Acute aerobic exercise does not modulate pain potentially due to differences in fitness levels and sex effects – results from a pharmacological fMRI study

Reviewer #1 (Public review):

Summary:

Participants in this study completed three visits. In the first, participants received experimental thermal stimulations which were calibrated to elicit three specific pain responses (30, 50, 70) on a 0-100 visual analogue scale (VAS). Experimental pressure stimulations were also calibrated at an intensity to the same three pain intensity responses. In the subsequent two visits, participants completed another pre-calibration check (Visit 2 of 3 only). Then, prior to the exercise NALOXONE or a SALINE placebo-control was administered intravenously. Participants then completed 1 of 4 blocks of HIGH (100%) or LOW (55%) intensity cycling which was tailored according to a functional threshold power (FTP) test completed in Visit 1. After each block of cycling lasting 10 minutes, participants entered an MRI scanner and were stimulated with the same thermal and pressure stimulations that corresponded to 30, 50, and 70 pain intensity ratings from the calibration stage. Therefore, this study ultimately sought to investigate whether aerobic exercise does indeed incur a hypoalgesia effect. More specifically, researchers tested the validity of the proposed endogenous pain modulation mechanism. Further investigation into whether the intensity of exercise had an effect on pain and the neurological activation of pain-related brain centres were also explored.

Results show that in the experimental visits (Visit 2 and 3), when participants exercised at two distinct intensities as intended. Power output, heart rate, and perceived effort ratings were higher during the HIGH versus LOW-intensity cycling. In particular. HIGH intensity exercise was perceived as "hard" / ~15 on the Borg (1974, 1998) scale, whereas LOW intensity exercise was perceived as "very light" / ~9 on the same scale.

The fMRI data from Figure 1 indicates that the anterior insula, dorsal posterior insula, and middle cingulate cortex show pronounced activation as stimulation intensity and subsequent pain responses increased, thus linking these brain regions with pain intensity and corroborating what many studies have shown before.

Results also showed that participants rated a higher pain intensity in the NALOXONE condition at all three stimulation intensities compared to the SALINE condition. Therefore, the expected effect of NALOXONE in this study seemed to occur whereby opioid receptors were "blocked" and thus resulted in higher pain ratings compared to a SALINE condition where opioid receptors were "not blocked". When accounting for participant sex, NALOXONE had negligible effects at lower experimental nociceptive stimulations for females compared to males who showed a hyperalgesia effect to NALOXONE at all stimulation intensities (peak effect at 50 VAS). Females did show a hyperalgesia effect at stimulation intensities corresponding to 50 and 70 VAS pain ratings. The fMRI data showed that the periaqueductal gray (PAG) showed increased activation in the NALOXONE versus SALINE condition at higher thermal stimulation intensities. The PAG is well-linked to endogenous pain modulation.

When assessing the effects of NALOXONE and SALINE after exercise, results showed no significant differences in subsequent pain intensity ratings.

When assessing the effect of aerobic exercise intensity on subsequent pain intensity ratings, authors suggested that aerobic exercise in the form of a continuous cycling exercise tailored to an individual's FTP is not effective at eliciting an exercise-induced hypoalgesia response -irrespective of exercise intensity. This is because results showed that pain responses did not differ significantly between HIGH and LOW intensity exercise with (NALOXONE) and without (SALINE) an opioid antagonist. Therefore, authors have also questioned the mechanisms (endogenous opioids) behind this effect.

Strengths:

Altogether, the paper is a great piece of work that has provided some truly useful insight into the neurological and perceptual mechanisms associated with pain and exercise-induced hypoalgesia. The authors have gone to great lengths to delve into their research question(s) and their methodological approach is relatively sound. The study has incorporated effective pseudo-randomisation and conducted a rigorous set of statistical analyses to account for as many confounds as possible. I will particularly credit the authors on their analysis which explores the impact of sex and female participants' stage of menses on the study outcomes. It would be particularly interesting for future work to pursue some of these lines of research which investigate the differences in the endogenous opioid mechanism between sexes and the added interaction of stage of menses or training status.

There are certainly many other areas that this article contributes to the literature due to the depth of methods the research team has used. For example, the authors provide much insight into: the impact of exercise intensity on the exercise-induced hypoalgesia effect; the impact of sex on the endogenous opioid modulation mechanism; and the impact of exercise intensity on the neurological indices associated with endogenous pain modulation and pain processing. All of which, the researchers should be credited for due to the time and effort they have spent completing this study. Indeed, their in-depth analysis of many of these areas provides ample support for the claims they make in relation to these specific questions. As such, I consider their evidence concerning the fMRI data to be very convincing (and interesting).

