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 Peripheral Sensitization Central Sensitization Temperature Sensation Plasticity & Brain Changes Muscle Pain Cytokines: the Future Nociceptive vs. Neuropathic Pain Other “Mixed” Pain Types? Nociceptive Pain (Inflammatory?)1 Postoperative pain Mechanical low back pain Arthritis Sickle cell crisis Sports/exercise injuries Neuropathic Pain2,3 CRPSII* Postherpetic neuralgia (PHN) Trigeminal neuralgia Neuropathic low back pain Central poststroke pain Distal polyneuropathy (e.g., diabetic, HIV) *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. The BIOMEDICAL Model • Pain as a sensory event reflecting underlying disease or tissue damage 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. Gate Control Theory A. Sensory B. Affective C. Evaluative Melzack R, Wall PD. Science. 1965;150:971-976. Enteroceptive Sensations • • • • Pain Thirst Hunger Thermoception • Neurophysiologic changes • Neurochemical changes Biological Functions of Pain Sherrington (1906) Exteroceptive: Escape and avoidance of external threats protection of injured or Interoceptive: dysfunctional tissues that disrupt homeostasis Price DD et al. Pain 2003, 106. 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 The Role of Plasticity in Chronic Pain Injury Acute Pain Normal Healing Pain Relief Healing With Plasticity Allodynia Hyperalgesia Chronic Pain Adapted from Marcus DM. Am Fam Physician. 2000;61:1331-1338. 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. 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 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 Physiology of Pain Perception1-3 Brain Perception Descending Pathway Ascending Pathway Spinal Cord C-Fiber α-β Fiber α-δ Fiber Conduction Peripheral Nerve Transduction Dorsal Horn Dorsal Root Ganglion Injury 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. Transmission/ Modulation Kidd, Urban. Br J Anaesthesia 2001;87(1). Pathologic vs. Physiologic Classification of Fibers in Peripheral Nerves Lloyd /Hunt Diameter (µm) Letter System Conduction velocity (m/sec) Myeli n I-a 12-20 - 70-120 + I-b - 12-20 - 70-120 + 12-20 A-α 70-120 + II 6-12+ A-β 30-70 + - 2-10 A-γ 10-50 + III 1-6 A-δ 5-30 + - <3 B 3-15 + IV <1.5 C 0.5-2.0 No Adapted from Nolte J. The human bran. St.Louis: Mosby, 1999:213. Receptor/ ending Muscle spindle primary endings Golgi Tendon organs Muscle efferents (extrafusal) Encapsulated endings;Merkel Muscle efferents (intrafusal) A-δ specific & polymodal; cold; hair; visceral (+/-) Preganglionic autonomic C-nociceptors; C-polymodal; warmth, mechano;postganglioic autonomic; enteric nerve fibers 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. 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 Kidd, Urban. Br J of Anaesth 87, 2001. Cutaneous C-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) Caterina, Cur Op in Neurobiology (9), 1999. 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 Primary Afferent C & Aβ Fibers Sensation Mediated Fibre Threshold Principal Class For Transmitters Activation SP/NKA C High CGRP EAA Aβ Low EAA Millan, Progress in Neurobiology, 1999. Receptors Physiological Pathological Engaged NK CGRP NMDA AMPA mGlu Noxious (pain) Highly noxious (hyperalgesia) Cold Allodynia (pain) AMPA Innocuous (no pain) Mechanical allodynia Receptor types on sensory neurons Transduction mechanism Example Cellular effect Ligand-gated channel Capsaicin-heat H , 5HT, ATP Glutamate, GABA-A Excitation G-protein linked GABA-B Opiated, Adenosine Adrenoreceptors NPY, 5HT Inhibition of transmitter & peptide release Bradykinin(B2) Histamine (H1) Adrenoreceptors (α2) PGE2 NGF (Trk A) Excitation and/or sensitization Tyrosine kinase linked Bevan S. Textbook of Pain, 4th ed. Wall, Malzack, 1999. Control of gene expression Ion Channels • Dynamic, constantly changing • Plasticity reflects sensitivity needed for survival • Injury: amygdala, hippocampus, and DRG • Normal peripheral nerves (resist) • Demyelination: density Receptors • Capsaicin/ Vanilloid • Purinergic (P2X) Ion Channel Linked Receptors Receptors • Vanilloid (VR-1) • Acid-sensing (ASIC) • Purinergic (P2X) • Cannabinoid Kidd BL, Urban LA, Br J of Anaesthesia (1). 2001. Ion Channels • Sodium – TTX-S – TTX-R • Calcium Caterina. Cur Op in Neurobiology (9), 1999. 