QUROC: Quantitative Ultrasound Response of Capsaicin

Sponsor
Toronto Rehabilitation Institute (Other)
Overall Status
Completed
CT.gov ID
NCT03944889
Collaborator
(none)
20
1
9
17.1
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Study Details

Study Description

Brief Summary

Central Sensitization is an aspect of chronic pain and is associated with over-excitability of the central nervous system. Central Sensitization normally presents itself with other chronic syndromes such as Myofascial Pain Syndrome, so it is difficult to separate the characteristics of the two. The purpose of this study is to determine whether sensitizing healthy muscle using capsaicin, a chilli pepper extract, induces a regional change in ultrasound texture features of the targeted muscle, or the muscles in that are in close proximity. This regional change will be accompanied by electromyography (EMG) recordings to confirm the presence of abnormality. Topical capsaicin and injectable capsaicin will be applied at three different concentrations, 0ug(placebo effect),50ug and 100ug.

Research Questions:

Does sensitization cause a significant regional change in the texture features of the targeted muscle or surrounding muscles? Is this regional change confirmed by abnormality of motor unit firing rates or EMG amplitudes? Is the response dose dependent? Does the induced central sensitization cause a change in force steadiness?

Experimental Protocol:

The physician on site will apply surface and intramuscular EMG sensors to the trapezius. A goniometer will be placed on the subjects arm to detect position. Following this, an ultrasound image of the trapezius, supraspinatus and infraspinatus will be taken.The participant will perform an increasing and decreasing contraction.The subject will then have capsaicin injected into their trapezius or applied onto their skin. The exercise and measurements will then be repeated. The ultrasound will be acquired by the Sonosite ultrasound system. The EMG data will be acquired by the Delsys Trigno EMG system for the surface EMG and the Cadwell Sierra Wave system for the intramuscular EMG. The data will be processed through Delsys EMGworks software and MATLAB. Texture features of the pre and post injection ultrasound images will be compared. Decomposition of motor units will allow for the analysis of motor unit action potential firing rate and amplitudes. Analysis of force steadiness will also be calculated via the goniometer.

Overall, the findings from this study should present preliminary evidence to inform central sensitization's effects on regional muscle structure changes, functional changes and motor unit activity.

Condition or Disease Intervention/Treatment Phase
  • Drug: Capsaicin
  • Device: Delsys Trigno Galileo System
  • Device: Cadwell Sierra Wave
  • Device: Sonosite Ultrasound Machine
  • Device: Goniometer
Early Phase 1

Detailed Description

Myofascial pain syndrome (MPS) is a prevalent chronic pain disorder primarily characterized by myofascial trigger points (MTrP). There is limited knowledge on the pathophysiology and mechanisms underlying MTrP and its development. Ultrasound investigations that have been performed on trigger points can differentiate between active and latent trigger points, but have not characterized the central sensitization aspect of them. The electromyography (EMG) investigations of central sensitization that have been performed mostly use hypertonic saline to induce hyperalgesia, and have demonstrated conflicting results. Central sensitization has been proposed as the primary mechanism underlying MTrP development. Central sensitization is associated with hyperexcitability of neuronal responses to normal or noxious stimuli. There is a need for a study that quantifies regional central sensitization using ultrasound to measure the changing structure, and electromyography to measure specific motor unit activity responses in the muscle.

Purpose The purpose of this study is to determine whether sensitizing healthy muscle using capsaicin induces a change in the structural integrity of the affected muscle, and determine if the motor unit frequency and amplitudes change within that region. Central sensitization will be induced using topical capsaicin and injectable capsaicin at three different concentrations. This is an exploratory trial that aims to provide preliminary evidence on whether central sensitization is a direct cause of taut band and MTrP development.

Our specific research questions are followings:
  1. Does sensitization cause a significant regional change in the texture features of the targeted muscle or surrounding muscles?

  2. Does capsaicin induced sensitization elicit a change in motor unit action potential(MUAP) amplitude by approximately 20 to 25% within the region of experimentally induced central sensitization or in the region of texture feature changes? Our hypothesis for this portion of the study is that sensitization modifies the anterior horn cell activity which will be measured by the amplitude of the potentials.

  3. Does capsaicin induced sensitization elicit continuous electrical activity as observed in MTrPs? This tests the hypothesis that sensitization creates the presence of continuous low amplitude action potentials.

  4. Does capsaicin induced sensitization influence the rate of recruitment of motor units in the muscle within the region induced? Does this occur within the regions identified by the changes in texture features? The recruitment of motor units is normally expected to follow the Henneman size principle.[20-23] Our hypothesis for this portion of the study is that sensitization will cause an aberration in recruitment. If this is demonstrated, then there is modification of the normal processing at both dorsal and ventral horns of the spinal cord.

