state using a continuous infusion
of sodium pentobarbital (10-15 mg/kg/h, iv) as previously
described (27, 28).
Tail flick testing
The tail flick (TF) latency was used as a measure
of nociceptive response. Each trial consisted
of a linear increase in temperature at 1.8˚C/s from
a holding temperature of 34˚C until the TF occurred
or to a maximum of 52˚C at less than 10
seconds. Trials were carried out at 5-minute intervals
throughout the experiment (32).
Extracellular single unit recording
Extracellular recordings from individual neurons
were obtained with glass micropipettes (2-5 MΩ impedance)
filled with 2% pontamine sky blue dye in
0.5 M sodium acetate. Micropipettes were stereotaxically
advanced into the RVM (10-10.5 mm ventral
to the skull surface). Micropipette recordings were
amplified by a microelectrode amplifier (DAM 80,
WPI), displayed continuously on a storage oscilloscope
as unfiltered and filtered (300 Hz-3 kHz bandpass)
signals, and monitored with an audio monitor
(WPI, USA). Spike waveforms were monitored and
stored on a personal computer (PC) with cool edit and
Igor pro (WaveMetrics, Lake Oswego, OR) software
for off-line analysis to ensure the unit under study was
unambiguously discriminated throughout the experiment.
The RVM neurons were classified as previously described (23, 24). Off-cells were characterized by
a pause in spontaneous activity just prior to the TF.
On-cells were characterized by a burst of spontaneous
activity before the TF. Neutral-cells were
characterized by no change in spontaneous activity
associated with TF and no response to noxious
stimulation.
Intracerebroventricular (ICV) microinjection
Rats were stabilized with light anesthesia. Next,
a 30 gauge microinjection cannula that had a tip 2
mm greater than the guide cannula was connected
to a 10 μl Hamilton syringe and inserted through
the guide cannula. We performed three nociceptive
testing trials and orexin-A (20 μM, 5 μl, Sigma,
USA) was injected over a 2-minute period.
Protocol and data analysis
We determined the effect of orexin-A microinjection
into the ICV on TF latency and on the
ongoing and reflex-related discharges of RVM
neurons. Following three baseline TF trials, either
orexin-A or savehicle were infused into the ICV.
Orexin-A was dissolved in saline and the aliquots
were stored at -20˚C until use. All ICV injections
were made in a volume of 5 μl , aliquots had saline
added to reach a volume of 5 microliters and
injected over a period of 2 minutes. TF latency and
cell activity were monitored for an additional period
of 60 minutes (32).Only one protocol was performed in each rat. In
two cases, two on-cells were recorded on a single
electrode. The average TF latencies and cell parameters
were calculated at the baseline period and compared
with 3 trials after the drug microinjection.Three parameters of cells were analyzed (32, 33)
as follows: 1. baseline spontaneous neural activity;
2. ongoing activity where we used the 30 second
period prior to each TF trial as an overall index of
ongoing firing; and 3. frequency analysis for each
neuron. For frequency analysis, we computed the
firing rate over 500 ms epochs before and after
orexin-A administration after which the percentage
of the time in the same firing rate was plotted.After a unit was isolated and its stability determined,
the pre-injection spontaneous firing rate
was calculated. Then orexin-A or saline were microinjected
into the ICV and the effect of their administration
on the unit activity of RVM neurons
was observed.
Histology
The tips of the micropipettes were marked by
iontophoretic ejection of pontamine sky blue
with negative current pulses (10 minutes) in the
RVM (21, 22). At the end of the experiments,
rats were deeply anesthetized with a urethaneoverdose (1.2 g/kg); a volume of 5 μl of pontamine
sky blue (0.2%) was also injected ICV
at 10–20 minutes before the animals were sacrificed.
Rats were then perfused intracardially
with 100 ml of 4% formalin after which the
brains were removed and sectioned. Coronal
slices of 200-300 μm thicknesses were then
cut through the brain stem from the trapezoid
body to the inferior olivary nuclei using a vibrating
microtome (Vibatome 1000 plus, US).
Locations of recording sites were identified according
to the atlas of Paxinos and Watson (31).
The RVM was comprised of the nucleus raphe
magnus and nucleus reticularis gigantocellularis
pars alpha (Gia) (Fig 1).
Fig 1
Location of recording sites in the rostral ventromedial
medulla (RVM). The plane was modified to a series of
three sections for the brain areas according to the atlas of
Paxinos and Watson (31). Representative coronal sections
show histologically verified locations of 24 on-cells (black
triangles), 18 off-cells (black square) and 10 neutral-cells
(black circle). Numbers to the right of each section indicate
the distance from the caudal to the bregma.
