Upload
edward-tsien
View
23.857
Download
3
Embed Size (px)
Citation preview
ALL ABOUT PAIN
The nervous system’s response to noxious (harmful) stimuli, also known as “nociception”
Examples of external stimuli: pricking, cutting, crushing, burning, freezing
Examples of internal stimuli: swelling, inflammation, distention (Note: These are noxious stimuli, but other stimuli must cause these stimuli—swelling, for instance, does not usually happen on its own)
Several factors contribute to reception of pain
Mechanical stimulation from sharp object
Potassium released from the insides of the damaged cells
Prostaglandins, histamines, and bradykinin from immune cells that invade area of inflammation
Substance P from nearby nerve fibers
So, What is Pain, Anyway?
There are Two “Waves” of Pain Nociceptors
Free nerve endings (dendrites) in the skin that pick up the information from the painful stimuli
Only responds to extreme pressure or temperature
Found almost everywhere: from skin to teeth pulp to joint membranes to muscles
Nociceptors are the dendrites of nerve fibers
There are two types of axons of these nerve fibers
A-delta fibers
C-nerve fibers (two types)
Both travel relatively slowly compared to other peripheral axons
A-DELTA NERVE FIBERS
First wave of pain (initial pain—sharp and highly localized)
Thick(er) and myelinated (moderately fast transmission)
Limited to responses from very strong pressure and extreme temperatures (tend to be from immediate stimuli)
C-NERVE FIBERS
Also known as “Polymodal nociceptors”
Second wave of pain (longer-lasting, duller, widespread pain)
Very thin and unmyelinated (very slow transmission)
Not limited to immediate stimuli—also respond to chemicals released by cells already damaged by burns, wounds, and infections ( this accounts for their long-lasting effect)
Just a little touch/pain humor….
….and something else to ponder.
Notice that the nociceptors labeled here are located in the EPIDERMIS and that they are FREE NERVE ENDINGS, or afferent nerve dendrites that are not encapsulated (as touch, heat, and pressure nerve endings are)
Cutaneous (“In the Skin”) Receptors
Pain’s Ascending Pathway to the Brain A-delta fibers and C-nerve fibers form synapses with dorsal horn of spinal cord
Cell bodies in dorsal root ganglia
Synapse between primary pain-sensing neurons and secondary pain-transmission neurons occurs in dorsal horn of spinal cord
Secondary neurons send signals upward through spinothalamic tract
Contralateral side of spinal cord
Face sends info through “mini-spinal cord” called trigeminal nerve into the medulla
Proposed by Ronald Melzack and Patrick Wall
Grew out of observations of WWII veterans and their injuries
Concept: pain messages are intercepted by specialized nerve cells in the spinal cord before they reach brainFor severe pain that could lead to damage
Nerve “gate” is wide openMessage travels almost instantaneously
For mild, weak painNerve gate sometimes closed Filter, block pain messages
Gate Control Theory
Nerve fibers that transmit touch influences gatekeeper cellsTouch stimulate gatekeeper cells to close
“gate”Decrease pain transmission
Rubbing sore area = relief
Gate Control Theory Cont’d
Pain and normal somatosensory neurons both synapse on projection cells (which go up into brain) and inhibitory interneurons in spinal cord
Normal somatosensory signals turns on both projection and inhibitory neurons= cancel each other out
Only pain turns on projection and inactivates the inhibitory- leading to pain
Gate Control Theory: In-Depth
Transmission:-Damaged Tissue-Thalamus-Parietal lobe and Limbic System-Cerebral Cortex
Pain and the Brain
When humans’ brains are mapped for response to lasers, this area activates.
While controversial, one area, the Vmpo, causes pain or temperature-related sensations when stimulated.
It gets messages from lamina I through the thalamus.
Lesions in the parieto-insular cortex reduces pain.
The Parieto-Insular Cortex
Medial Frontal Cortex
This is part of an area involved in controlling motivational behavior
It activates in response to perceiving the unpleasantness of pain
The parieto-insular cortex is responsible for the physical sensation processing
The anterior cingulate is responsible for the emotional response to pain
This theory suggests that pain in primates is “phylogenetically novel” because involved areas are large in primates, but especially large in humans
It could explain the effects of pain and the autonomic system on feelings
Simpler animals experience pain in the brainstem, but do not experience it cortically
One Possible Theory
The Descending Pathway
Descending system suppresses the transmission of pain signals from the dorsal horn of spinal cord to higher brain centers
Originate in the somatosensory cortex and hypothalamus
Thalamic neurons suppress ascending nerve signals at synapses in midbrain
Periaqueductal Gray
Also stimulate release of natural chemicals in body….
