Author Response
Reviewer #1 (Public Review):
The objective of this investigation was to determine whether experimental pain could induce alterations in cortical inhibitory/facilitatory activity observed in TMS-evoked potentials (TEPs). Previous TMS investigations of pain perception had focused on motor evoked potentials (MEPs), which reflect a combination of cortical, spinal, and peripheral activity, as well as restricting the focus to M1. The main strength of this investigation is the combined use of TMS and EEG in the context of experimental pain. More specifically, Experiment 1 investigated whether acute pain altered cortical excitability, reflected in the modulation of TEPs. The main outcome of this study is that relative to non-painful warm stimuli, painful thermal stimuli led to an increase on the amplitude of the TEP N45, with a larger increase associated with higher pain ratings. Because it has been argued that a significant portion of TEPs could reflect auditory potentials elicited by the sound (click) of the TMS, Experiment 2 constituted a control study that aimed to disentangle the cortical response related to TMS and auditory activity. Finally, Experiment 3 aimed to disentangle the cortical response to TMS and reafferent feedback from muscular activity elicited by suprathreshold TMS applied over M1. The fact that the authors accompanied their main experiment with two control experiments strengthens the conclusion that the N45 TEP peak could be implicated in the perception of painful stimuli.
Perhaps, the addition of a highly salient but non-painful stimulus (i.e. from another modality) would have further ruled out that the effects on the N45 are not predominantly related to intensity/saliency of the stimulus rather than to pain per se.
We thank the reviewer for their comment on the possibility of whether stimulus salience influences the N45 as opposed to pain per se. However, we note that in Experiment 1, despite the same level of stimulus salience/intensity for all participants (46 degrees), individual differences in pain ratings were associated with the change in the N45 amplitude, suggesting that the results cannot be explained by stimulus intensity/salience.
Reviewer #2 (Public Review):
The authors have used transcranial magnetic stimulation (TMS) and motor evoked potentials (MEPs) and TMS-electroencephalography (EEG) evoked potentials (TEPs) to determine how experimental heat pain could induce alterations in these metrics.In Experiment 1 (n = 29), multiple sustained thermal stimuli were administered over the forearm, with the first, second, and third block of stimuli consisting of warm but non-painful (pre-pain block), painful heat (pain block) and warm but non-painful (post-pain block) temperatures respectively. Painful stimuli led to an increase in the amplitude of the fronto-central N45, with a larger increase associated with higher pain ratings. Experiments 2 and 3 studied the correlation between the increase in the N45 in pain and the effects of a sham stimulation protocol/higher stimulation intensity. They found that the centro-frontal N45 TEP was decreased in acute pain.
The study comes from a very strong group in the pain fields with long experience in psychophysics, experimental pain, neuromodulation, and EEG in pain. They are among the first to report on changes in cortical excitability as measured by TMS-EEG over M1.
While their results are in line with reductions seen in motor-evoked responses during pain and effort was made to address possible confounding factors (study 2 and 3), there are some points that need attention. In my view the most important are:
- The method used to calculate the rest motor threshold, which is likely to have overestimated its true value : calculating highly abnormal RMT may lead to suprathreshold stimulations in all instances (Experiment 3) and may lead to somatosensory "contamination" due to re-afferent loops in both "supra" and "infra" (aka. less supra) conditions.
The method used to assess motor threshold was the TMS motor threshold Assessment Tool (Awiszus et al., 2003). This was developed as a quicker alternative for calculating motor threshold compared to the traditional Rossini-Rothwell method which involves determining the lowest intensity that evokes 5/10 MEPs of at least 50 microvolts. The method has been shown to achieve the same accuracy of determining motor threshold as the traditional Rossini-Rothwell method, but with fewer pulses (Qi et al., 2011; Silbert et al., 2013). Therefore, the high RMTs in our study cannot be explained by the threshold assessment method. Instead, they are likely explained by aspects of the experimental setup that increased the distance between the TMS coil and the scalp, including the layer of foam placed over the coil, the EEG cap and the fact that the electrodes we used had a relatively thick profile.
