Putting Pain in Perspective: Pain Matters Mary Christenson, PT, PhD DPT 781 O Fall 2010 1 American Pain Foundation Virtual March on Washington Launches September 1, 2010 September Pain Awareness Month is rapidly approaching! 2 A Story Mailis-Gagnon A, Israelson D. Beyond Pain: Making the Mind-Body Connection. University of Michigan Press; 2005:98. What do you want to learn in this course? http://www.cvshealthresources.com/Imageb ank/Articles_images/chronic-pain.jpg 3 Who/What Is Affected by Persistent Pain? Individual ADLs Self-esteem Confidence, other? Family Friends Work environment Society How will this present in the clinic? 4 Reflection Who treats persistent pain? Why is the study of pain important? What do you currently know about the treatment of persistent pain? 5 Pain Defined “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” 2 6 Statistics One out of six Americans, minimally, live with chronic pain (American Chronic Pain Association) 20% globally have pain longer than 3 months 3 ~$100 billions/year costs of persistent pain (AACPI - American Alliance of Cancer Pain Initiatives ) $61.2 billion/year lost business income due to employees pain – only included musculoskeletal problems6 7 Statistics (continued) ~50 million Americans have persistent pain (American Pain Foundation) Headaches are the most common type of pain (National Headache Foundation) Elderly : Community-dwelling – up to 50% c/o pain Institutionalized – 71-83% c/o of at least one source of pain4 8 Terminology Acute Pain Occurs with tissue damage or potential damage = a symptom Protects from tissue damage and or until healing has occurred Persistent Pain (Chronic Pain) Extends beyond normal tissue healing time, and/or Causes challenges greater than expected from tissue injury or medical findings, and/or Occurs without known tissue damage 9 Terminology Hyperalgesia Hyperpathia Allodynia Neurogenic pain Neuropathic pain Nociceptor Nociception Nociceptive pain Sensitization Peripheral Central http://static.disaboom.com/content/images/articles/thumbna il/chronic-pain-with-nmd-is-und_thumbnail1.jpg 10 http://www.painfoundation.org/ 11 Models of Pain Historical Specificity Theory Separate nerve endings for each type of sensation (temperature, touch, pain) Challenged: Phantom limb pain? Blockage of pain pathways? Pattern Theory Pain recognized by “sense organs” in skin Consists of signals in the CNS Sensation is a learned event – no specific pathways for each sensation 12 Models (continued) Gate Control Theory (Melzack and Wall, 1965) Physiological and psychological components of pain Nerve ending signals are modulated in the spinal cord Large (non-nociceptor) and small (nociceptor) diameter afferent signals to the substantia gelatinosa (SG) and T cell T cell initiates consequences of pain SG cells are inhibitory to the T cell Nociceptor signals inhibit the SG neurons, therefore allowing pain signals to continue Increased signals from large diameter fibers results in increased firing of SG neurons, which ultimately decreases firing of T-cells (Result?) (Clinical application?) System under control of supraspinal sites that affect outcomes Challenges 13 http://www.lupusuk.org.uk/images/latestnews/lwcpfig1.gif 14 Gate Control Theory (continued) This theory resulted in recognition that “pain is a CNS phenomenon, that treatments for pain must be aimed not only at the peripheral nervous system but also at modulating the CNS, and that pain is multidimensional.” 2 15 Models (continued) Biomedical Model Biopsychosocial Model (conceptual model by the American College of Physicians) Nociception Pain Pain Appraisal Pain Behaviors Social Roles for Pain and Illness 16 Biopsychosocial Models of Pain http://www.continuingedcourses.net/active/courses/images/course033-image002.jpg 17 http://www.painxchange.com.au/images/BiopsychosocialPain.png 18 Peripheral Primary Afferent Nociceptors fire in response to a noxious stimulus Mechanical Thermal Chemical 19 Peripheral Nerve Fiber Types Letter System Conduction velocity, m/sec General Function Type of fiber Diameter, micrometer s A-alpha 13-22 70-120 alpha-motoneurons, muscle spindle primary endings, Golgi tendon organs, touch A-beta 8-13 40-70 touch, kinesthesia, muscle spindle secondary endings A-gamma 4-8 15-40 touch, pressure, gamma-motoneurons A-delta 1-4 5-15 pain, crude touch, pressure, temperature B 1-3 3-14 preganglionic autonomic C 0.1-1 0.2-2 pain, touch, pressure, temperature, postganglionic autonomic http://www.unmc.edu/physiology/Mann/mann12.html 20 Peripheral Nerve Fiber Types Roman Numeral System Conduction velocity, m/sec General Function Type