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In recent years, epidemiological data has shown an increasing number of young people who deliberately self-injure. There have also been parallel increases in the number of people with tattoos and those who voluntarily undergo painful procedures associated with piercing, scarification, and tattooing. People with self-injury behaviors often say that they do not feel the pain. However, there is no information regarding pain perception in those that visit tattoo parlors and piercing studios compared to those who don't. The aim of this study was to compare nociceptive sensitivity in four groups of subjects (n=105, mean age 26 years, 48 women and 57 men) with different motivations to experience pain (i.e., with and without multiple body modifications) in two different situations; (1) in controlled, emotionally neutral conditions, and (2) at a "Hell Party" (HP), an event organized by a piercing and tattoo parlor, with a main event featuring a public demonstration of painful techniques (burn scars, hanging on hooks, etc.). Pain thresholds of the fingers of the hand were measured using a thermal stimulator and mechanical algometer. In HP participants, information about alcohol intake, self-harming behavior, and psychiatric history were used in the analysis as intervening variables. Individuals with body modifications as well as without body modifications had higher thermal pain thresholds at Hell Party, compared to thresholds measured at control neutral conditions. No such differences were found relative to mechanical pain thresholds. Increased pain threshold in all HP participants, irrespectively of body modification, cannot be simply explained by a decrease in the sensory component of pain; instead, we found that the environment significantly influenced the cognitive and affective component of pain.
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PHYSIOLOGICAL RESEARCH ISSN 0862-8408 (print) ISSN 1802-9973 (online)
2017 Institute of Physiology of the Czech Academy of Sciences, Prague, Czech Republic
Fax +420 241 062 164, e-mail:,
Physiol. Res. 66 (Suppl. 4): S493-S500, 2017
Do Multiple Body Modifications Alter Pain Threshold?
1Department of Normal, Pathological and Clinical Physiology, Third Faculty of Medicine, Charles
University, Prague, Czech Republic
Received March 22, 2017
Accepted November 3, 2017
In recent years, epidemiological data has shown an increasing
number of young people who deliberately self-injure. There have
also been parallel increases in the number of people with tattoos
and those who voluntarily undergo painful procedures associated
with piercing, scarification, and tattooing. People with self-injury
behaviors often say that they do not feel the pain. However,
there is no information regarding pain perception in those that
visit tattoo parlors and piercing studios compared to those who
don’t. The aim of this study was to compare nociceptive
sensitivity in four groups of subjects (n=105, mean age 26 years,
48 women and 57 men) with different motivations to experience
pain (i.e., with and without multiple body modifications) in two
different situations; (1) in controlled, emotionally neutral
conditions, and (2) at a "Hell Party" (HP), an event organized by
a piercing and tattoo parlor, with a main event featuring a public
demonstration of painful techniques (burn scars, hanging on
hooks, etc.). Pain thresholds of the fingers of the hand were
measured using a thermal stimulator and mechanical algometer.
In HP participants, information about alcohol intake, self-harming
behavior, and psychiatric history were used in the analysis as
intervening variables. Individuals with body modifications as well
as without body modifications had higher thermal pain thresholds
at Hell Party, compared to thresholds measured at control neutral
conditions. No such differences were found relative to mechanical
pain thresholds. Increased pain threshold in all HP participants,
irrespectively of body modification, cannot be simply explained by
a decrease in the sensory component of pain; instead, we found
that the environment significantly influenced the cognitive and
affective component of pain.
Key words
Pain threshold Tattoos Piercing Scarification Body
Corresponding author
A. Yamamotová, Department of Normal, Pathological and Clinical
Physiology, Third Faculty of Medicine, Charles University,
Ke Karlovu 4, 120 00 Prague 2, Czech Republic. E-mail:
Pain is defined as an unpleasant sensory and
emotional experience associated with acute or potential
tissue damage, or is described by such expressions. Pain
is always subjective.
Like any definition, this one has its limitations.
Pain, by definition, is unpleasant; however, there are
individuals who intentionally caused pain to themselves
without much suffering. In people with self-harming
behaviors, physical pain can release and/or ameliorates
mental tension or mental pain (Niedtfeld and Schmahl
2009). Deliberately induced pain may also help people
with dissociative disorders return from a dissociated state
to reality, or to escape from reality to a dissociated state
(Fishbain et al. 2001). Another category includes those
who voluntarily undergo pain during aesthetic changes to
the body, such as tattoos, piercings, and scarification via
cutting or burning.
Recent epidemiological data points to
an increasing trend not only in the incidence of self-harm
but also in the incidence of body modifications
(Montgomery and Parks 2001, Laumann and Derrick
2006, Stirn et al. 2006). The steepest increase has been
primarily seen among adolescents (Greydanus and Shek
2009). Although some associations have been found
between the frequency of ear piercing and borderline
personality disorders, these relationships were neither
significant nor specific (Mi 1990).
S494 Yamamotová et al. Vol. 66
The motivational aspects for body modifications
are many and diverse. Multiple body modifications are
often associated with those searching for identity, a desire
to be affiliated with a certain subculture, or as
a manifestation of a specific type of non-verbal
communication (Stirn et al. 2011). Additionally, those
associated with body modifications are often regarded as
having antisocial behaviors. Tattoos and piercings can
express personal endurance to overcome pain as well as
having an addictive character that might be linked to
activation of the endogenous opioid system (Wohlrab et
al. 2007).