  5. Is there a location dependent EMG response to capsaicin induced sensitization? In other words, do the texture features or EMG responses from muscles that lie anatomically distant from the location of the site of intramuscular capsaicin injection have changes from their baseline calculations? This would test the hypothesis that type III and IV afferents have an influence on the anterior horn cells that lie distant to the ones that are supplying muscle fibers in the vicinity of the stimulated sensory afferents.

  6. Is there a dose dependent EMG response at motor units to capsaicin induced sensitization? Here, the hypothesis of causality will be assessed in a preliminary manner. If there is a relationship then further experiments that more thoroughly assess causality will be needed.

This proposed study is a single centered, factorial, randomized placebo-controlled trial with two independent variables, depth of capsaicin application(3 levels) and dose of capsaicin(3 levels), for a total of 6 treatment arms and three control groups.The first between groups variable will be topical capsaicin application, injectable(intrafascial) and injectable(intramuscular) capsaicin injection. Within each partition, there will be three treatments: control, 50 micrograms, 100 micrograms. The control group will receive a topical skin lotion that is inert and has no sensitization effect. An equal number of participants will be allocated to each of the six treatment groups using an electronic randomization generator. Block randomization will be used to ensure equal allotment into each group.

Capsaicin Application and Injection Capsaicin will be applied directly to the region of the innervation zone at the muscle belly to sensitize the neurons within the region of taut band development. Topical and intramuscular capsaicin will be used. The capsaicin formula will be compounded by a registered pharmacist. Topical capsaicin will be delivered in a cream and injectable capsaicin will be intermixed with saline prior to injection. The control group in the topical capsaicin arm will be treated with the cream base used during the experiment without added capsaicin and the injection arm will be injected with saline. A trained medical professional on the research team will apply the topical capsaicin or topical placebo treatments. The region of topical application will measure 5cm squared in the dermatome zone location to cover an area of approximately 25cm2. A trained physician in physical medicine and rehabilitation will deliver injectable capsaicin using a 27-gauge needle at the location of the superior fascia of the upper trapezius muscle with ultrasound guidance. Intramuscular capsaicin will also be injected using ultrasound guidance to avoid the superior or inferior fascia.

To confirm the presence of central sensitization, brush allodynia will be used to detect mechanical hyperalgesia outside the region of primary nociception. The size of the region of secondary hyperalgesia will be measured to characterize the extent of central sensitization. This will be accomplished using a tape measure and the perpendicular dimensions of the region of secondary hyperalgesia will be recorded in square centimeters.

Experimental Protocol The anatomical location for ultrasound probe and electrode placement will be identified for each participant. The ultrasound probe will be placed on 3 muscles: the trapezius, the supraspinatus, and the infraspinatus. Two ultrasonic pictures will be taken of each. The area will then be cleaned with alcohol and water. The Delsys Galileo sensor, and the intramuscular needle electrode will be placed directly on the trapezius' identified area. Participants will be asked to gently contract their trapezius muscle. They will be instructed to perform a gradually increasing contraction in isometric condition, in a controlled manner. They will hold this contraction at 30% of their maximal voluntary contraction, and then perform a gradually decreasing contraction to rest. This will be performed four times for each type of study intervention and before as well as after each intervention, namely topical control cream, topical capsaicin at 50ug and 100 ug, injection of the superior aspect of the superior fascia followed by intramuscular injection with these two concentrations of capsaicin. The placement of these latter will be verified by ultrasound guidance. The intramuscular needle will then be removed and participants will be bandaged and cared for appropriately by the expert physician performing the experiment. Participants will be re-examined to determine if there were any adverse effects from the experimental procedures. If any occurred, then these will be carefully managed by the medical members of the research team and recorded. Participants will be asked to remain at the lab for an additional 30 minutes to ensure they are well prior to leaving.

Ultrasound Analysis Texture analysis will be performed using MATLAB and the image and signal processing toolbox. Analyses will include first order parameters such as mean and standard deviation of the pixel level values, as well as second order parameters, which provide details on the spatial distribution of pixel values. These include co-occurance and run-length matrices, local binary pattern and blob analysis.

EMG Analysis The following parameters will be analyzed: the firing times and frequency of individual motor units, motor unit action potential amplitude and shapes, the root mean square value (RMS) of each channel and of the entire signal, the coefficient of variation for force steadiness, and the centroid of the EMG signal in the cranial-caudal and the medial-lateral directions. These procedures will be repeated for each contraction.

