Enlarged Areas of Pain and Pressure Hypersensitivityby Spatially Distributed Intramuscular Injections ofLow-Dose Nerve Growth Factor

Published:December 01, 2018DOI:


      • Distributed low-dose NGF injections induce pronounced muscle hypersensitivity
      • Distributed NGF injections affect a larger muscle area compared to single-bolus NGF
      • Low-dose NGF sensitize muscle nociceptors locally
      • Distributed NGF may mimic clinical pain better as a larger muscle area is affected


      Intramuscular injection of nerve growth factor (NGF) causes muscle hyperalgesia without immediate pain. This double-blinded, randomized study assessed pain and muscle hypersensitivity after a single-site bolus NGF injection (5 µg) compared with 5 spatially distributed, low-dose NGF injections (1 µg, 4 cm distance) into the tibialis anterior (TA) muscles in 20 healthy subjects. Injection pain was rated on a visual analog scale. Reports of muscle pain with functional tasks (Likert scale score) and the presence of spontaneous pain were collected daily by using a diary. Pressure pain threshold (PPT), overall pain intensity (numerical rating scale), and pain areas following the TA contraction were collected at baseline; 3 hours; and 1, 3, 7, 14, and 21 days postinjection. Low immediate visual analog scale scores were associated with both injection protocols. Likert scale scores showed moderate pain intensities but no spontaneous pain, until day 12, for both injection protocols (P < .05). Reduced PPTs at the 5- and 1-µg injection sites were found after 3 hours, lasting until day 7 (P < .05). The 1-µg injection provoked decreased PPTs at day 1 (P = .036) at the proximal injection site and at day 1 (P = .02) and day 3 (P = .01) at the distal injection site. The TA muscle contraction resulted in larger pain areas and higher numerical rating scale scores at day 3 for the distributed injections compared with the single-site injection (P < .001).
      Perspective: Spatially distributed low-dose NGF injections induced prolonged pain, mechanical muscle hypersensitivity, and enlarged contraction-evoked pain areas. These features mirror some clinical muscle pain conditions in which diffuse pain areas and muscle hypersensitivity are present during the activities of daily living. Low-dose NGF injections may be useful for further studies of prolonged pain conditions.