Although the number of people with body
modifications has significantly increased over the past
several decades (Kluger 2015, Breuner et al. 2017), there
have been no studies that test pain perception in these
individuals. Therefore, the objective of this study was to
compare pain threshold to thermal and mechanical stimuli
in groups with different motivations to experience pain,
i.e., (1) in control subjects without body modifications,
and (2) in subjects with multiple body modification under
two different conditions, (a) emotionally neutral and
(b) emotionally intense. We tested the hypothesis that
people with multiple body modifications have higher pain
thresholds than those without body modifications.
Participants and method
Pain threshold was measured in 105 participants
with different motivations to experience pain (with and
without body modifications) (48 women and 57 men,
mean age 26±8 years) under two different conditions. The
first part of experiment was conducted in familiar
environments. Control subjects without body
modifications (C N, mostly medical students and their
friends; n=18) were tested under standard laboratory
conditions; participants with body modifications (BM N,
employees of tattoo parlors; n=12) were tested in a tattoo
parlor setting. Both these groups were tested under what
they perceived as natural and emotionally neutral
conditions. The second part of experiment was conducted
in a more emotionally charged environment, i.e., at a Hell
Party (HP), which was characterized by the organizers as
"a slightly rougher party for enthusiasts of piercings,
tattoos, and other body modifications, as well as fans of
BDSM (Bondage, Domination, Sadism and Masochism)."
Volunteers for research participation were
recruited via internet advertisement in the program of
a Hell Party. In this environment, two groups of
volunteers were measured. One group consisted of
participants with multiple body modifications (BM HP,
n=45), and the second group consisted of those without
body modifications (C HP, n=30), but with an active
interest in the experiences of the first group.
Given that pain perception can be influenced by
factors other than the environment, volunteers at the
HP filled out an anonymous questionnaire, regarding
information that we considered relevant to the modulation
of pain perception. These factors included: (1) alcohol or
other substances that had been used prior to pain testing
(amounts were in the range 1-2 glasses of beer or spirits,
with none of the participants describing use/abuse of
other addictive substances), (2) prescription medication
use at the time of pain testing (results: hypnotics 1,
antidepressants 1, analgesics 3, and antibiotics 2),
(3) previous or current psychiatric history, (4) self-injury
behaviors (SIB), and (5) types of body modifications
(tattoos, piercings, or scarification). The group with body
modifications included those participants who had tattoos
on more than 18 % of the body surface (without other
types of body modifications) or those with lesser tattooed
area but in combination with another types of body
modifications (numerous piercings and/or scarification).
Demographic characteristics associated with the
intervening variables are shown in Table 1.
Testing of the pain threshold at a Hell Party took
place in an isolated space without the presence of other
participants, just like in a laboratory or tattoo parlor.
A portable pen-like thermal stimulator of our own
production, operating on the principle of heating the skin
with hot air in a range from 20-70 °C, was used to induce
thermal pain (Fig. 1). In all settings, the pain threshold
was measured on the dorsal aspect of the index, middle,
and ring fingers of the non-dominant hand. The tip of
thermal stimulator was located behind the nail bed.
An average of the three measurements was used in the
analysis. When the thermal stimulus reached threshold
intensity, participants turned the apparatus off using
a computer mouse. Mechanical pain threshold was
measured on the same fingers using an electronic
algometer (Somedic, Sweden), operating on an area of
one square centimeter generating pressures in a range
from 0-2,000 kPa.
2017 Body Modifications and Nociception S495
Table 1. Demographic characteristics for the subgroups defined by intervening variables.
Neutral conditions
Hell Party
Sex (N)
F (11)
M (7)
F (5)
M (21)
M (22)
F (23)
Age (years)
Thermal pain (°C)
Pressure pain (kPa) 951±263 630±218 1021±127 664±119 950±366 751±242 983±325 922±349
Alcohol (N)
Psychiatric history (N)
Tattoo (N)
Piercing (N)
Scarification (N)
No 6 5 20 20
C N: control subjects without body modifications measured in neutral settings; BM N: subjects with body modifications measured in
neutral settings; C HP: control subjects without body modifications measured at a Hell Party; BM HP: subjects with body modifications
measured at a Hell Party; F: female; M: male. Data are presented as Mean ± SD.
Fig. 1. The thermal stimulator device.
Statistical analyses
Differences in pain thresholds among control
subjects and those with body modifications in two
different experimental conditions were analyzed using the
two-way ANOVA (four levels of factor group: 1st group
control subjects without body modifications measured
in neutral settings (C N); 2nd group subjects with body
modifications measured in neutral settings (BM N);
3rd group control subjects without body modifications
measured at a HP (C HP); 4th group subjects with body
S496 Yamamotová et al. Vol. 66
modifications measured at a HP (BM HP) and two levels
of factor sex: men and women) separately for thermal and
mechanical threshold. Where indicated, simple planned
comparisons were used in post hoc analyses. Differences
were considered significant if p<0.05.
Thermal pain threshold
A significant main effect of group (F(3,97)=12.04,
p=0.000001) indicated that both groups measured in
emotionally neutral conditions (with or without body
modifications) had significantly lower pain thresholds
than the two other groups, which were measured under
emotionally stimulating or intense conditions at the
HP (Fig. 2). In spite of the fact that these two neutral
conditions are different, they represented for our
participants their habitual environment.