The results of this study should provide insight into the structural changes and motor changes at the region of sensitization, as well as in adjacent muscles.This will provide further insight as to whether structural changes are accompanied by motor changes within the same region, and inform further investigations into the pathophysiology of myofascial pain.

The full study protocol and statistical analysis plan is submitted in the documents section.

Study Design

Study Type:
Interventional
Actual Enrollment :
20 participants
Allocation:
Randomized
Intervention Model:
Factorial Assignment
Intervention Model Description:
A single-centered, factorial, randomized, placebo-controlled trial with two independent variables (dosage and depth of application).A single-centered, factorial, randomized, placebo-controlled trial with two independent variables (dosage and depth of application).
Masking:
Single (Participant)
Masking Description:
Participants and investigators will be blinded to the delivered dose; however, the type of capsaicin delivery cannot be blinded from either participants or investigators. The member of the research team conducting the randomization schedule and concealing allocation will have knowledge of and keep track of the doses contained in the containers and vials of the topical and injectable capsaicin, respectively. They will deliver the appropriate dose to the team member implementing the experimental protocol to ensure there is blinding with respect to dose.
Primary Purpose:
Basic Science
Official Title:
Quantitative Response of Healthy Muscle Following the Induction of Capsaicin
Actual Study Start Date :
Jul 1, 2019
Actual Primary Completion Date :
Jul 1, 2020
Actual Study Completion Date :
Dec 1, 2020

Arms and Interventions

Arm Intervention/Treatment
Placebo Comparator: Placebo Topical

Placebo Cream, applied topically to trapezius muscle

Device: Delsys Trigno Galileo System
This device is a wireless surface EMG device.

Device: Cadwell Sierra Wave
Intramuscular EMG recording machinery

Device: Sonosite Ultrasound Machine
Ultrasound System

Device: Goniometer
A device to measure angular position

Active Comparator: Low Dose, Topical

Capsaicin Cream- low dosage, applied topically to trapezius

Drug: Capsaicin
Capsaicin 50ug (low dose), Capsaicin 100ug(high dose) will be administered as a topical skin cream and will be intermixed with saline for the injectable solution.

Device: Delsys Trigno Galileo System
This device is a wireless surface EMG device.

Device: Cadwell Sierra Wave
Intramuscular EMG recording machinery

Device: Sonosite Ultrasound Machine
Ultrasound System

Device: Goniometer
A device to measure angular position

Active Comparator: High Dose, Topical

Capsaicin Cream- higher dosage, applied topically to trapezius

Drug: Capsaicin
Capsaicin 50ug (low dose), Capsaicin 100ug(high dose) will be administered as a topical skin cream and will be intermixed with saline for the injectable solution.

Device: Delsys Trigno Galileo System
This device is a wireless surface EMG device.

Device: Cadwell Sierra Wave
Intramuscular EMG recording machinery

Device: Sonosite Ultrasound Machine
Ultrasound System

Device: Goniometer
A device to measure angular position

Placebo Comparator: Placebo, Intrafascial

Injection placebo(saline)- injected intrafascially into trapezius

Device: Delsys Trigno Galileo System
This device is a wireless surface EMG device.

Device: Cadwell Sierra Wave
Intramuscular EMG recording machinery

Device: Sonosite Ultrasound Machine
Ultrasound System

Device: Goniometer
A device to measure angular position

Active Comparator: Low Dose, Intrafacial

Injection Capsaicin formulation low dose- injected intrafascially into trapezius

Drug: Capsaicin
Capsaicin 50ug (low dose), Capsaicin 100ug(high dose) will be administered as a topical skin cream and will be intermixed with saline for the injectable solution.

Device: Delsys Trigno Galileo System
This device is a wireless surface EMG device.

Device: Cadwell Sierra Wave
Intramuscular EMG recording machinery

Device: Sonosite Ultrasound Machine
Ultrasound System

Device: Goniometer
A device to measure angular position

Active Comparator: High Dose, Intrafascial

Injection Capsaicin formulation higher dose- injected intrafascially into trapezius

Drug: Capsaicin
Capsaicin 50ug (low dose), Capsaicin 100ug(high dose) will be administered as a topical skin cream and will be intermixed with saline for the injectable solution.

Device: Delsys Trigno Galileo System
This device is a wireless surface EMG device.

Device: Cadwell Sierra Wave
Intramuscular EMG recording machinery

Device: Sonosite Ultrasound Machine
Ultrasound System

Device: Goniometer
A device to measure angular position

Placebo Comparator: Placebo, Intramuscular

Injection placebo (saline) - injected intramuscularly into trapezius

Device: Delsys Trigno Galileo System
This device is a wireless surface EMG device.