The Neurotransmitters of PAIN Nerves transmitting pain signals, as well as those involved in pain regulation, use excitatory and inhibitory neurotransmitters
Excitatory Neurotransmitters of Pain Signaling Glutamate—
-NMDA , AMPA, and metabotropic receptors are involved in excitatory synaptic transmission of pain.
-With NMDA (C-fibers), Mg++ clogs receptor
-Nearby peptide receptors stimulatedchannel opens
-Depolarizes the neuron
Tachykinins—-G-protein coupled receptors-Neurokinin A binds to NK-2 receptors, and
Neurokinin B binds to NK-3 receptors
Substance P (The “P is for Pain” Molecule), a Tachykinin
-Found in C-fibers-First described by von Euler & Gaddum in
1931 during research of equine brain and intestines
-Sequenced in 1971-Binds to NK-1 receptors , but is synthesized
by nociceptors-Vasodilation (swelling of capillaries) and
release of histamine by mast cells (see below)
Neurotensin-Detected during isolation of Substance P
from bovine samples-Causes vasodilation in already-open wounds
Histamine-In mast cells of the immune system; subtance P and foreign substances like bee venom cause release onto nociceptors, triggering depolarization-Also “punctures” blood capillaries, causing swelling and redness at location of injury
ATP-Released by damaged cells and binds to ATP-
gated channels on nociceptors (then the cell is depolarized...)
-Neurotransmitter associated with prostaglandin (a hormone)
H+—from build up of lactic acid, activate H+-gated channels
Potassium Ions-Released by damaged cells; indirect
depolarization of nociceptors
Proteases-Break down kininogen from outside cell into
bradykinin, which binds to receptors opening ion-gated channels
Calcitonin and other neuropeptides (there are MANY that are related)
NOTE: THESE ONLY APPLY TO CERTAIN A-DELTA AND C-FIBERS
-There are certain c-fibers known as IB4-positive fibers, which so far only seem to bind to plant isolectin
Inhibitory Neurotransmitters of Pain Signaling Most important: GABA
-Ligand-gated and G-protein coupled receptors-Most important for interneurons (gate-control theory)
Glycine
Neurotransmitters Mediating Pain Regulation-Serotonin and Norepinephrine are involved in transmission between neurons of the descending pathway
-Often working in tandem with Substance P
A Remarkable Discovery with FosShows up in the spinal cord after even brief noxious stimulation, particularly of C-nerve fibers, but disappears after 2-7 days; expression of C-Fos gene in damaged nerves that do not typically express Fos
An Inducible Transcription Factor, which changes the internal environment of the cell on a long-term basis
Therefore, provides a link between persistent stimulation and consequences for the future by gene expression!
Although the transcription of C-Fos is understood generally, itsprecise mechanisms involvingneurons, especially concerning cellReplication, are not quite understood
How the Pain We Feel is Different
Different types of nerves and neurotransmitters
Nociceptors are simultaneously activated with other cutaneous receptors, like mechanoreceptors, giving us:
-Pressure-pain-Hot-pain
-Cold-pain-Etc.
As for spicy foods….
Spicy Foods are Moderated by Capsaicin
First isolated as a vanilloid in red peppers (then chilies, jalapeños….)
Simultaneous activation of nociceptors by capsaicin and taste receptors by other ingredients provides for different “types” of spicy
Selective activation of C-fibers (and sometimes A-delta fibers)
Depolarization of unique ion-gated channel with “vanilloid” receptor -VR1, vanilloid receptor subtype 1
has a very specific antagonist, capsazepine
“Excitotoxin”-death of neurons of the dorsal root ganglion with prolonged exposure
BUT just the right amount of repeated application results in depletion of substance P
Pain that lasts 6 months or longerPersists long after trauma has healed or
in the absence of traumaCommon causes of chronic pain
Physical problems stemming from chronic illness or internal injuriesArthritis: inflammation of the joints
Damage to peripheral or spinal nervesNeuropathic painCan result from accidents, infections, surgeryUnknown cause (possibly psychological?)