Fig. 2. Gender and group differences in thermal pain threshold.
Abbreviations are the same as in Table 1. Vertical bars denote
0.95 confidence intervals; **** p<0.00001.
We observed a tendency toward lower pain
thresholds in women compared to men (F(1,97)=3.55,
p=0.06), but interaction of factors group x sex was not
significant (F(3,97)=0.22, p=0.88).
Pressure pain threshold
Contrary to thermal pain, sensitivity to pressure
pain did not differ between groups (F(3,97)=1.46, p=0.23).
A significant difference was found in factor sex
(F(1,97)=11.43, p=0.001) with lower pain thresholds in
women compared to men. Group x sex interaction was
also not significant (F(3,97)=1.2, p=0.31) (Fig. 3).
Fig. 3. Gender and group differences in pressure pain threshold.
Abbreviations are the same as in Table 1. Vertical bars denote
0.95 confidence intervals; * p<0.05 M vs. F.
Effect of intervening variables
Since 45 persons, from the total number of
75 participants at the HP, stated alcohol use prior to pain
testing, we analyzed the effect on pain thresholds
separately using ANOVA with factors groups (with and
without body modification) and alcohol intake.
Regarding thermal pain threshold, alcohol intake had no
significant effect (main effect of alcohol F(1,72)=2.98,
p=0.09) on either group of participants (group x alcohol
interaction F(1,72)=0.73, p=0.39). Regarding pressure pain
threshold, alcohol intake also had no significant effect
(F(1,72)=1.45, p=0.23), however, the effect on the two
groups were not the same (group x alcohol interaction
F(1,72)=4.7, p=0.03), i.e. pain threshold was increased in
participants with body modifications.
The effect of other intervening variables on pain
thresholds in the HP participants with body modifications
are summarized in Table 2.
In subjects with body modifications, thermal and
pressure pain thresholds were influenced by self-injurious
behavior (SIB) differently. SIB did not affect thermal
pain threshold (main effect F(1,41)=2.1, p=0.16) whereas
SIB decreased pressure pain threshold (main effect
F(1,41)=4.0, p=0.05). This effect was probably caused by
the larger number of women with self-injurious behavior
in this group.
Current psychiatric comorbidity was associated
with decreased thermal as well as pressure pain
thresholds (main effects F(1,41)=5.2, p=0.03 and
F(1,41)=5.74, p=0.02, respectively). Again, this effect
could have been caused by the larger number of women
in this group.
2017 Body Modifications and Nociception S497
With regard to the nature of body modifications,
thermal pain threshold was not influenced by any of them
(main effect of tattoo F(1,41)=0.98, p=0.32; main effect of
piercing F(1,41)=2.9, p=0.1, main effect of scarification
F(1,41)=0.8, p=0.38).
In contrast, pressure pain threshold was higher in
persons with tattoos compared with those without tattoos
(F(1,41)=8.38, p=0.006). However, scarification had the
opposite effect; scarified participants had lower pressure
threshold than those without scarifications (F(1,41)=3.99,
p=0.05). Piercing was not found to have any effect on
pressure pain.
Table 2. Effect of intervening variables on heat and mechanical pain threshold in Hell Party participants with body modifications.
Males (22)
Females (23)
ANOVA (F(1,41))
variable (IV) Yes No Yes No
of IV Sex
Alcohol Thermal 57.4±6.3 57.4±5.7 55.9.0 51.6±7.1 F=0.60,
Pressure 1,022±343 812±153 1,092±264 766±353 F=5.92,
SIB Thermal 60.3±5.0 56.8±6.2 55.3±8.8 51.7±7.4 F=2.06,
Pressure 880±154 1,006±351 754±363 1,076±264 F=4.04,
Thermal 45.6 58.0±5.6 49.1±2.6 54.6±8.8 F=5.19,
Pressure 551 1,004±317 604±249 1,010±324 F=5.74,
Tattoo Thermal 57.9±6.5 57.0±5.8 54.7±9.1 51.3±6.3 F=0.98,
Pressure 1,022±378 938±258 1,097±264 650±290 F=8.38,
Piercing Thermal 56.2±4.7 60.7±8.4 52.7±7.4 57.0±11.7 F=2.90,
Pressure 966±309 1,030±391 933±327 868±497 F=0.00,
Scarification Thermal 50.5±6.9 58.1±5.7 54.7±10.3 53.2±8.1 F=0.80,
Pressure 688±194 1,013±323 653±484 962±321 F=3.99,
Data are presented as Mean ± SD; significant differences are in bold; n.s. nonsignificant.
Effect of body modification on nociception
We expected that individuals repeatedly
undergoing body modifications to have higher pain
thresholds than subjects without body modifications and,
as such, it would be easier for them to tolerate pain in an
experimental setting. In both experimental conditions,
neutral and emotional, we found differences in
nociception among male and female participants. Gender
differences that were seen were more associated with
pressure than with thermal pain thresholds, with lower
thresholds observed in women, which is in agreement
with many other published studies (Lautenbacher and
S498 Yamamotová et al. Vol. 66
Rollman 1993, Fillingim 2000, Hashmi and Davis 2014).