Device: Cadwell Sierra Wave
Intramuscular EMG recording machinery

Device: Sonosite Ultrasound Machine
Ultrasound System

Device: Goniometer
A device to measure angular position

Active Comparator: Low Dose, Intramuscular

Injection Capsaicin formulation low dose - injected intramuscularly into trapezius

Drug: Capsaicin
Capsaicin 50ug (low dose), Capsaicin 100ug(high dose) will be administered as a topical skin cream and will be intermixed with saline for the injectable solution.

Device: Delsys Trigno Galileo System
This device is a wireless surface EMG device.

Device: Cadwell Sierra Wave
Intramuscular EMG recording machinery

Device: Sonosite Ultrasound Machine
Ultrasound System

Device: Goniometer
A device to measure angular position

Active Comparator: High Dose, Intramuscular

Injection Capsaicin formulation higher dose - injected intramuscularly into trapezius

Drug: Capsaicin
Capsaicin 50ug (low dose), Capsaicin 100ug(high dose) will be administered as a topical skin cream and will be intermixed with saline for the injectable solution.

Device: Delsys Trigno Galileo System
This device is a wireless surface EMG device.

Device: Cadwell Sierra Wave
Intramuscular EMG recording machinery

Device: Sonosite Ultrasound Machine
Ultrasound System

Device: Goniometer
A device to measure angular position

Outcome Measures

Primary Outcome Measures

  1. Motor Unit Action Potential Firing Rate [up to 6 months]

    Firing rate will be determined using EMGworks software and compared with baseline firing rates.

  2. Root Mean Square EMG values [up to 6 months]

    Root mean square values will be compared with baseline values using EMGworks software.

  3. Coefficient of Variation- Force steadiness [up to 6 months]

    Force steadiness will be measured by the coefficient of variation (standard deviation/mean) using EMGworks software, validated through the goniometer measurements

  4. Motor Unit Action Potential Amplitudes [up to 6 months]

    Amplitudes will be measured from the overall amplitude difference from baseline for each motor unit using EMGworks software

  5. Centroid of Frequency Spectrum [up to 6 months]

    Centroid frequency will be measured and the frequency shift of the signal will be compared with baseline. Measured using EMGworks software

  6. Texture Feature Analysis [up to 6 months]

    91 features will be extracted using MATLAB, then a reduction of variables will be performed using principal component analysis. The experimental data will be compared with baseline results.

Secondary Outcome Measures

  1. Severity of pain [up to 6 months]

    Pain, or burning sensation measured by the visual analogue scale(0-no pain to 10-worst pain imaginable)

Eligibility Criteria

Criteria

Ages Eligible for Study:
18 Years to 64 Years
Sexes Eligible for Study:
All
Accepts Healthy Volunteers:
Yes
Inclusion Criteria:
  • healthy with no past medical history

  • a visual analogue score below 3 indicating low pain severity, ideally who complain of no pain

  • right or left handed

  • normal body mass index

  • have sufficient knowledge of the English language to provide informed consent and understand the protocols

  • agree to sign a consent form.

Exclusion Criteria:
  • history of pain

  • detectable myofascial trigger points upon physical examination

  • history of pain related disturbances such as poor sleep

  • cognitive disturbances, psychiatric disorders

  • history of general medical disorder that may affect the outcome of the study such as diabetes mellitus

  • history of cervical radiculopathies

  • history of inflammatory arthropathy

Contacts and Locations

Locations

Site City State Country Postal Code
1 Toronto Rehabilitation Institute Toronto Ontario Canada M5S 1A1

Sponsors and Collaborators

  • Toronto Rehabilitation Institute

Investigators

  • Principal Investigator: Dinesh M Kumbahre, MD,PhD, Toronto Rehabilitation Institute

Study Documents (Full-Text)

More Information

Publications

Responsible Party:
Dinesh Kumbhare, Affiliate Scientist, Toronto Rehabilitation Institute
ClinicalTrials.gov Identifier:
NCT03944889
Other Study ID Numbers:
  • CapsaicinUltrasound
First Posted:
May 10, 2019
Last Update Posted:
Dec 3, 2020
Last Verified:
Dec 1, 2020
Individual Participant Data (IPD) Sharing Statement:
No
Plan to Share IPD:
No
Studies a U.S. FDA-regulated Drug Product:
Yes
Studies a U.S. FDA-regulated Device Product:
Yes
Product Manufactured in and Exported from the U.S.:
Yes
Keywords provided by Dinesh Kumbhare, Affiliate Scientist, Toronto Rehabilitation Institute
Additional relevant MeSH terms:

Study Results

No Results Posted as of Dec 3, 2020