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 Visceral Pain Psychophysics • Not evoked from all viscera • Not always linked to injury • Referred to body wall • Diffuse & poorly localized • Intense motor & autonomic reactions Cervero F, Laird J, Lancet 353, 1999. 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 Siddal, Cousins. Neural Blockade in Clinical Anesthesia and Management of Pain, Third Ed.,1998. Milan MJ, Progress in Neurobiology 66, 2002. Inflammation • • • • • Redness (rubor) Heat (calor) Swelling (tumor) Loss of function (function lasea) Pain (dolor) 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. 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. Hyperalgesia pain threshold pain to suprathreshold stimuli Spontaneous pain Sensitization threshold for response response to suprathreshold stimuli Spontaneous activity Peripheral Sensitization Tissue Damage Inflammation Sympathetic Terminals SENSITIZING ‘SOUP’ Hydrogen Ions Noradrenaline Bradykinin Leukotrienes Histamine Potassium Prostaglandins 5-HT Woolf, Chong. Anesth. Analgesia (77), 1993. Purines Cytokines NGF Neuropeptides Peripheral Sensitization SKIN Plasma Extravasation Vasodilation Macrophage Mast Cell TNF-α IL-6 LIF Tissue Damage Pressure ? Heat 5-HT3 Histamine PGE2 VR1 H+ 5-HT3 H1 Bradykinin EP H+ IL1ß NGF ATP B1/B2 IL1-R TrkA P2X ASIC Ca2+ (PKC) PKA PKC TTXr (SNS/SNS2) TTXs Gene Regulation TTXr Sub P Adapted from Woolf CJ, et al. Science. 2000;288:1765-1768. Peripheral Nerve Terminal Central Sensitization: wind up With permission. Jensen TS et al. Acta Anaesth Scand, 45, 2001. 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. With Permission. Woolf,2000. 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. 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. Examples of Peripheral vs. Central Sensitization Sensory function after nerve injury with spontaneous firing along axon To Brain No Stimulus Nociceptor Dorsal Horn Neuron Pain Sensation Central sensitization occurs as a result of increased nociceptor drive or disinhibition after nerve injury, leading to exaggerated dorsal horn response Inhibitory Input Is Downregulated To Brain Innocuous Stimulus Dorsal Horn Neuron Increased Nociceptor Drive Adapted from Woolf CJ, Mannion RJ. Lancet. 1999;353:1959-1964. Innocuous or Noxious Stimulus Dorsal Horn Neuron Disinhibition 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 Beydoun A, Backonja. J Pain Symp Management 2003. Temperature Thermosensation Julius D, Proc 10th Word Conference of Pain, 2003. 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. Thermosensation Cold Heat • 10-15% C & A-delta • Specificity vs. modulation of excitatory & inhibitory channels • K, Na, Ca channels • CMRI (cold- and mentholsensitive receptor) cloned • TRP (transient receptor potential) • 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. Capsaicin genus Capsicum: mildest (bell) to hottest (habanero) Capsaicin: 16,000,000 SHU Classic: habanero: 200,000 SHU • 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. W. Clin J Pain 16(2), 2000. Robbins TRPV Channels: Szalassi et al. Nature Rev 2007;6. 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. Pain Neurochemistry Transmission via spinothalamic tract to brain Dorsal horn Ion fluxes (H+/ K+) Dorsal root ganglion Tissue injury Bradykinin Prostaglandins Leukotrienes Spinal cord Substance P To brain Histamine Substance P, aspartate, neurotensin, glutamate Sensitized nociceptor Neuromatrix Apkarian AV, et al. J of Neuroscience, 24(46), 2004. Price DD. Science 2000. Price DD. Science. 2000;288:1769-1772. Price DD. Science. 2000;288:1769-1772. “Pain Matrix” Moseley GL. Man Ther. 2003;8(3):130-140. “Pain Matrix” • • • • • Anterior cingulate cortex (ACC) Insular cortex (IC) Thalamus Sensorimotor cortex (SSI, SSII) Cerebellum Moseley GL. Man Ther. 2003;8(3):130-140. Petrovic P, et al. Science 2002;295:1737-1740. Petrovic P, et al. Science. 2002;295:1737-1740. 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. Tracey, 2008 INJURY Tissue Damage PERIPHERAL ACTIVITY SYMPTOMS Spontaneous Hyperalgesia Allodynia CENTRAL SENSITIZATION Decreased threshold to peripheral stimuli Nerve Damage Pain Expansion of Receptive field Increased Spontaneous activity 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