Effect of environment
Regardless of whether participants at the HP had
or did not have body modifications, their thresholds for
thermal and pressure pain were similar. Thermal pain
thresholds in both groups measured at the HP were
significantly higher than in the corresponding groups
measured in a natural, less emotionally charged
environment, while no such differences were found in
pressure pain thresholds. Thermal and mechanical pain
sensitivity do not necessary have to correlate and
differences can depend on the types of nerve fibers
involved in pain transmission. C-fibers, which respond to
noxious heat, play a major role in heat sensation, whereas
A-fiber nociceptors are predominately heat and/or
mechanosensitive (Dubin and Patapoutian 2010).
Nociceptive stimulation of C fibers, triggered by thermal
stimuli, correlates well with pain sensation, however,
similar activation of C fibers caused by mechanical
stimulation, which also activates A beta
mechanoreceptors, does not necessarily produce any pain
sensation (Hees and Gybels 1981).
Increased pain thresholds among HP participants
can be explained by the influence of the emotionally
charged or intense HP environment, which was perceived
as an overall positive experience. Several experimental
studies have shown that positive emotions as well as
pleasant music can lead to pain reduction (Rhudy and
Meagher 2001, Villemure and Bushnell 2002, Roy et al.
2008, Dubnar et al. 2012). Therefore, the HP party, as
a body modification festival, with music and workshops
demonstrating different techniques represented for both
active and passive participants a very emotionally
stimulating experience, which could have motivated them
to exceed either their own borders or empathically share
the pain experiences of others as well as sharing the
emotional responses of others. Several fMRI studies have
shown that during subjective experiences “to feel
another’s pain” requires, at least partially, activation of
a mental representation of one’s own pain, which is
located mainly in the anterior cingulate and insular
cortices, i.e. structures involved in processing the
affective component of pain (Jackson et al. 2006, Zaki et
al. 2007). Recently, Loggia et al. (2008) showed that
empathy itself can alter the sensory component of pain.
Consumption of alcohol
Alcohol intake at the HP increased pressure pain
thresholds, but not the thermal pain thresholds, in those
with body modifications. Experimental results indicate
that pressure pain stimulation might be more sensitive at
detecting the pain-dampening effects of alcohol than
electrical stimulation, the cold pressor test, and von Frey
hairs (Horn-Hofmann et al. 2015). Since alcohol is
known to have anxiolytic and stress-dampening effects,
changes in pain perception might be attributable to
changes in emotional state (Sayette 1999), which might
be more responsive in participants with body
Effect of psychiatric history
Most works dealing with pain perception in
patients with a spectrum of psychiatric disorders have
described decreased pain sensitivity (Lautenbacher and
Krieg 1994, Blumensohn et al. 2002, Papežová et al.
2005). Contrary to this, we found that our participants
with a psychiatric diagnosis had reduced thermal and
pressure pain thresholds. This result should be interpreted
with caution considering the small number of subjects
and the prevalence of women in this subgroup.
Effect of scarification on pain threshold
We showed that persons with scarification had
a significantly reduced mechanical pain threshold. It could
be a manifestation of hyperalgesia, due to a previous
painful invasive technique. Among our participants,
scarification, with the cutting of strips of skin for later
formation of ornamental visible scars, probably represents
the most painful procedure. Due to the small number of
subjects with scarification, a physiological interpretation of
their response is rather difficult; however, similar results
were also obtained in participants with self-injury
behaviors, which most frequently involved cutting; this
could be explained by the similarity of techniques used
during scarification and SIB. Regardless of the
explanation, our results contradict many literature findings,
which describe increased pain thresholds in subjects with
SIB (Bunderla and Kumperščag 2015).
For people who deliberately self-injure, and thus
voluntarily induce pain, it is believed that the
neurobiological mechanism mainly involves
a dysfunction of the opioid system, and to a lesser degree
the serotonergic and dopaminergic systems (Stanley et al.
2010, Groschwitz and Plenar 2012). Many patients that
repetitively self-mutilate seem to have developed a kind
of addiction to the experience. The addiction appears to
be based on a rapid reward effect that could be associated
2017 Body Modifications and Nociception S499
with either an up-regulation of opioid receptors in the
central nervous system or they may suffer from
premorbid changes in the activity of endogenous opioid
system (Frecska and Arata 2002). The functions of opioid
and dopaminergic systems are critical in motivation and
analgesia. Since these systems interact with each other,
the anatomical substrates of pleasure and pain can be
considered as overlapping (Leknes and Tracey 2008).
One of the motivations of HP participants was to
watch BDMS practices. Even though we did not gather
information regarding participant masochistic behavior, we
cannot rule-out this behavior as motivation for attending
the HP. This behavior may also contribute to an increased
pain threshold. It has been experimentally demonstrated,
using fMRI, that brain areas activated in association with
masochistic behavior were involved in sensory-
discriminative processing rather than affective pain
processing, during receipt of painful stimuli delivered in
the context of masochism (Kamping et al. 2016).
In this study, we showed that subjects with
multiple body modifications did not differ in nociceptive
sensitivity from control subjects without body
modifications in control/neutral environments. When
subjects both with multiple body modifications and
control subjects without body modifications were tested
in emotionally charged/intense environment (i.e. at a Hell
Party) they also did not differ in nociceptive sensitivity.
The observation that participants with and
without body modifications measured at the Hell Party
had higher nociceptive thresholds than the corresponding
groups measured in neutral environment leads us to
conclude that increased nociceptive thresholds cannot be
simply explained by reduced sensory perception caused
by body modification. Instead it suggests that pain
threshold in our participants was top-down modulated via
affective and cognitive processes.