Chronic Pain
Autoimmune DiseasesMS, lupus
CancerCompression/
TraumaCrush nerves
DiabetesMost common
Drug side effects
Nutritional Deficiencies
Infectious DiseaseLyme disease,
herpes, HIVToxic Substances
Mercury, lead, arsenic
More Causes of Pain and Nerve Damage
“Off” Perception of Pain Allodynia—“painful” response to a typically non-painful stimulus Hyperalgesia—increased “painful” response to a painful stimulus
Pain Enhancement during illness Stops person from wasting energy Immune system interaction?
Pain Enhancement after Injury Damage to/recent activation of nocioceptorsrespond to weaker stimuli (use of local anesthetics) Stops person from touching wounds/getting infections
Sensitization
Nervous system amplifies and distorts painResulting pain out of proportion to original injury
or diseaseCauses
Inflammation: nociceptors fire w/ greater intensity, longer time, lower threshold
Abnormal chemical reactions in spinal cord that increase transmission of pain messages
Lower threshold of pain receptors Examples of Sensitizers: bradykinin,
prostaglandins, and substance PLinked to sensing, feeling, and thinking
regions of brainLeading to emotional, psychological suffering
But Don’t Forget the Most Curious Substance of All.....~Endorphins, or Endogenous Morphine-like
Substances
In the late 60s, researchers identified the so-called opioid receptors: mu, kappa, and delta
Increasing identification of opioid antagonists (ex. Naloxone)
We must have a natural substance in our brain such that we would from an evolutionary perspective require, or at least benefit from, the presence of opioid receptors
In and around 1975, discovery of the Met-enkephalins (Methionine), Leu-enkephalins (Leucine), dynphins, and Beta-endorphin, which bind to opioid receptors
-Proenkephalins are produced by the cell body then split into active peptides
-Enkephalins then hyperpolarize the neuron by inhibiting excitatory neurotransmitters
PAIN CONTROL
Which Leads Us To……
Ascending Regulation Simultaneous activity in A-beta fibers (low-threshold mechanoreceptors) ex. Massaging bruises
Descending Regulation Electrode Therapy Perhaps most important: electrical stimulation of the PAG
Input from the thalamus and other structures Medulla, especially raphe nuclei, using serotonin back to dorsal horn of spinal cord
Drug-Mediated Management Partial and full opioid agonists
ex. Morphine, heroine, fentanyl, oxycodone, demerol Nerve terminals of primary pain neurons in dorsal horn contain opioid receptors, activation of which inhibits transmitter releaseInjection of opioids into midbrain can cause profound pain relief (connected to primary pain neurons)
CCK Antagonists Mu receptor activation releases CCK, which goes on to inhibit opioid effects (through activation of other substances, such as substance P)
Corticosteroids (anti-inflammatory medications) Capsaicin (sounds counterintuitive, I know….)Anesthetics (nitrous oxide, PCP, cocaine) Cannabis
NSAIDs Inhibit prostaglandin Tend to inhibit all prostaglandin—analgesia and anti-inflammation, but no muscle regeneration
Anti-Histamines Reduce swelling and irritation at injury site
Antidepressants
Stress-Induced Analgesia Endorphins
Suppress glutamate and hyperpolarize neurons In response to stress and physical exertion
Belief-Induced Analgesia “Placebo Effect”
Other Therapies
Surgery (an extreme) Psychedelics and caffeine for headache relief Alternative Therapies: hot/cold compresses, chiropracty, massage, hypnosis, herbal medicines, acupuncture
Pain Tolerance Pain tolerance is generally higher in men than in women, and decreases with age
In men pain tolerance increases significantly in repeat testing
Researchers expect that gender role expectations effect how men perform on the test
A woman’s ability to handle pain may also relate to where she is in her hormone cycles
In animal studies it was found that females have fewer opioid receptors than males, which may account for gender differences.
