pathophysiology of acute & chronic pain
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Pathophysiology of Acute & Chronic Pain. Steven Stanos, DO Center for Pain Management Rehabilitation Institute of Chicago Dept. of PM&R, Northwestern University Medical School Feinberg School of Medicine. Nociceptive vs. Neuropathic Receptors and channels Inflammation - PowerPoint PPT PresentationTRANSCRIPT
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Pathophysiology of Acute & Chronic Pain
Steven Stanos, DOCenter for Pain Management
Rehabilitation Institute of ChicagoDept. of PM&R, Northwestern
University Medical SchoolFeinberg School of Medicine
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• Nociceptive vs. Neuropathic• Receptors and channels• Inflammation• Peripheral Sensitization• Central Sensitization• Temperature Sensation• Plasticity & Brain Changes• Muscle Pain• Cytokines: the Future
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Nociceptive vs. Neuropathic Pain
*Complex regional pain syndrome type II.1. Portenoy RK, Kanner RM. In: Pain Management: Theory and Practice. Philadelphia, PA: FA Davis Company; 1996:4.2. Merskey H, Bogduk N, eds. Classification of Chronic Pain. 2nd ed. Seattle, WA: IASP Press; 1994. 3. Galer BS, Dworkin RH. A Clinical Guide to Neuropathic Pain. Minneapolis, MN: McGraw-Hill; 2000.
Other “Mixed” Pain Types?
NociceptivePain
(Inflammatory?)1
Neuropathic Pain2,3
Postoperativepain
Mechanicallow back pain
Sickle cellcrisis
Arthritis
Postherpeticneuralgia
(PHN)
Neuropathic low back pain
CRPSII*
Sports/exerciseinjuries
Central post-stroke pain
Trigeminalneuralgia
Distalpolyneuropathy (e.g., diabetic, HIV)
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The BIOMEDICAL Model
• Pain as a sensory event reflecting underlying disease or tissue damage
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Gate Control Theory
Melzack R. In: Cousins MJ, Bridenbaugh PO, eds. Neural Blockade in Clinical Anesthesia and Management of Pain. 3rd ed. Philadelphia, Penn: Lippincott Williams & Wilkins; 1998.
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Gate Control Theory
Melzack R, Wall PD. Science. 1965;150:971-976.
A. Sensory
B. Affective
C. Evaluative
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Enteroceptive Sensations
• Pain
• Thirst
• Hunger
• Thermoception
• Neurophysiologic changes
• Neurochemical changes
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Biological Functions of Pain
Sherrington (1906)
Exteroceptive:
Interoceptive:
Escape and avoidance of external threats
protection of injured or dysfunctional tissues that
disrupt homeostasis
Price DD et al. Pain 2003, 106.
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Physiological Pain
• Initiated and by specialized sensory nociceptors innervating peripheral tissues and responding only to noxious stimuli
• Projects to spinal cord and cortex
• Activates reflex withdrawal, increase in arousal, emotional, autonomic and neurohumoral responses
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Chronic Pain
Hyperalgesia Allodynia
The Role of Plasticity in Chronic Pain
Injury
Acute Pain
Healing With PlasticityNormal Healing
Pain Relief
Adapted from Marcus DM. Am Fam Physician. 2000;61:1331-1338.
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Neuronal Plasticity and Pain
• Normal adaptive function• Neurons detecting and transmitting pain
display “plasticity”– A capacity to change function, chemical profile,
or structure– A response to painful stimuli and inflammation– A contributor to altered sensitivity to pain
• When persistent can lead to permanent neuropathic pain
Woolf CJ, et al. Science. 2000;288:1765-1768.
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Pain Pathophysiology
• Nociceptive pain– Believed to be related to ongoing activation of an
intact nervous system by tissue injury • Somatic • Visceral
• Neuropathic pain– Believed to be related to aberrant somatosensory
processing in the peripheral nervous system, the central nervous system, or both
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Nociception
• Transduction: detection of noxious or damaging stimuli
• Conduction: passage of resulting sensory input from peripheral terminals to the spinal cord
• Transmission: synaptic transfer of input to neurones within specific laminae of DH
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Physiology of Pain Perception1-3
1. Galer BS, Dworkin RH. A Clinical Guide to Neuropathic Pain. Minneapolis, MN: McGraw-Hill; 2000.2. Irving GA, Wallace MS. Pain Management for the Practicing Physician. New York, NY: Churchill Livingstone; 1997.3. Woolf CJ, et al. Ann Intern Med. 2004;140:441-451.