Awiszus, F. (2003). TMS and threshold hunting. In Supplements to Clinical neurophysiology (Vol. 56, pp. 13-23). Elsevier.
Qi, F., Wu, A. D., & Schweighofer, N. (2011). Fast estimation of transcranial magnetic stimulation motor threshold. Brain stimulation, 4(1), 50-57.
Silbert, B. I., Patterson, H. I., Pevcic, D. D., Windnagel, K. A., & Thickbroom, G. W. (2013). A comparison of relative-frequency and threshold-hunting methods to determine stimulus intensity in transcranial magnetic stimulation. Clinical Neurophysiology, 124(4), 708-712.
- The low number of pulses used for TEPs (close to ⅓ of the usual and recommended)
We agree that increasing the number of pulses can increase the signal to noise ratio. During piloting, participants were unable to tolerate the painful stimulus for long periods of time and we were required to minimize the number of pulses per condition.
We note that there is no set advised number of trials in TMS-EEG research. According to the recommendations paper, the number of trials should be based on the outcome measure e.g., TEP peaks vs. frequency domain measures vs. other measures and based on previous studies investigating test-retest reliability (Hernandez-Pavon et al., 2023). The choice of 66 pulses per condition was based on the study by Kerwin et al., (2018) showing that optimal concordance between TEP peaks can be found with 60-100 TMS pulses delivered in the same run (as in the present study). The concordance was particularly higher for the N40 peak at prefrontal electrodes, which was the key peak and electrode cluster in our study.
Further supporting the reliability of the TEP data in our experiment, we note that the scalp topographies of the TEPs for active TMS at various timepoints (Figures 5, 7 and 9) were similar across all three experiments, especially at 45 ms post-TMS (frontal negative activity, parietal-occipital positive activity).
In addition to this, the interclass correlation coefficient (Two-way fixed, single measure) for the N45 to active suprathreshold TMS across timepoints for each experiment was 0.90 for Experiment 1 (across pre-pain, pain, post-pain time points), 0.74 for Experiment 2 (across pre-pain and pain conditions), and 0.95 for Experiment 3 (across pre-pain conditions). This suggests that even with the fluctuations in the N45 induced by pain, the N45 for each participant was stable across time, further supporting the reliability of our data. These ICCs will be reported in the next revision.
Hernandez-Pavon, J. C., Veniero, D., Bergmann, T. O., Belardinelli, P., Bortoletto, M., Casarotto, S., ... & Ilmoniemi, R. J. (2023). TMS combined with EEG: Recommendations and open issues for data collection and analysis. Brain Stimulatio, 16(3), 567-593
Kerwin, L. J., Keller, C. J., Wu, W., Narayan, M., & Etkin, A. (2018). Test-retest reliability of transcranial magnetic stimulation EEG evoked potentials. Brain stimulation, 11(3), 536-544.
Lack of measures to mask auditory noise.
In TMS-EEG research, various masking methods have been proposed to suppress the somatosensory and auditory artefacts resulting from TMS pulses, such as white noise played through headphones to mask the click sound (Ilmoniemi and Kičić, 2010), and a thin layer of foam placed between the TMS coil and EEG cap to minimize the scalp sensation (Massimini et al., 2005). However, recent studies have shown that even when these methods are used, sensory contamination of TEPs is still present, as shown by studies that show commonalities in the signal between active and sensory sham conditions that mimic the auditory/somatosensory aspects of real TMS (Biabani et al., 2019; Conde et al., 2019; Rocchi et al., 2021). This has led many authors (Biabani et al., 2019; Conde et al., 2019) to recommend the use of sham conditions to control for sensory contamination. To separate the direct cortical response to TMS from sensory evoked activity, Experiment 2 (n = 10) included a sham TMS condition that mimicked the auditory/somatosensory aspects of active TMS to determine whether any alterations in the TEP peaks in response to pain were due to changes in sensory evoked activity associated with TMS, as opposed to changes in cortical excitability. Therefore, the lack of auditory masking does not impact the main conclusions of the paper.