More connections
to regions of the brain
associated with external
functions
More connections
to regions of the brain
associated with internal
functions
And Now, Some Weird Stuff……
Music and Pain
An hour a day keeps the doctor away
Phantom limb pain—pain without stimuli or receptors
Ramachandran Destruction of nerves and pain modulation Mirror therapies
SCN9A, CIPA and EvolutionSCN9A instructs the protein sodium channel that allows neurons to pass on messages
In a study of children where this was faulty, scientists found that they felt no pain
They frequently bit their lips and two of them had bitten at least a third of their tongue off. In fact, one girl thought it was funny to bite her fingers and see the blood.
In a study of people who had too much of SCN9A, the people experienced chronic burning in their extremities
CIPA is a nerve disorder in which the nerves for sensing temperature and pain don’t form
Mutations of the NTRK1 gene—NGF binding to TrkA receptor on nociceptive and sympathetic nerves not encoded
Some estimate that CIPA affects approximately one in 125,000,000
Issues: Common infections -> amputation
Accidentally biting tongue through or clean off when eating Dying of overheating
BibliographyAndreae-Jones, Sarah, MB BS. “Capsaicin, Corticosteroids, and CCK Antagonists.” A.S.A.M. Society. July 2000.
<http://www.arachnoiditis.info/content/capsaicin_corticosteroids_cck_antagonists/capsaicin_corticosteroids_cck_antagonists.html>. 2 Feb. 2010.
Barrett, Julia, Ken R. Wells, and Jacqueline L. Longe. “Pain. (Disease/Disorder overview).” The Gale Encyclopedia of Medicine. Jan. 1, 2008. Gale. Academic OneFile. Web. 31 Jan. 2010. <http://find.galegroup.com/gtx/start.do?prodId=AONE&userGroupName=ntn>.
Brownstein, M. J. “A brief history of opiates, opioid peptides, and opioid receptors.” Proc. Natl. Acad. Sci. USA. Vol. 90, pp. 5391-5393, June 1993.
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC46725/pdf/pnas01469-0022.pdf>. 2 Feb. 2010.
Calandra, Bob M. “Feeling your pain.” MedicineNet.com. Aug. 27, 2002. <http://www.medicinenet.com/script/main/art.asp?articlekey=51160>. 3 Feb. 2010.
Chudler, Eric H. Neuroscience for Kids: Conduction Velocity. 2008. <http://faculty.washington.edu/chudler/cv.html>. 31 Jan. 2010.
Chudler, Eric H. Pain and Why It Hurts. <http://faculty.washington.edu/chudler/pain.html>.31 Jan. 2010.
“CIPA.” Sick Du Jour. March 19, 2009. <http://sickdujour.blogspot.com/search?updated‑max=2009‑03‑20T08%3A50%3A00‑04%3A00&m ax‑results=4 >. 3 Feb. 2010.
“Congenital Insensitivity to Pain with Anhidrosis.” Science Online. <http://www.scionline.org/index.php/Congenial_Insensitivity_to_Pain_with_Anhidrosis>. 30 May 2009.
Connors, Barry W., Mark F. Bear, and Michael Paradiso. Neuroscience Exploring the Brain 2nd Edition B01_0829. Maryland: Lippincott Williams & Wilkins, 2001. Print.
Craig, A. D. (Bud). “Mapping pain in the brain.” The Wellcome Trust. <http://www.wellcome.ac.uk/en/pain/microsite/science2.html>. 2 Feb. 2009.
Dray, A. “Mechanisms of action of capsaicin-like molecules on sensory neurons.” Life Sci. 1992;51(23):1759-65.<http://www.ncbi.nlm.nih.gov/pubmed/1331641>.
Fields, Howard L. “Pain Perception—The Dana Guide.” The Dana Foundation. Nov. 2007. <http://www.dana.org/news/brainhealth/detail.aspx?id=10072>. 2 Feb. 2010.
Fisher, Brian D, Ph.D. “NSAIDs Case Analysis: New Approaches to Soft Tissue Injuries.” NSAIDs. July 7, 1999. <http://www.nsaids.com/>. 3 Feb. 2010.
Freudenrich, Ph.D., Craig. "How Pain Works." Nov. 9, 2007. HowStuffWorks.com. <http://health.howstuffworks.com/pain.htm>. 3 Feb. 2010.
“Gender and Pain.” Society for Neuroscience. May 2007. <http://www.sfn.org/index.aspx?pagename=brainBriefings_Gender_and_Pain>. 3 Feb. 2010.