Conflict of Interest
There is no conflict of interest.
This study was supported by project PROGRES Q35 and
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... Body modification, i.e. tattooing, piercing or scarification, is another example of an activity clearly associated with pain, and yet actively sought out by some people. A study by Yamamotovo and colleagues suggests that thermal pain thresholds are strongly influenced by the context in which the modification is done [74]. Remarkably, Kamping and colleagues came to the same conclusion when looking at pain perception in masochistic individuals [56]. ...
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Introduction BDSM is an abbreviation used to reference the concepts of bondage and discipline, dominance and submission, sadism and masochism, enacted by power exchanges between consensual partners. In recent years, attention has shifted from the idea of BDSM as a pathological and tabooed niche practice towards viewing BDSM as a healthy form of intimacy. Aim This systematic review brings together all existing literature on the biology of BDSM and places it in a broader biological context. Method A systematic search was conducted on Pubmed, Web of Science and PsycARTICLES, of which ten articles are included and discussed in this systematic review. Results There is evidence for cortisol changes in submissives as a result of a BDSM interaction, suggesting involvement of the physiological stress system. Endocannabinoid changes implicate the pleasure and reward system. In dominants, this biologically measured pleasure seemed to be dependent on power play rather than pain play. Testosterone and oxytocin are also implicated in BDSM, though their role is less evident. Research into brain region activity patterns related to BDSM interest suggests a role for the parietal operculum and ventral striatum in the context of the pleasure and reward system, the primary and secondary somatosensory cortex in the context of pain perception, empathy-related circuits such as the anterior insula (AI), anterior midcingulate cortex (ACC) and sensorimotor cortex and the left frontal cortex in the context of social and sexual interactions. Pain thresholds are shown to be higher in submissive individuals and a BDSM interaction may cause pain thresholds to rise in submissives as well. Conclusion BDSM interactions are complex and influenced by several psychological, social and biological processes. Though research is limited, there is emerging evidence for an interaction between several biological systems involved in these types of interests and activities. This means there is an important role for future research to replicate and supplement current results.
... The tactile threshold was tested by the von Frey method (touchtest sensory evaluators, North Coast Medical). The thermal pain threshold was measured with a portable thermal stimulator of Algic stimuli (Yamamotová et al., 2017), a uniquely modified device that creates thermal stimulations with steadily increasing temperature (20-70 • C), until a participant indicates, by pressing the left button of a computer mouse, their first perception of the relevant sensation and then the first perception of pain (Summers et al., 2004). ...
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Over the past decade, theta-burst stimulation (TBS) has become a focus of interest in neurostimulatory research. Compared to conventional repetitive transcranial magnetic stimulation (rTMS), TBS produces more robust changes in cortical excitability (CE). There is also some evidence of an analgesic effect of the method. Previously published studies have suggested that different TBS parameters elicit opposite effects of TBS on CE. While intermittent TBS (iTBS) facilitates CE, continuous TBS (cTBS) attenuates it. However, prolonged TBS (pTBS) with twice the number of stimuli produces the opposite effect. In a double-blind, placebo-controlled, cross-over study with healthy subjects (n = 24), we investigated the effects of various pTBS (cTBS, iTBS, and placebo TBS) over the right motor cortex on CE and pain perception. Changes in resting motor thresholds (RMTs) and absolute motor-evoked potential (MEP) amplitudes were assessed before and at two time-points (0–5 min; 40–45 min) after pTBS. Tactile and thermal pain thresholds were measured before and 5 min after application. Compared to the placebo, prolonged cTBS (pcTBS) transiently increased MEP amplitudes, while no significant changes were found after prolonged iTBS. However, the facilitation of CE after pcTBS did not induce a parallel analgesic effect. We confirmed that pcTBS with twice the duration converts the conventional inhibitory effect into a facilitatory one. Despite the short-term boost of CE following pcTBS, a corresponding analgesic effect was not demonstrated. Therefore, the results indicate a more complex regulation of pain, which cannot be explained entirely by the modulation of excitability.
... In our previous study we have shown that individuals with body modifications as well as without body modifications had higher thermal pain thresholds during public demonstration of painful techniques compared to thresholds measured at control neutral conditions. These observations lead us to conclude that in emotionally charged environment, pain threshold in our participants was top-down modulated via affective and cognitive processes (Yamamotová et al. 2017). ...
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The biological significance of pain is to protect the organism from possible injury. However, there exists a situation, where, in the interest of survival, it is more important not to perceive pain. Spontaneous suppression of pain or weakening of nociception is mediated by an endogenous antinociceptive (analgesic) system. Its anatomical substrate ranges from the periaqueductal gray matter of the midbrain, through the noradrenergic and serotonergic nuclei of the brain stem to the spinal neurons, which receive "pain" information from nociceptors. Moreover, the activity of this system is under significant control of emotional and cognitive circuits. Pain can be moderated primarily through stimulation of positive emotions, while negative emotions increase pain. Paradoxically, one pain can also suppress another pain. Analgesia can be induced by stress, physical exercise, orosensory stimulation via a sweet taste, listening to music, and after placebo, i.e. when relief from pain is expected. Since pain has sensory, affective, and cognitive components, it turns out that activation of these entire systems can, in specific ways, contribute to pain suppression.