Ilmoniemi, R. J., & Kičić, D. (2010). Methodology for combined TMS and EEG. Brain topography, 22, 233-248.
Massimini, M., Ferrarelli, F., Huber, R., Esser, S. K., Singh, H., & Tononi, G. (2005). Breakdown of cortical effective connectivity during sleep. Science, 309(5744), 2228-2232.
Biabani, M., Fornito, A., Mutanen, T. P., Morrow, J., & Rogasch, N. C. (2019). Characterizing and minimizing the contribution of sensory inputs to TMS-evoked potentials. Brain stimulation, 12(6), 1537-1552.
Conde, V., Tomasevic, L., Akopian, I., Stanek, K., Saturnino, G. B., Thielscher, A., ... & Siebner, H. R. (2019). The non-transcranial TMS-evoked potential is an inherent source of ambiguity in TMS-EEG studies. Neuroimage, 185, 300-312.
Rocchi, L., Di Santo, A., Brown, K., Ibáñez, J., Casula, E., Rawji, V., ... & Rothwell, J. (2021). Disentangling EEG responses to TMS due to cortical and peripheral activations. Brain stimulation, 14(1), 4-18.
- A supra-stimulus heat stimulus not based on individual HPT, that oscillates during the experiment and that lead to large variations in pain intensity across participants is unfortunate.
The choice of whether to calibrate or fix stimulus intensity is a contentious question in experimental pain research. A recent discussion by Adamczyk et al., (2022) explores the pros and cons of each approach and recommends situations where one method may be preferred over the other. That paper suggests that the choice of the methodology is related to the research question – when the main outcome of the research is objective (neurophysiological measures) and researchers are interested in the variability in pain ratings, the fixed approach is preferrable. Given we explored the relationship between MEP/N45 modulation by pain and pain intensity, this question is better explored by using the same stimulus intensity for all participants, as opposed to calibrating the intensity to achieve a similar of pain across participants.
Adamczyk, W. M., Szikszay, T. M., Nahman-Averbuch, H., Skalski, J., Nastaj, J., Gouverneur, P., & Luedtke, K. (2022). To calibrate or not to calibrate? A methodological dilemma in experimental pain research. The Journal of Pain, 23(11), 1823-1832.
So is the lack of report on measures taken to correct for a fortuitous significance (multiple comparison correction) in such a huge number of serial paired tests.
Note that we used a Bayesian approach for all analyses as opposed to traditional frequentist approach. In contrast to the frequentist approach, the Bayesian approach does not require corrections for multiple comparisons (Gelman et al., 2000) given that they provide a ratio representing the strength of evidence for the null vs. alternative hypotheses as opposed to accepting or rejecting the null hypothesis based on p-values. As such, throughout the paper, we frame our interpretations and conclusions based on the strength of evidence (e.g. anecdotal/weak, moderate, strong, very strong) as opposed to referring to the significance of the effects.
Gelman A, Tuerlinckx F. (2000). Type S error rates for classical and Bayesian single and multiple comparison procedures. Computational statistics, 15(3):373-90.
Reviewer #3 (Public Review):
The present study aims to investigate whether pain influences cortical excitability. To this end, heat pain stimuli are applied to healthy human participants. Simultaneously, TMS pulses are applied to M1 and TMS-evoked potentials (TEPs) and pain ratings are assessed after each TMS pulse. TEPs are used as measures of cortical excitability. The results show that TEP amplitudes at 45 msec (N45) after TMS pulses are higher during painful stimulation than during non-painful warm stimulation. Control experiments indicate that auditory, somatosensory, or proprioceptive effects cannot explain this effect. Considering that the N45 might reflect GABAergic activity, the results suggest that pain changes GABAergic activity. The authors conclude that TEP indices of GABAergic transmission might be useful as biomarkers of pain sensitivity.
Pain-induced cortical excitability changes is an interesting, timely, and potentially clinically relevant topic. The paradigm and the analysis are sound, the results are mostly convincing, and the interpretation is adequate. The following clarifications and revisions might help to improve the manuscript further.