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        • Andersen H
        • Arendt-Nielsen L
        • Svensson P
        • Danneskiold-Samsøe B
        • Graven-Nielsen T
        Spatial and temporal aspects of muscle hyperalgesia induced by nerve growth factor in humans.
        Exp Brain Res. 2008; 191: 371-382
        • Apfel SC
        Nerve growth factor for the treatment of diabetic neuropathy: What went wrong, what went right, and what does the future hold?.
        Int Rev Neurobiol. 2002; 50: 393-413
        • Apfel SC
        • Schwartz S
        • Adornato BT
        • Freeman R
        • Biton V
        • Rendell M
        • Vinik A
        • Giuliani M
        • Stevens JC
        • Barbano R
        • Dyck PJ
        Efficacy and safety of recombinant human nerve growth factor in patients with diabetic polyneuropathy: A randomized controlled trial. rhNGF Clinical Investigator Group.
        JAMA. 2000; 284: 2215-2221
        • Bergin MJG
        • Hirata R
        • Mista C
        • Christensen SW
        • Tucker K
        • Vicenzino B
        • Hodges P
        • Graven-Nielsen T
        Movement evoked pain and mechanical hyperalgesia after intramuscular injection of nerve growth factor: A model of sustained elbow pain.
        Pain Med. 2015; 16: 2180-2191
        • Deising S
        • Weinkauf B
        • Blunk J
        • Obreja O
        • Schmelz M
        • Rukwied R
        NGF-evoked sensitization of muscle fascia nociceptors in humans.
        Pain. 2012; 153: 1673-1679
        • Doménech-García V
        • Palsson TS
        • Herrero P
        • Graven-Nielsen T
        Pressure-induced referred pain is expanded by persistent soreness.
        Pain. 2016; 157: 1164-1172
        • Dyck P
        • Peroutka S
        • Rask C
        • Burton E
        • Baker M
        • Lehman K
        • Gillen D
        • Hokanson J
        • O'Brien P
        Intradermal recombinant human nerve growth factor induces pressure allodynia and lowered heat-pain threshold in humans.
        Neurology. 1997; 48: 501-505
        • Gerber RKH
        • Nie H
        • Arendt-Nielsen L
        • Curatolo M
        • Graven-Nielsen T
        Local pain and spreading hyperalgesia induced by intramuscular injection of nerve growth factor are not reduced by local anesthesia of the muscle.
        Clin J Pain. 2011; 27: 240-247
        • Graven-Nielsen T
        • Arendt-Nielsen L
        Assessment of mechanisms in localized and widespread musculoskeletal pain.
        Nat Rev Rheumatol. 2010; 6: 599-606
        • Graven-Nielsen T
        • Arendt-Nielsen L
        • Svensson P
        • Staehelin Jensen T
        Quantification of local and referred muscle pain in humans after sequential i.m. injections of hypertonic saline.
        Pain. 1997; 69: 111-117
        • Graven-Nielsen T
        • McArdle A
        • Phoenix J
        • Arendt-Nielsen L
        • Jensen TS
        • Jackson MJ
        • Edwards RHT
        In vivo model of muscle pain: Quantification of intramuscular chemical, electrical, and pressure changes associated with saline-induced muscle pain in humans.
        Pain. 1997; 69: 137-143
        • Hayashi K
        • Shiozawa S
        • Ozaki N
        • Mizumura K
        • Graven-Nielsen T
        Repeated intramuscular injections of nerve growth factor induced progressive muscle hyperalgesia, facilitated temporal summation, and expanded pain areas.
        Pain. 2013; 154: 2344-2352
        • Hoheisel U
        • Reuter R
        • De Freitas MF
        • Treede RD
        • Mense S
        Injection of nerve growth factor into a low back muscle induces long-lasting latent hypersensitivity in rat dorsal horn neurons.
        Pain. 2013; 154: 1953-1960
        • Hoheisel U
        • Unger T
        • Mense S
        Excitatory and modulatory effects of inflammatory cytokines and neurotrophins on mechanosensitive group IV muscle afferents in the rat.
        Pain. 2005; 114: 168-176
        • Hoheisel U
        • Unger T
        • Mense S
        Sensitization of rat dorsal horn neurons by NGF-induced subthreshold potentials and low-frequency activation. A study employing intracellular recordings in vivo.
        Brain Res. 2007; 1169: 34-43
        • Jensen K
        • Andersen HO
        • Olesen J
        • Lindblom U
        Pressure-pain threshold in human temporal region. Evaluation of a new pressure algometer.
        Pain. 1986; 25: 313-323
        • McArthur JC
        • Yiannoutsos C
        • Simpson DM
        • Adornato BT
        • Singer EJ
        • Hollander H
        • Marra C
        • Rubin M
        • Cohen BA
        • Tucker T
        • Navia BA
        • Schifitto G
        • Katzenstein D
        • Rask C
        • Zaborski L
        • Smith ME
        • Shriver S
        • Millar L
        • Clifford DB
        • Karalnik IJ
        A phase II trial of nerve growth factor for sensory neuropathy associated with HIV infection. AIDS Clinical Trials Group Team 291.
        Neurology. 2000; 54: 1080-1088
        • Munkholm TK
        • Arendt-Nielsen L
        The interaction between NGF-induced hyperalgesia and acid-provoked pain in the infrapatellar fat pad and tibialis anterior muscle of healthy volunteers.
        Eur J Pain. 2017; 21: 474-485
        • Nie H
        • Madeleine P
        • Arendt-Nielsen L
        • Graven-Nielsen T
        Temporal summation of pressure pain during muscle hyperalgesia evoked by nerve growth factor and eccentric contractions.
        Eur J Pain. 2009; 13: 704-710
        • Norman BH
        • McDermott JS
        • Targeting the nerve growth factor (NGF) pathway in drug discovery
        Potential applications to new therapies for chronic pain.
        J Med Chem. 2017; 60: 66-88
        • Petty BG
        • Cornblath DR
        • Adornato BT
        • Chaudhry V
        • Flexner C
        • Wachsman M
        • Sinicropi D
        • Burton LE
        • Peroutka SJ
        The effect of systemically administered recombinant human nerve growth factor in healthy human subjects.
        Ann Neurol. 1994; 36: 244-246
        • Pezet S
        • McMahon SB
        Neurotrophins: Mediators and modulators of pain.
        Ann Rev Neurosci. 2006; 29: 507-538
        • World Medical Association General Assembly
        World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects.
        J Int Bioethique. 2004; 15: 124-129
        • Rukwied R
        • Mayer A
        • Kluschina O
        • Obreja O
        • Schley M
        • Schmelz M
        NGF induces non-inflammatory localized and lasting mechanical and thermal hypersensitivity in human skin.
        Pain. 2010; 148: 407-413
        • Sarchielli P
        • Mancini ML
        • Floridi A
        • Coppola F
        • Rossi C
        • Nardi K
        • Acciarresi M
        • Pini LA
        • Calabresi P
        Increased levels of neurotrophins are not specific for chronic migraine: Evidence from primary fibromyalgia syndrome.
        J Pain. 2007; 8: 737-745
        • Schabrun SM
        • Christensen SW
        • Mrachacz-Kersting N
        • Graven-Nielsen T
        Motor cortex reorganization and impaired function in the transition to sustained muscle pain.
        Cereb Cortex. 2016; 26: 1878-1890
        • Slater H
        • Arendt-Nielsen L
        • Wright A
        • Graven-Nielsen T
        Experimental deep tissue pain in wrist extensors—a model of lateral epicondylalgia.
        Eur J Pain. 2003; 7: 277-288
        • Staud R
        • Koo E
        • Robinson ME
        • Price DD
        Spatial summation of mechanically evoked muscle pain and painful aftersensations in normal subjects and fibromyalgia patients.
        Pain. 2007; 130: 177-187
        • Svensson P
        • Cairns BE
        • Wang K
        • Arendt-Nielsen L
        Injection of nerve growth factor into human masseter muscle evokes long-lasting mechanical allodynia and hyperalgesia.
        Pain. 2003; 104: 241-247
        • Svensson P
        • Wang MW
        • Dong XD
        • Kumar U
        • Cairns BE
        Human nerve growth factor sensitizes masseter muscle nociceptors in female rats.
        Pain. 2010; 148: 473-480
        • Tsao H
        • Tucker KJ
        • Coppieters MW
        • Hodges PW
        Experimentally induced low back pain from hypertonic saline injections into lumbar interspinous ligament and erector spinae muscle.
        Pain. 2010; 150: 167-172