Location of recording sites in the rostral ventromedial
medulla (RVM). The plane was modified to a series of
three sections for the brain areas according to the atlas of
Paxinos and Watson (31). Representative coronal sections
show histologically verified locations of 24 on-cells (black
triangles), 18 off-cells (black square) and 10 neutral-cells
(black circle). Numbers to the right of each section indicate
the distance from the caudal to the bregma.
Statistical analysis
The obtained results are expressed as means
± standard error of mean (SEM). The data were
subjected to the paired t test, one-way or twoway
analysis of variance (ANOVA) which were
followed by protected Dunnett’s test for multiple
comparisons, as needed. P<0.05 was considered to
be significant.
Results
Data analysis according to two-way ANOVA
followed by protected Dunnett’s test showed that
ICV application of orexin-A (20 μM) in lightly anesthetized
rats produced an increase in TF latency
whereas infusion of saline (vehicle) into the ICV
had no effect on TF latency (Fig 2). We recorded
42 neurons from 40 animals in the orexin-A group
and 13 neurons from 13 animals in the vehicle
group. In this study, we discriminated three physiological
types of RVM neurons according to a previous
study (32). The off-cells and on-cells showed
a pause and sudden increase in activity just before
tail withdrawal reflexes, respectively . Activity of
the neutral cells remained unchanged corresponding
with the tail withdrawal reflexes (Fig 3).
Fig 2
Intracerebroventricular (ICV) microinjection of orexin-
A (20 μM) produced thermal analgesia. Orexin-A produced
a significant increase in tail flick (TF) latency when
microinjected into the right ventricle compared to vehicle
(saline, 5 μl). There was no difference among the groups
in baseline latencies. Data were successfully recorded in 40
animals in the orexin-A group and 13 out of 13 animals in
the vehicle group.
Fig 3
Single oscilloscope sweep shows activity of a representative
off, on and neutral-cells during the tail heat trial. Top trace
is cell discharge, the middle line shows heat exposure and stop,
and the lower triangles show tail withdrawal point.
Intracerebroventricular (ICV) microinjection of orexin-
A (20 μM) produced thermal analgesia. Orexin-A produced
a significant increase in tail flick (TF) latency when
microinjected into the right ventricle compared to vehicle
(saline, 5 μl). There was no difference among the groups
in baseline latencies. Data were successfully recorded in 40
animals in the orexin-A group and 13 out of 13 animals in
the vehicle group.Single oscilloscope sweep shows activity of a representative
off, on and neutral-cells during the tail heat trial. Top trace
is cell discharge, the middle line shows heat exposure and stop,
and the lower triangles show tail withdrawal point.After the stability of extracellular single unit recording
from the RVM neurons, orexin-A (20 μM, 5 μl)
was injected into the right ICV of the rats. We successfully
recorded a total of 21 on-cells, 15 off-cells
and 6 neutral-cells in RVM. Administration of orexin-
A inhibited or decreased spontaneous basal activity,
which was 64.57 ± 5% at baseline and decreased to
42.13 ± 5.94% (p<0.001 in 13 of 21 on-cells). Following
ICV microinjection of orexin-A, 13 out of
21 on-cells displayed a decrease in ongoing activity
(paired t test; p<0.05, Fig 4). On the other hand, as
demonstrated in figure 5, the vehicle microinjection
did not affect spontaneous firing rate and firing activity
associated with reflex-related response which was
4.46 ± 2.82 sp/s at baseline and 4.29 ± 3.63 sp/s after
saline injection (n=5, paired t test, p>0.05, Fig 5).
Fig 4
Rate-meter records show the effect of intracerebroventricular
(ICV) orexin-A injection on spontaneous firing
rate and ongoing discharge of 2 on-cells in the rostral
ventromedial medulla (RVM). In both cases, firing pattern
and rate decreased by orexin administration. Triangles indicate
tail flick (TF) trials. 1-s bins.
Fig 5
Vehicle infusion showed no effect on on-cell discharge.
On-cells were recorded during infusion of saline
vehicle in the ventricle. Firing pattern and rate were unaltered.
Triangles indicate tail flick (TF) trials. 1-s bins.
Rate-meter records show the effect of intracerebroventricular
(ICV) orexin-A injection on spontaneous firing
rate and ongoing discharge of 2 on-cells in the rostral
ventromedial medulla (RVM). In both cases, firing pattern
and rate decreased by orexin administration. Triangles indicate
tail flick (TF) trials. 1-s bins.Vehicle infusion showed no effect on on-cell discharge.
On-cells were recorded during infusion of saline
vehicle in the ventricle. Firing pattern and rate were unaltered.