... It is evident that hormones influence perception of pain: oestrogens mitigate pain with concentration-dependent mechanisms, whereas testosterone reduces the sensitivity to chronic pain [280]. Pain responses seem to change during life depending on hormonal variability: at puberty, the perception of pain increases in women, while sex differences in chronic pain rates disappear in menopause [281]. The gonadal hormones affect the incidence of pain, as it was observed in transsexuals who received cross sex hormones to develop and maintain somatic characteristics of the opposite sex [282]. ...
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. Gender medicine is the first step of personalized medicine and patient-centred care, an essential development to achieve the standard goal of a holistic approach to patients and diseases. By addressing the interrelation and integration of biological markers (i.e., sex) with indicators of psychological/cultural behaviour (i.e., gender), gender medicine represents the crucial assumption for achieving the personalized health-care required in the third millennium. However, ‘sex’ and ‘gender’ are often misused as synonyms, leading to frequent misunderstandings in those who are not deeply involved in the field. Overall, we have to face the evidence that biological, genetic, epigenetic, psycho-social, cultural, and environmental factors mutually interact in defining sex/gender differences, and at the same time in establishing potential unwanted sex/gender disparities. Prioritizing the role of sex/gender in physiological and pathological processes is crucial in terms of efficient prevention, clinical signs’ identification, prognosis definition, and therapy optimization. In this regard, the omics-approach has become a powerful tool to identify sex/gender-specific disease markers, with potential benefits also in terms of socio-psychological wellbeing for each individual, and cost-effectiveness for National Healthcare systems. “Being a male or being a female” is indeed important from a health point of view and it is no longer possible to avoid “sex and gender lens” when approaching patients. Accordingly, personalized healthcare must be based on evidence from targeted research studies aimed at understanding how sex and gender influence health across the entire life span. The rapid development of genetic tools in the molecular medicine approaches and their impact in healthcare is an example of highly specialized applications that have moved from specialists to primary care providers (e.g., pharmacogenetic and pharmacogenomic applications in routine medical practice). Gender medicine needs to follow the same path and become an established medical approach. To face the genetic, molecular and pharmacological bases of the existing sex/gender gap by means of omics approaches will pave the way to the discovery and identification of novel drug-targets/therapeutic protocols, personalized laboratory tests and diagnostic procedures (sex/gender-omics). In this scenario, the aim of the present review is not to simply resume the state-of-the-art in the field, rather an opportunity to gain insights into gender medicine, spanning from molecular up to social and psychological stances. The description and critical discussion of some key selected multidisciplinary topics considered as paradigmatic of sex/gender differences and sex/gender inequalities will allow to draft and design strategies useful to fill the existing gap and move forward.
... Other possible therapeutic approaches have been postulated. These include (for example) newer intradiscal therapies (Charneux et al. 2017), modulation of galanin receptors (Zhang et al. 2019), modulation of TRPA-1 ( Liu et al. 2019, Yamamotova et al. 2017), monoclonal antibody tanezumab (Webb et al. 2018), etc. (Bhangare et al. 2017. ...
Low back pain (LBP) represents an important subgroup of vertebrogenic pain with estimated prevalence around 80 %. Locally acting injectable collagen for topical application has recently extended the limited range of treatment options. The aim of the study was to evaluate the efficacy and safety of injectable collagen in patients with LBP. Patients suffering from LBP (< three months) were enrolled. They were administered either collagen 4 ml or trimecaine 1 % 4 ml in the form of subcutaneous paravertebral injections into eight pre-specified points (0.5 ml per each point) in the following schedule: two administrations in the first and second week, one in the third week. The pain intensity, Thomayer distance, Oswestry disability index, Lasseque test, quality of life, consumption of rescue medication and safety were evaluated. Exertional and rest pain, evaluated by a visual analogue scale, gradually decreased in both groups. Both treatments showed a statistically significant improvement in mobility and quality of life. The consumption of paracetamol as a rescue medication was significantly lower in patients treated with collagen than in the group treated with trimecaine (p=0.048). The analgesic efficacy of locally acting injectable collagen, as well as an analgesic sparing effect when compared to local anesthetics were demonstrated.
... (ii) Multiple types of cosmetic procedures are associated with sensations from mild discomfort to pain. There is no unified literature on cosmetic procedures I am aware of, although lessened thermal pain sensitivity has been reported in individuals with multiple body modifications [55]. These procedures underline an interesting discrepancy in discussions of pain of different types. ...
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Research in the neuroscience of pain perception and visual perception has taken contrasting paths. The contextual and the social aspects of pain judgements predisposed pain researchers to develop computational and functional accounts early, while vision researchers tended to simple localizationist or descriptive approaches first. Evolutionary thought was applied to distinct domains, such as game-theoretic approaches to cheater detection in pain research, versus vision scientists' studies of comparative visual ecologies. Both fields now contemplate current motor or decision-based accounts of perception, particularly predictive coding. Vision researchers do so without the benefit of earlier attention to social and motivational aspects of vision, while pain researchers lack a comparative behavioural ecology of pain, the normal incidence and utility of responses to tissue damage. Hybrid hypotheses arising from predictive coding as used in both domains are applied to some perplexing phenomena in pain perception to suggest future directions. The contingent and predictive interpretation of complex sensations, in such domains as ‘runner's high’, multiple cosmetic procedures, self-harm and circadian rhythms in pain sensitivity is one example. The second, in an evolutionary time frame, considers enhancement of primary perception and expression of pain in social species, when expressions of pain might reliably elicit useful help. This article is part of the Theo Murphy meeting issue ‘Evolution of mechanisms and behaviour important for pain’.