Injury
PeripheralNerve
Brain
DescendingPathway
AscendingPathway
SpinalCord
DorsalHorn
DorsalRoot
Ganglion
C-Fiber
α-β Fiber
α-δ Fiber
Conduction
Transduction
Transmission/Modulation
Perception
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Kidd, Urban. Br J Anaesthesia 2001;87(1).
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Pathologic vs. PhysiologicPathologic vs. Physiologic
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C-nociceptors; C-polymodal; warmth, mechano;postganglioic autonomic; enteric nerve fibers
No0.5-2.0C <1.5IV
Preganglionic autonomic
+3-15B<3-
A-δ specific & polymodal; cold; hair; visceral (+/-)
+5-30A-δ1-6III
Muscle efferents (intrafusal)
+10-50A-γ2-10-
Encapsulated endings;Merkel
+30-70A-β6-12+II
Muscle efferents
(extrafusal)+70-120A-α12-20-
Golgi Tendon organs+70-120-12-20I-b
Muscle spindle primary endings
+70-120-12-20I-a
Receptor/ endingMyelin
Conduction velocity
(m/sec)
Letter
System
Diameter
(µm)
Lloyd /Hunt
Adapted from Nolte J. The human bran. St.Louis: Mosby, 1999:213.
Classification of Fibers in Peripheral Nerves
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Conduction Velocity: Aδ & C fibers
• Aδ (Fast pain)1
• C-fibers (Slow pain)1
• Age related impairment in fast pain fibers2
1. Julius D, Basbaum A, Nature 2001(413).2. Chakour M,, et al. Pain 1996; 64:143.
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Kidd, Urban. Br J of Anaesth 87, 2001.
Receptors
Non-painful stimuli:• Specificity for a particular stimulus• High degree of gain to amplify weak signals• Rapid adaptation to increasing intensities
Painful stimuli:• Specificity less important• High threshold receptors: thermal, chemical and
mechanical stimuli (polymodal)• Threshold for firing may decrease
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Caterina, Cur Op in Neurobiology (9), 1999.
CutaneousC-fiber • Small diameter• Slow conducting• Unmyelinated
1. Proinflammitory peptides
Subst P
CGRP
Lamina I/II
* tissue inflammation
(NGF)
2. Specific enzymes/ Lectin IB4
*chronic neuropathic pain
(GDNF)
A-δ• Medium diameter• Fast conducting• Lightly myelinated• Polymodal
Type I
Long response latency
> 50°C
Persistent pain
2. Type II
Short response
43°C
Initial burn
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Millan, Progress in Neurobiology, 1999.
Primary Afferent C & Aβ Fibers
Sensation MediatedFibre Class
Threshold For Activation
Principal Transmitters
Receptors Engaged
Physiological Pathological
C High SP/NKA
CGRP
EAA
NK
CGRP
NMDA
AMPA
mGlu
Noxious (pain)
Highly noxious
(hyperalgesia)
Cold Allodynia
(pain)
Aβ Low EAA AMPA Innocuous (no pain)
Mechanical
allodynia
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Receptor types on sensory neurons
Transduction mechanism Example Cellular effect
Ligand-gated channel Capsaicin-heat ExcitationH , 5HT, ATPGlutamate, GABA-A
G-protein linked GABA-B Inhibition ofOpiated, Adenosine transmitter &Adrenoreceptors peptide releaseNPY, 5HT
Bradykinin(B2) Excitation Histamine (H1) and/or Adrenoreceptors (α2) sensitizationPGE2
Tyrosine kinase linked NGF (Trk A) Control of geneexpression
Bevan S. Textbook of Pain, 4th ed. Wall, Malzack, 1999.
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• Dynamic, constantly changing
• Plasticity reflects sensitivity needed for survival
• Injury: amygdala, hippocampus, and DRG
• Normal peripheral nerves (resist)
• Demyelination: density
Ion Channels
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Receptors
• Capsaicin/ Vanilloid • Purinergic (P2X)
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Ion Channel Linked Receptors
Receptors• Vanilloid (VR-1)• Acid-sensing (ASIC)• Purinergic (P2X)• Cannabinoid
Ion Channels• Sodium
– TTX-S– TTX-R
• Calcium
Kidd BL, Urban LA, Br J of Anaesthesia (1). 2001.
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Caterina. Cur Op in Neurobiology (9), 1999.
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Nociception in Other Organs
• Less differentiation
• Autonomic component
• Poorly localized
• Referred pain
• Absence of Aβ in viscera
• Skeletal muscle: group III, group IV
• Joint: group III & group IV respond to stretch
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Cervero F, Laird J, Lancet 353, 1999.