Weaknesses:

Although the authors have their own view of their results, I do however, have a slightly different take on what the post-exercise pain ratings seem to show and its implications for judging whether an exercise-induced hypoalgesia effect is present or not. From what I have read, I cannot seem to find whether the authors have compared the post-exercise pain ratings against any data that was collected pre-exercise/at rest or as part of the calibration. Instead, I believe the authors have only compared post-exercise pain ratings against one another (i.e., HIGH versus LOW, NALOXONE versus SALINE). In doing so, I think the authors cannot fully assume that there is no exercise-induced hypoalgesia effect as there is no true control comparison (a no-exercise condition).

In more detail, Figure 6A appears to show an average of all pain ratings combined per participant (is this correct?). As participants were exposed to stimulations expected to elicit a 30, 50, or 70 VAS rating based on pre-calibration values, therefore the average rating would be expected to be around 50. What Figure 6A shows is that in the SALINE condition, average pain ratings are in fact ~10-15 units lower (~35) and then in the NALOXONE condition, average pain ratings are ~5 units lower (~45) for both exercise intensities. From this, I would surmise the following:

It appears there is an exercise-induced hypoalgesia effect as average pain ratings are ~30% lower than pre-calibrated/resting pain ratings within the SALINE condition at the same temperature of stimulation (it would also be interesting to see if this effect occurred for the pressure pain).

It appears there is evidence for the endogenous opioid mechanism as the NALOXONE condition demonstrates a minimal hypoalgesia effect after exercise. I.e., NALOXONE indeed blocked the opioid receptors, and such inhibition prevented the endogenous opioid system from taking effect.

It appears there is no effect of exercise intensity on the exercise-induced hypoalgesia effect. That is, participants can cycle at a moderate intensity (55% FTP) and incur the same hypoalgesia benefits as cycling at an intensity that demarcates the boundary between heavy and severe intensity exercise (100%FTP). This is a great finding in my mind as anyone wishing to reduce pain can do so without having to engage in exercise that is too effortful/intense and therefore aversive - great news! This likely has many applications within the field of public health.

I will very slightly caveat my summaries with the fact that a more ideal comparison here would be a control condition whereby participants did the same experimental visit but without any exercise prior to entering the MRI scanner. I consider the overall strength of the evidence to be solid, with the answer to the primary research question still a little ambiguous.

Reviewer #2 (Public review):

Summary:

This interesting study compared two different intensities of aerobic exercise (low-intensity, high-intensity) and their efficacy in inducing a hypoalgesic reaction (i.e. exercise-induced hypoalgesia; EIH). fMRI was used to identify signal changes in the brain, with the infusion of naloxone used to identify hypoalgesia mechanisms. No differences were found in post-exercise pain perception between the high-intensity and low-intensity conditions, with naloxone infusion causing increased pain perception across both conditions which was mirrored by activation in the medial frontal cortex (identified by fMRI). However, the primary conclusion made in this manuscript (i.e. that aerobic exercise has no overall effect on pain in a mixed population sample) cannot be supported by this study design, because the methodology did not include a baseline (i.e. pain perception following no exercise) to compare high/low-intensity exercise against. Therefore, some of the statements/implications of the findings made in this manuscript need to be very carefully assessed.

Strengths:

(1) The use of fMRI and naloxone provides a strong approach by which to identify possible mechanisms of EIH.

(2) The infusion of naloxone to maintain a stable concentration helps to ensure a consistent effect and that the time course of the protocol won't affect the consistency of changes in pain perception.

(3) The manipulation checks (differences in intensity of exercise, appropriate pain induction) are approached in a systematic way.

(4) Whilst the exploratory analyses relating to the interactions for fitness level and sex were not reported in the study pre-registation, they do provide some interesting findings which should be explored further.

Weaknesses:

(1) Given that there is no baseline/control condition, it cannot be concluded that aerobic exercise has no effect on pain modulation because that comparison has not been made (i.e. pain perception at 'baseline' has not been compared with pain perception after high/low-intensity exercise). Some of the primary findings/conclusions throughout the manuscript state that there is 'No overall effect of aerobic exercise on pain modulation', but this cannot be concluded.

(2) Across the manuscript, a number of terms are used interchangeably (and applied, it seems, incorrectly) which makes the interpretation of the manuscript difficult (e.g. how the author's use the term 'exercise-induced pain').

(3) There is a lack of clarity on the interventions used in the methods, for example, it is not exactly clear the time and order in which the exercise tasks were implemented.

(4) The exercise test (functional threshold power) used to set the intensity of the low/high exercise bouts is not an accurate means of demarcating steady state and non-steady state exercise. As a result, at the intensity selected for the high-intensity exercise in this study, it is likely that the challenge presented for the high-intensity exercise would have been very different between participants (e.g. some would have been in the 'heavy' domain, whereas others would be in the 'severe' domain).

(5) It is likely that participants did not properly understand how to use the 6-20 Borg scale to rate their perceived effort, and so caution must be taken in how this RPE data is used/interpreted.

(6) Although interesting, the secondary analyses (relating to the interaction effects of fitness level and sex) were not included in the study pre-registration, and so the study was not designed to undertake this analysis. These findings should be taken with caution.