Gray, Peter O. Psychology, Fourth Edition. null ed. New York: Worth Publishers, 2002. Print.
Holzer, Peter. “Neural Injury, Repair, and Adaptation in the GI Tract, II. The elusive action of capsaicin on the vagus nerve.” Am J Physiol Gastrointest Liver Physiol July 1998: Vol. 275, Issue 1, G8-G13.
Hopley, Laura and Jo van Schalkwyk. “Pain Physiology.” Oct. 24 2006. <http://www.anaesthetist.com/icu/pain/Findex.htm#pain3.htm>. 2 Feb. 2010.
“How you feel pain.” Mayo Clinic. Feb. 13, 2009. <http://www.mayoclinic.com/health/pain/PN00017>. 3 Feb. 2010.
Leeman, Susan E. “Substance P and Neurotensin: Discovery, Isolation, Chemical Characterization and Physiological Studies.” J. Exp. Biol. (1980), vol. 89. pp. 193-200. <http://jeb.biologists.org/cgi/reprint/89/1/193.pd>. 29 Jan. 2010.
Luttrell, Andy. “The Neurology of Pain Perception: How the Brain Feels Pain with Nociception.” Oct. 28, 2009. <http://biology.suite101.com/article.cfm/the_neurology_of_pain_perception>. 2 Feb. 2010.
Miranda, Claudia et al. “Novel Pathogenic Mechanisms of CIPA Genetic Disorders Unveiled by Functional Analysis of NTRK1/NGF Receptor Mutations.” JBC Papers in Press.
<http://www.jbc.org/cgi/reprint/M110016200v1.pdf>. Manuscript M110016200 (Nov. 21, 2001).
“Nerve Pain and Nerve Damage: Symptoms and Causes.” Brain & Nervous System Health Center; WebMD. Oct. 8, 2008. <http://www.webmd.com/brain/nerve-pain-and-nerve-damage-symptoms-and-causes>. 3 Feb. 2010.
"Neuroscience for Kids - Receptors." UW Faculty Web Server. <http://faculty.washington.edu/chudler/receptor.html >. 1 Feb. 2010.
“Neurotransmission.” The Merck Manuals Online Medical Library.” Nov. 2005. <http://www.merck.com/mmpe/sec16/ch207/ch207a.html>. 3 Feb. 2010.
Oliviera, Carlos R. D. et al. “Spinal Anesthesia in a Patient with Congenital Insensitivity to Pain with Anhidrosis.” Pain Medicine. <http://www.anesthesia‑analgesia.org/cgi/content/full/104/6/1561104>. (2007): 1561-2.
“Pain.” Jan. 12, 2009. <http://courses.washington.edu/conj/sensory/pain.htm>. 1 Feb. 2010.
“Pain.” Magill’s Encyclopedia of Social Science: Psychology Volume 3. Ed. Nancy A. Piotrowski, Ph.D. Pasadena: Salem Press, 2003.
"Pain." Neuroscience For Kids. Web. <http://faculty.washington.edu/chudler/pain.html>. 2 Feb. 2010.
“Pain Perception.” Lewis & Clark College. <http://legacy.lclark.edu/~reiness/neurobiology/Lectures/Pain%20Perception.pdf>. 3 Feb. 2010.
Pathways 4 Pain. Aug. 9, 2009. <http://relievepain.wordpress.com/2009/08/09/pathways-4-pain/>. 2 Feb. 2010.
“Scientists Study Children Who Feel No Pain.” Feb. 20, 2007. Voice of America News. <http://www.voanews.com/specialenglish/archive/2007-02/2007-02-20-voa3.cfm?moddate=2007-02- 20>. 2 Feb. 2010.
Stucky, Cheryl L., Michael S. Gold, and Xu Zhang. “Mechanisms of Pain.” Proceedings of the National Academy of Sciences of the United States of America. Oct. 9, 2001. vol. 98, no. 21. pp. 11845-11846. <http://www.pnas.org/content/98/21/11845.full>.
Woodrow, Kenneth D., M.D. et al. “Pain Tolerance: Differences According to Age, Sex and Race.” Psychosomatic Medicine, Vol. 34, No. 6 (November-December 1972). <http://www.psychosomaticmedicine.org/cgi/reprint/34/6/548.pdf>. 1 Feb. 2010.