Visceral PainPsychophysics• Not evoked from all
viscera• Not always linked to
injury• Referred to body wall• Diffuse & poorly
localized• Intense motor &
autonomic reactions
Neurobiology• Not all innervated by
“sensory receptors”• Functional properties of
afferents• Viscerosomatic
convergence in CNS• Few “sensory” visceral
afferents, diverge CNS• Warning system,
capacity for amplification
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Siddal, Cousins. Neural Blockade in Clinical Anesthesia and Management of Pain, Third Ed.,1998.
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Milan MJ, Progress in Neurobiology 66, 2002.
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Inflammation
• Redness (rubor)
• Heat (calor)
• Swelling (tumor)
• Loss of function (function lasea)
• Pain (dolor)
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Inflammation
• Macrophages:
– Cytokines(IL1, IL6, TNF-α)
– Nerve Growth Factor
• Damaged Cells:
– ATP and protons
• Mast Cells:
– Histamine, serotonin, prostaglandins, arachidonic acid metabolites
• Upregulation of receptors
– VR1, SNS, SNS-2 & Peptides
• Phenotypic Switch ( A-fiber into C-fiber)
Jensen et al. Acat Anaesthesiol Scand 45, 2001.
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Inflammation
• Short-term– Modifications in excitation & sensitization of
peripheral sensory terminals
• Longer-term– Changes in properties of afferents– Decrease in threshold for firing– Increase in excitability of spinal neurons
Mamet et al. J of Neuroscience, 22(24), 2002.
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Hyperalgesia Sensitization
pain threshold threshold for response
pain to suprathreshold response to
stimuli suprathreshold stimuli
Spontaneous pain Spontaneous activity
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SENSITIZING ‘SOUP’Hydrogen Ions Histamine Purines
Noradrenaline Potassium Cytokines
Bradykinin Prostaglandins NGF
Leukotrienes 5-HTNeuropeptides
Tissue Damage
Woolf, Chong. Anesth. Analgesia (77), 1993.
Peripheral Sensitization
Inflammation Sympathetic Terminals
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SKIN
Peripheral Sensitization
PeripheralNerve
Terminal
Pressure ?
Plasma ExtravasationVasodilation
Heat 5-HT3 PGE2
Bradykinin
VR1 5-HT3 EP B1/B2
IL1ß
MastCell
Macrophage
(PKC)
TNF-α IL-6LIF
IL1-R TrkAH+
PKC
TTXr(SNS/SNS2)
Sub P
Gene Regulation
TTXr
TTXs
H+
P2X ASIC
Adapted from Woolf CJ, et al. Science. 2000;288:1765-1768.
TissueDamage
ATPNGF
H1
Histamine
Ca2+
PKA
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Central Sensitization: wind up
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With permission. Jensen TS et al. Acta Anaesth Scand, 45, 2001.
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Mechanisms of Nociceptive Central Pain
• Autosensitization of receptors
• Ectopic firing of DRG cells
• Calcium-induced molecular cascades from excess glutamate
• Phenotypic change of A-β cells and DRG
• Changes in gene expression of sodium channels and neuropeptides
• Anatomic changes at dorsal horn
Schwarzman et al. Neurological Review, 58, 2001.
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With Permission. Woolf,2000.
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Mechanisms of nociceptive central pain
1. Autosensitization of receptors
2. Ectopic firing of DRG cells
3. Calcium-induced molecular cascades from excess glutamate
4. Phenotypic change of A-β cells and DRG
5. Changes in gene expression of sodium channels and neuropeptides
6. Anatomic changes at dorsal horn
Schwarzman et al. Neurological Review, 58, 2001.
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Neuropathic Pain Is Defined as…
…Pain caused by a lesion or dysfunction of the nervous system1
• Nerve sensitization or damage can be located in the peripheral or central nervous system1
• Manifests with sensory symptoms and signs2
• May have both positive and negative sensory and motor symptoms and signs2
1. Merskey H, Bogduk N, eds. Classification of Chronic Pain. 2nd ed. Seattle, WA: IASP Press; 1994.2. Backonja MM. Anesth Analg. 2003;97:785-790.
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Examples of Peripheral vs. Central Sensitization
Adapted from Woolf CJ, Mannion RJ. Lancet. 1999;353:1959-1964.