Acupuncture and related techniques involve physical stimulation of cutaneous tissues and cells, but the specific tissue targets of acupuncture and the underlying mechanism in human skin remain largely unknown. Acupuncture-reachable cutaneous tissue structures and cells are reviewed, and the thicknesses of human skin at different acupuncture areas were measured in tissue sections from skin biopsies. For the first time, an approach of natural pathological experiment for acupuncture (NPEA) has been used to observe and study acupuncture-related physiology and pathology. Based on clinical information of both dermatology and acupuncture, 46 pathological conditions/diagnoses from author’s clinical practice were selected as NPEA cases to discuss individually in details. These cases include physical injuries, foreign body reactions, naturally occurring insults, tumors of specific cell types or structures, and inflammatory, defense, or immune reactions. For each NPEA condition, typical morphological evidence is presented with multiple histological micrographs and clinical photos. The discussion includes medical definition, clinical presentations, histopathological changes, and related pathogenesis. The relevance and significance to acupuncture for each condition are broadly discussed. These NPEA studies on acupuncture provide important observational evidence for acupuncture research while identifying critical clues for the future exploration of acupuncture insight with advanced technology or controlled experiments.
Conference Paper
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Introduction: Cases of pneumothorax have been reported by various authors in patients with COVID-19. The association between these two diseases, as well as its frequency, have not yet been well studied. Aim: To present the first three cases of spontaneous pneumothorax associated with COVID-19 registered in the University Hospital “Sveti Georgi” Plovdiv. Clinical cases: Three cases of pneumothorax associated with COVID-19 were presented in two men aged 76 and 33 years and one woman aged 72 years. All three patients were on mechanical ventilation. They underwent thoracentesis with the placement of a chest drain. Due to the worsening of the underlying disease, all three patients died. Discussion: Pneumothorax associated with COVID-19 has been reported in 1% of patients requiring hospitalization. Association between barotrauma and pneumothorax is observed in the intubated patients in ICU. Another pathogenetic mechanism is the diffuse alveolar damage caused by the virus with the formation of interstitial emphysema and pneumatocele. The surgical method of choice is thoracentesis. The outcome in patients with COVID-19 and pneumothorax depends on the severity of the underlying lung injury. Conclusion: Pneumothorax is a rare but serious complication of COVID-19. It is often associated with poor outcome, especially in patients on mechanical ventilation.
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Background: The pathophysiology of non-suicidal self-injury (NSSI) is controversial. There is growing evidence of altered pain perception in people engaging in NSSI. Some hypotheses have been made on addictive aspects of this behavior. Pain and addictive behavior are modulated by the opioid system, which makes the endogenous opioids one of the candidate neurotransmitters related to NSSI. This article explains the theoretical background on NSSI as an addictive behavior, endogenous opioids involvement and pain perception changes in NSSI and updates the latest findings in this field. The main aim of this paper is a comprehensive review of published studies on pain perception in NSSI and an evaluation of the impact of NSSI functions and other psychological elements on pain perception measures. Subjects and methods: We have reviewed six studies of pain perception in participants with NSSI compared with controls. The participants of these studies were not mentally disabled or autistic and did not have a diagnosed personality disorder. Results: The reviewed studies have demonstrated a higher pain threshold and longer pain tolerance or endurance in five of six studies. Emotional dysregulation was significantly associated with all pain perception variables in one study. Neuroticism, self-criticism and painful and provocative experiences revealed correlated with pain endurance or pain tolerance. No correlation between pain perception measures and dissociation, hopelessness or locus of control was found. Conclusions: Pain perception was altered in participants with NSSI. Pain perception was associated to emotional dysregulation, self-criticism, neuroticism and painful and provocative experiences. Because of the small number of studies reviewed, results should be seen as guidelines for further studies. They should be replicated on a bigger sample of studies. Further research should focus on pain perception measures in participants with NSSI and an excluded personality disorder.
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Alcohol is believed to have pain-dampening effects and is often used as self-medication by persons with pain problems; however, experimental evidence confirming this effect is scarce. We conducted a systematic review of experimental studies on the effects of nonrecurring alcohol administration on pain perception in healthy human subjects and the underlying mechanisms. Three databases (PubMed, PsycINFO, and Web of Science) were searched for relevant studies using a predefined algorithm. In a next step, irrelevant articles were excluded by screening titles and abstracts. Finally, articles were checked regarding a set of methodological criteria; only publications meeting these criteria were selected for this review. A total of 14 experimental studies were identified. Overall, most of the studies were able to show a pain-dampening effect of alcohol. However, many of them had methodological shortcomings (eg, lack of placebo control, insufficient blinding, or very small sample sizes). In addition, comparability is limited due to considerable variations in alcohol administration and pain measurement. More importantly, potential mechanisms of action and moderating variables have scarcely been investigated. Despite the frequent use of alcohol as self-medication by persons with pain problems, there are to date only a few experimental investigations of alcohol effects on pain perceptions. The results of these studies suggest that alcohol does in fact have pain-dampening effects. However, the mechanisms implicated in these effects are still unknown, and experimental research has been limited to pain-free subjects. Future research should provide more knowledge about alcohol effects on pain, especially in chronic pain patients.