- Non-painful control condition. In this condition, stimuli are applied at warmth detection threshold. At this intensity, by definition, some stimuli are not perceived as different from the baseline. Thus, this condition might not be perfectly suited to control for the effects of painful vs. non-painful stimulation. This potential confound should be critically discussed.
In Experiment 3, we also collected warmth ratings to confirm whether the pre-pain stimuli were perceived as different from baseline. We did not include this data initially in the first submission, but will do so in the supplemental material in our next revision. This data showed warmth ratings were close to 2/10 on average. This confirms that the non-painful control condition produced some level of non-painful sensation.
- MEP differences between conditions. The results do not show differences in MEP amplitudes between conditions (BF 1.015). The analysis nevertheless relates MEP differences between conditions to pain ratings. It would be more appropriate to state that in this study, pain did not affect MEP and to remove the correlation analysis and its interpretation from the manuscript.
The interindividual relationship between changes in MEP amplitude and individual pain rating is statistically independent from the overall group level effect of pain on MEP amplitude. Therefore, conclusions for the individual and group level effects can be made independently.
It is also important to note that in the pain literature, there is now increasing emphasis placed on investigating the individual level relationship between changes in cortical excitability and pain as opposed to the group level effect (Seminowicz et al., 2019; Summers et al., 2019). As such, it is important to make these results readily available for the scientific community.
Summers, S. J., Chipchase, L. S., Hirata, R., Graven-Nielsen, T., Cavaleri, R., & Schabrun, S. M. (2019). Motor adaptation varies between individuals in the transition to sustained pain. Pain, 160(9), 2115-2125.
Seminowicz, D. A., Thapa, T., & Schabrun, S. M. (2019). Corticomotor depression is associated with higher pain severity in the transition to sustained pain: a longitudinal exploratory study of individual differences. The Journal of Pain, 20(12), 1498-1506.
- Confounds by pain ratings. The ISI between TMS pulses is 4 sec and includes verbal pain ratings. Considering this relatively short ISI, would it be possible that verbal pain ratings confound the TEP? Moreover, could the pain ratings confound TEP differences between conditions, e.g., by providing earlier ratings when the stimulus is painful? This should be carefully considered, and the authors might perform control analyses.
It is unlikely that the verbal ratings contaminated the TEP response as the subsequent TMS pulse was not delivered until the verbal rating was complete and given that each participant was cued by the experimenter to provide the pain rating after each pulse (rather than the participant giving the rating at any time). As such, it would not be possible for participants to provide earlier ratings to more painful stimuli. We will make this part of the protocol clearer in the next revision of the manuscript.
- Confounds by time effects. Non-painful and painful conditions were performed in a fixed order. Potential confounds by time effects should be carefully considered.
Previous research suggests that pain alters neural excitability even after pain has subsided. In a recent meta-analysis (Chowdhury et al., 2022) we found effect sizes of 0.55-0.9 for MEP reductions 0-30 minutes after pain had resolved. As such, we avoided intermixing pain and warm blocks given subsequent warm blocks would not serve as a valid baseline, as each subsequent warm block would have residual effects from the previous pain blocks.
At the same time, given there was no conclusive evidence for a difference in N45 amplitude between pre-pain and post-pain conditions of Experiment 1 (Supplementary Figure 1), it is unlikely that the effect of pain was an artefact of time i.e., the explanation that successive thermal stimuli applied to the skin results an increase in the N45, regardless of whether they are painful or not. We will make this point in our next revision.
Chowdhury, N. S., Chang, W. J., Millard, S. K., Skippen, P., Bilska, K., Seminowicz, D. A., & Schabrun, S. M. (2022). The Effect of Acute and Sustained Pain on Corticomotor Excitability: A Systematic Review and Meta-Analysis of Group and Individual Level Data. The Journal of Pain, 23(10), 1680-1696.
- Data availability. The authors should state how they make the data openly available.
We will upload the MEP, TEP and pain data on the Open science framework at the time of the next revision.