Sensory function after nerve injury with spontaneous firing along axon
No Stimulus Pain
SensationNociceptorDorsal Horn
Neuron
To Brain
Central sensitization occurs as a result of increased nociceptor drive or disinhibition after nerve injury, leading to exaggerated dorsal horn response
Disinhibition
Innocuous or Noxious Stimulus
Dorsal Horn Neuron
To Brain
Increased Nociceptor Drive
Innocuous Stimulus
Dorsal Horn Neuron
Inhibitory Input Is Downregulated
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Persistent Pain as a Disease Entity:
• Increase peripheral input: increase DH firing
• Increase firing: increased NMDA, Ca, PKC, Nitric Oxide
• Increase PKC, Ca: genetic changes
• Increase NO: decreased GABA neurons
• Increase Neurotrophins: sprouting
Cousins, MJ, 2009 AAPM
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Beydoun A, Backonja. J Pain Symp Management 2003.
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Temperature
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Thermosensation
Julius D, Proc 10th Word Conference of Pain, 2003.
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Thermosensation
TRP channel family
• TRV2 >53 C Noxious heat
• TRPV1 (Vanilloid) >43 C Heat, capsaicin, acid
• TRPV3/TRPV4 >30-40 C Warm
• TRPM8 (CMRI) >25 C Cold, menthol
• TRPA1 <17 C Noxious cold
Szalassi et al. Nature Rev 2007;6.
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ThermosensationCold• 10-15% C & A-delta• Specificity vs. modulation
of excitatory & inhibitory channels
• K, Na, Ca channels• CMRI (cold- and menthol-
sensitive receptor) cloned• TRP (transient receptor
potential)
Heat• Capsaicin• Vanilloid receptor subtype
1 (VR1 or TRPV1)• Thermal activation
threshold ~43°C• Polymodal, influenced by
a variety of substances
Julius D, Proc 10th Word Conference of Pain, 2003.
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Capsaicin
genus Capsicum:
mildest (bell) to hottest (habanero)
Capsaicin: 16,000,000 SHU habanero: 200,000 SHU
Classic:
• Activates, desensitize (Ca²), and exert neurotoxic effects on polymodal nociceptors
• release of Subst P & CGRP, nerve degeneration (NGF), loss of intraepidermal fibers
• “pharmacological” & “functional desensitization” via VR1 receptor
Anand P. Gut 52, 2003. Robbins W. Clin J Pain 16(2), 2000.
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TRPV Channels:
Szalassi et al. Nature Rev 2007;6.
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Menthol: natural analgesic
• Mentha species• peppermint plant, cornmint oil,
citronella, eucalyptus & Indian turpentine oil
• “coolness”: stimulation of cold receptors by (-) Calcium currents of neuronal membranes, increasing pain thresholds
• Activation of central “κ” Opioid system
Galeotti N. Neuroscience Letters 322 (2002). McKeny, Nature 416, 2002.
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Pain Neurochemistry
To brain
Dorsal horn
Substance P, aspartate, neurotensin, glutamate
Spinal cord
Dorsal root ganglion
Tissue injury
Bradykinin
Leukotrienes
Ion fluxes (H+/ K+)
Prostaglandins
Transmission via spinothalamic tract
to brain
Substance P
Histamine Sensitized nociceptor
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Neuromatrix
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Apkarian AV, et al. J of Neuroscience, 24(46), 2004.
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Price DD. Science 2000.
Price DD. Science. 2000;288:1769-1772.
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Price DD. Science. 2000;288:1769-1772.
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“Pain Matrix”
Moseley GL. Man Ther. 2003;8(3):130-140.
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“Pain Matrix”
• Anterior cingulate cortex (ACC)
• Insular cortex (IC)
• Thalamus
• Sensorimotor cortex (SSI, SSII)
• Cerebellum
Moseley GL. Man Ther. 2003;8(3):130-140.
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Petrovic P, et al. Science 2002;295:1737-1740.
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Petrovic P, et al. Science. 2002;295:1737-1740.
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Opioid Systems
• Reynolds: (1969)
• Endogenous opioid system
• PAG & NMM: “funnel”
• Homeostatic and behavioral adjustments
Mason P. J Neurophysiol. 2005;94:1659-1663. Finniss DB, Benedetti F. Pain. 2005;114:3-6. Petrovic P, Ingvar M. Pain. 2002;95:1-5.
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INJURY SYMPTOMS
Tissue Damage
Nerve Damage
HyperalgesiaSpontaneous
PainAllodynia
PERIPHERAL ACTIVITY
CENTRAL
SENSITIZATION
Decreased threshold to
peripheral stimuli Expansion of
Receptive field
Increased
Spontaneous
activity
Tracey, 2008
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Summary: “a gain in pain”
• Nociceptive vs. Neuropathic pain• Chronic changes in the nervous system
may not be reversible• Understanding of channels and receptors
evolving• Medications and therapies targeted at
specific mechanisms• Pain is not just a passive transfer of input
along a fixed system