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In 1974, the first professional French tattooist C. Bruno wrote a book, entitled 'Tatoués, qui êtes-vous?', depicting his experience as a tattooist in the picturesque Pigalle tourist district of Paris. However, we have come a long way since then. Tattooing has gained tremendous visibility, notoriety and popularity in Western countries. In Germany, 8.5% of the population (aged between 14 and 90 years) has a tattoo. Similar trends have been found in France, Finland and Australia, where approximately 10% of the populations have at least one tattoo. However, the overall tattoo prevalences overseas and in Europe are even higher, especially among the youth, for whom it is up to 15-25% according to the country. Much has been written about the tattooed and tattooists. However, who are they currently? What motivates them to get tattooed and give tattoos? How do they see themselves? Why do some individuals remove their tattoos? Is there a 'profile' of the tattooed? Are they really 'risk takers'? And how do the nontattooed perceive them? Through a critical review of the literature, we will reconsider tattooing from an epidemiological aspect, challenge current beliefs and explore new insights into the motivations and fears of tattoo artists and their clients. © 2015 S. Karger AG, Basel.
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In this article we review the literature to note that sex differences in pain detection thresholds are nuanced and this factor limits deriving any clear conclusions on this topic. Despite of this ambiguity, the prevailing opinion among the scientific community is that women are more pain sensitive than men. Here we highlight that fact that when sex differences in perception do exist, women in most cases show higher sensitivity in detecting sensory stimuli belonging to all perceptual modalities including pain, touch, smell, sound and vision. This suggests that some women have an overall higher sensory acuity than men. Existing studies also indicate that women may be more sensitive to dynamic pain stimuli such as those with rapid increase in intensity while men may be more responsive to noxious stimuli with static intensity. We propose a new mechanistic framework for future investigations on sex differences in pain. In conclusion, the effect of sex on pain should not be generalized as it is complex,and may depend on a variety of individual and disease co-factors.
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It is well known that music arouses emotional responses. In addition, it has long been thought to play an important role in creating a sense of community, especially in small scale societies. One mechanism by which it might do this is through the endorphin system, and there is evidence to support this claim. Using pain threshold as an assay for CNS endorphin release, we ask whether it is the auditory perception of music that triggers this effect or the active performance of music. We show that singing, dancing and drumming all trigger endorphin release (indexed by an increase in post-activity pain tolerance) in contexts where merely listening to music and low energy musical activities do not. We also confirm that music performance results in elevated positive (but not negative) affect. We conclude that it is the active performance of music that generates the endorphin high, not the music itself. We discuss the implications of this in the context of community bonding mechanisms that commonly involve dance and music-making.
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Patients with Borderline Personality Disorder (BPD) experience intense emotions and show a deficient reper-toire of emotion regulation skills at the same time. Moreover, they display high prevalence rates of self-injurious behav-ior, which they report to engage in due to its effect of immediate relief of emotional tension. Exploring the mechanisms behind these core symptoms, we review previous research indicating that BPD is characterized by a specific pattern of emotion dysregulation, manifested in hyperreactivity of limbic structures (bottom-up processes) paralleled by deficient prefrontal control mechanisms (top-down processes). This issue will be integrated into existing theories of emotion regulation. As a novel aspect in this field, we provide an overview of the interaction between somatosensory pain and affect regula-tion. According to our own research it can be assumed that patients with BPD show reduced pain perception compared to healthy controls, which is caused by an alteration of the affective-motivational pain component rather than sensory-discriminative deficits. By virtue of the discussed findings we reason that self-injurious behavior may compensate for a lack of emotion regulation strategies by causing an attentional shift away from unwanted emotions. Finally, open research questions which can be derived from the theoretical considerations will be briefly discussed.
Tattoos, piercing, and scarification are now commonplace among adolescents and young adults. This first clinical report from the American Academy of Pediatrics on voluntary body modification will review the methods used to perform the modifications. Complications resulting from body modification methods, although not common, are discussed to provide the pediatrician with management information. Body modification will be contrasted with nonsuicidal self-injury. When available, information also is presented on societal perceptions of body modification.
Sex differences in thermo- and electrocutaneous responsiveness to painful and non-painful stimuli were investigated in 20 women and 20 men. Heat pain, warmth, and cold thresholds were assessed on the hand and foot with a Peltier thermode system. In addition, subjects used magnitude estimation to judge the sensation intensity evoked by temperatures ranging from 38°C to 48°C applied to the forearm. To measure detection, pain, and tolerance thresholds of electrocutaneous sensitivity, electrical pulses were administered to the hand. Magnitude estimates of sensation intensity were assessed for stimuli ranging from 0.5 mA to 4.0 mA. There were no sex differences in heat pain, warmth and cold thresholds. There were significant sex differences in electrical detection, pain and tolerance thresholds, with lower thresholds in women. Correspondingly, magnitude estimates were similar in women and men when using thermal stimuli while women judged stimuli from 2.5 mA on as more intense than men when using electrical stimuli. Despite these discrepancies, the measures for pain responsiveness from the two stimulation methods correlated significantly. In contrast, no significant correlations between the methods were found when considering the responsiveness to non-painful stimuli. The findings help to clarify controversies in the pain literature about sex differences. Results affirming and denying such differences could be obtained within a single sample, with stimulation method as the critical variable.