Triangles indicate tail flick (TF) trials. 1-s bins.As seen in Figure 6, the off-cells had an increased
spontaneous firing rate from 6.74 ± 1.44 sp/s at baseline
to 9.34 ± 0.65 sp/s after administration of orexin-
A (p<0.05, Fig 6). Vehicle microinjection had no effect
on off-cell firing rate (n=4, Fig 7). As shown in figure
8, the firing rate and ongoing activity of neutral-cells
remained unchanged following ICV injection of saline
and orexin-A (Fig 8, p>0.05). Additionally, there
was an increase in ongoing activity following ICV
microinjection of orexin-A, but it was not statistically
significant (paired t test, Fig 9). Frequency analysis
of the firing rate distributions of the four on-cells in
RVM in baseline (white bars) and after Orexin-A injection
(black bars) showed that Orexin-A induced a
shift to the left of the firing rate of on-cells, indicating
a probability decrease in low firing rate after Orexin-
A injection (p<0.01, Fig 10). Frequency analysis of
the firing rate of the four off-cells in RVM at baseline
(white bars) and after orexin-A injection (black
bars) showed that orexin-A induced a shift to the right
of the firing rate of off-cells which indicated an increased
probability in high firing rate after orexin-A
injection (paired t test, p<0.01, Fig 11).
Fig 6
Rate-meter records show effects of ICV injection of
orexin-A on spontaneous activity and ongoing discharge of
identified off-cells in the RVM. Top: excitation of an offcell
after ICV injection of orexin-A. Bottom: This neuron
showed substantial cycling activity throughout recording,
but active periods were increased following orexin-A injection.
Triangles indicate TF trials. 1-s bins.
Fig 7
Vehicle infusion had no effect on off-cell discharge.
Off-cells were recorded during infusion of saline in the ventricle.
Firing pattern and rate were unaltered. Top three histograms
of each cell show point of TF (black triangle) and
stimulus-related changes in firing rate before (a) and after
(b and c in different time) ICV saline injection. Triangles
indicate TF trials. 1-s bins.
Fig 8
Rate-meter records show lack of effect of ICV saline
and orexin-A injection on the ongoing discharge of 2 neutral-
cells in the RVM. In both cases, firing pattern and rate
were completely unaffected by orexin. Triangles indicate TF
trials. 1-s bins.
Fig 9
Mean ongoing firing of on-cells, off-cells, and neutral
cells at baseline compared with the post-injection period in
animals that received intracerebroventricular (ICV) microinjections
of orexin-A or vehicle. *p<0.05, discharges following
orexin-A compared with the value at baseline.
Fig 10
Frequency analysis of firing rate distributions of four on-cells in the rostral ventromedial medulla (RVM) at baseline
(white bars) and after orexin-A injection (black bars). Firing rate was measured for each bin (500 ms) and plotted as a percentage
of baseline activity and after orexin-A injection for each cell. Orexin-A induced a shift to the left of the firing rate of on-cells
indicating a probability decrease in high firing rate after orexin-A injection.
Fig 11
Frequency analysis of firing rate distributions of four off-cells of rostral ventromedial medulla (RVM) in baseline
(white bars) and after orexin-A injection (black bars). Firing rate was measured for each bin (500 ms) and plotted as a percent
of time in baseline and after orexin-A injection for each cell. Orexin-A induced a shift to the right of the firing rate indicating
an increase in frequency after the injection.
Rate-meter records show effects of ICV injection of
orexin-A on spontaneous activity and ongoing discharge of
identified off-cells in the RVM. Top: excitation of an offcell
after ICV injection of orexin-A. Bottom: This neuron
showed substantial cycling activity throughout recording,
but active periods were increased following orexin-A injection.
Triangles indicate TF trials. 1-s bins.Vehicle infusion had no effect on off-cell discharge.
Off-cells were recorded during infusion of saline in the ventricle.
Firing pattern and rate were unaltered. Top three histograms
of each cell show point of TF (black triangle) and
stimulus-related changes in firing rate before (a) and after
(b and c in different time) ICVsaline injection. Triangles
indicate TF trials. 1-s bins.Rate-meter records show lack of effect of ICVsaline
and orexin-A injection on the ongoing discharge of 2 neutral-
cells in the RVM. In both cases, firing pattern and rate
were completely unaffected by orexin. Triangles indicate TF
trials. 1-s bins.Mean ongoing firing of on-cells, off-cells, and neutral
cells at baseline compared with the post-injection period in
animals that received intracerebroventricular (ICV) microinjections
of orexin-A or vehicle. *p<0.05, discharges following
orexin-A compared with the value at baseline.Frequency analysis of firing rate distributions of four on-cells in the rostral ventromedial medulla (RVM) at baseline
(white bars) and after orexin-A injection (black bars). Firing rate was measured for each bin (500 ms) and plotted as a percentage
of baseline activity and after orexin-A injection for each cell. Orexin-A induced a shift to the left of the firing rate of on-cells
indicating a probability decrease in high firing rate after orexin-A injection.Frequency analysis of firing rate distributions of four off-cells of rostral ventromedial medulla (RVM) in baseline
(white bars) and after orexin-A injection (black bars). Firing rate was measured for each bin (500 ms) and plotted as a percent
of time in baseline and after orexin-A injection for each cell. Orexin-A induced a shift to the right of the firing rate indicating
an increase in frequency after the injection.