of fiber Diameter, micromet ers Ia 12-20 70-120 muscle spindle primary endings Ib 11-19 66-114 Golgi tendon organs II 5-12 20-50 touch, kinesthesia, muscle spindle secondary endings III 1-5 4-20 pain, crude touch, pressure, temperature IV 0.1-2 0.2-3 pain, touch, pressure, temperature II = Aβ ; III = Aδ ; IV = C http://www.unmc.edu/physiology/Mann/mann12.html 21 Peripheral Receptors Ia: muscle spindle Ib: Golgi tendon organ II: Meissner corpuscle, Merkel’s cell, Pacinian corpuscle, Ruffini ending, hair follicle, Paciniform endings, muscle spindle III: Free nerve endings (noxious stim) IV: Free nerve endings (noxious stim) 22 Free Nerve Ending 23 Silent Nociceptors ~1/3 of nociceptors in skin, joints or viscera do not respond to stimulus until inflammation = “silent nociceptors” May be activated by mediators such as prostaglandins that are released during inflammation Increases pain response 24 Peripheral Sensitization Increased responsiveness to stimuli after initial injury Potential mechanisms: Lower threshold to stimulus Increase in neuron activity Increase in area of receptor fields Increase in response to the same stimulus 25 Neuronal Activators of Pain Neuropeptides Opioids Glutamate Ion Channels 26 Non-neuronal Activators of Pain Inflammatory processes cause the release of factors that can result in activating afferent nerves Serotonin released from platelets Bradykinin released plasma Prostaglandins released from arachidonic acid cascade Cytokines released by macrophages Others: mast cells, neutrophils, T and B cells 27 Structures of Pain http://journals.prous.com/journals/dnp/20041703/html/dn170172/images/Block_f1.jpg 28 Physiology of Pain 29 Central Mechanisms Spinal Cord Laminae I-VI make up the dorsal horn Sensory afferents terminate (majority) on “2nd neuron” Noxious information from skin: I, II, V (primarily) Noxious information from muscles/joints: I (primarily) Interneurons Afferents from skin, joints, muscles, viscera may terminate on one neuron – referred pain? 30 Dorsal Horn http://www.wdv.com/Cancer/Pain/Images/Anatomy1.gif 31 Central Sensitization Neurons in dorsal horn High-threshold – respond to noxious stim Low-threshold – respond to innocuous stim Wide-dynamic-range (WDR) – respond to both Tissue injury: increased sensitivity of highthreshold and WDR neurons Expansion of receptive fields in central neurons common – referred pain? 32 Sensitization Continued input from sensitized nociceptors can maintain sensitization of dorsal horn neurons Need to reduce peripheral input? Sensitization of dorsal horn neurons can also be maintained in absence of peripheral input Need to reduce central sensitization? 33 Potential Influences: Hyperalgesia (found in spinal cord) Can produce hyperalgesia Glial cells Neurotransmitters – Spinal Cord Glutamate Substance P Can reduce hyperalgesia Adenosine GABA 34 Pain Sensory Pathways: Spinal Cord to Brain Spinothalamic Tract Transmits nociceptive pain up through the thalamus (VPL nucleus and medial thalamic nuclei) to higher centers VPL to 1o and 2o somatosensory cortex: location, duration quality, and intensity of pain Medial thalamic to anterior cinglate, etc.: “unpleasantness” of pain Spinomesencephalic and Spinoreticular Tracts Transmits to midbrain/brainstem respectively Integrates information with areas involved in descending inhibition, facilitation, and autonomic pain responses 35 Thalamus and Cortex Thalamus Integrate information from peripheral noxious stimulation Cortex S1 and S2: increased blood flow noted to these areas with painful stimuli Homunculus (more to come) Anterior cingulate cortex Many other centers (to be continued) 36 Brainstem Centers Contains centers that contribute facilitation and or inhibition signals A balance between all brain/brainstem signals determines pain perception Other brain influences? PAIN IS AN OUTPUT 37 Measures of Pain 38 Measures of Pain 39 Associations American Academy of Pain Management American Pain Foundation American Pain Society American Chronic Pain Association International Association for the Study of Pain (IASP) 40 References 1 Mailis-Gagnon A, Israelson D. Beyond Pain: Making the Mind-Body Connection. University of Michigan Press; 2005:98. 2 Sluka KA, ed. Mechanisms and Management of Pain for the Physical Therapist. Seattle, WA: IASP Press; 2009. 3 Butler DB, Moseley L. Explain Pain. Adelaide, Australia: Notgroup Publications; 2003. 4 Galieze L. Chronic Pain in Elderly People. Pain. 1997;70(1):3-14. 5 Marchand F, Perretti M, McMahon SB. Role of the immune system in chronic pain. Nature Reviews/Neuroscience. 2005;6:521-532. 6 JAMA. 2003;290:2443-2454. 41