Discussion
Orexinergic neurons have widespread projections
from the lateral hypothalamus that
lead to their involvement in a number of different
functions, including feeding (2), sleep (9,
10), stress induced analgesia (11, 12), reward
and addiction (13-15). More recently, the role
of orexin in pain modulation has been demonstrated
(16, 17, 20, 22, 34, 35). In a study,
central administration of orexin-A produced a
dose-dependent antinociceptive effect in the
hotplate test model in rats . In other mouse
models, orexin-A inhibited visceral nociception
and thermal hyperalgesia induced by an
intraplantar carrageenan injection model produced
an efficacy equivalent to morphine (17).
Morphological studies have established that
the orexin-containing neurons are distributed
along most parts of pain circuitry including the
RVM region which is considered important for
pain modulation (3).Although most studies are concerned with
orexin-A induced analgesia through the spinal
cord but, specific brain regions that include
PAG and paragigantocellularis lateralis have
been implicated in the antinociceptive effect of
orexin-A (21, 22). We have previously shown
that infusion of orexin-A into the RVM caused
a decrease in formalin-induced nociceptive behaviors
(36). It has been determined that intra-
PAG microinjection of orexin-A elicits an
analgesic effect in the hot-plate and formalin
tests for rats, which confirms that PAG is a supraspinal
center involved in orexin-A induced
analgesia through orexin receptor 1 (20,22).
The principal finding of the present study h as
shown that ICV administration of orexin-A inhibited
the spontaneous firing rate and ongoing
activity of on-cells while it produced thermal
analgesia. In addition, orexin-A activated the
spontaneous firing rate of off-cells whereas the
neutral-cells were unaffected. These data supported
previous behavioral observations 20, 22
in which orexin-A produced an analgesic effect.
The decrease in on-cell firing rate by orexin-A
and increase in off-cell spontaneous firing rate
might be involved in orexin-A induced analgesia.
Thus, our findings suggested that the RVM
might either directly or indirectly be necessary
for an orexin-A induced analgesic effect.Two reports have emphasized the presence of
orexin-induced analgesia through a top-down
modulating system (20, 22). Production of
orexin is restricted to the lateral hypothalamus
(1, 2), a region known to modulate pain processing
through the brain stem (4). This has
supported the current study’s hypothesis that
either direct or indirect action of orexin-A is
mediated through RVM neurons. RVM is involved
in a top-down pain-modulating system
through the first synapse in dorsal horn neurons
(23) and innervated by orexinergic fibers
(3). Thus, RVM may directly and/or indirectly
(projection from PAG) be an important site of
action for orexin-induced supraspinal antinociception.We believed that orexin-A might indirectly activate
off-cells via disinhibition. In this model, orexin-
A activated on-cells as inhibitory interneurons
responsible for disinhibition of off-cells; these, in
turn, induced antinociception through the dorsal
horn neuron in the spinal cord.Orexin has been shown to produce excitatory
effects on most areas in the brain in addition to
inhibitory effects on a few neurons obtained from
other regions (37, 40). The latter observation supports
the indirect effect of orexin-A. Indirect effects
of orexin-A have been shown in other brain
regions such as the substantia nigra (37), laterodorsal
tegmental nucleus (39), hypothalamus (40),
and raphe nucleus (38).In consistent to above studies, the data of the
present study speculated that Orexin-A has bidirectional
effects on RVM neurons, to recognize the
direct or indirect mechanism(s), we might require
further studies at the cellular and/or molecular levels.
Conclusion
These results have shown that orexin-A might
produce analgesia through activation/inhibition
of RVM neurons required for pain modulation.
It has been suggested that the orexinergic system
from the hypothalamus to RVM might have
a potential role in modulation of nociceptive
transmission. Although orexin-A and morphine
have similar effects as antinociceptives, these
substances have extremely different actions in
arousal conditions.
Authors: S Bingham; P T Davey; A J Babbs; E A Irving; M J Sammons; M Wyles; P Jeffrey; L Cutler; I Riba; A Johns; R A Porter; N Upton; A J Hunter; A A Parsons Journal: Pain Date: 2001-05 Impact factor: 6.961