Mechanisms and Management of Chronic Pain.

Chronic pain symptoms account up to half of all health care visits, afflicts >10% of US adults, at a higher prevalence in women with current analgesic drugs rarely provide enough efficacy in the absence of serious side effects. Chronic pain is also the root cause of the national opioid health crisis, which adds to health care costs and deaths. Thus, new pain therapies based on detailed understanding of nociceptive mechanisms are needed as alternatives to opioid analgesics and are of great societal importance. Chronic pain is one of the most prevalent human health problems that often is associated by the concomitant decline in cognitive and motor functions. Pain is strongly associated with other diseases that can lack of awareness to its pathology. Despite a successful reduction of pain with available medications, majority of treated patients were seeking professional help again. The average time duration between the onset of pain symptoms and the diagnosis is couple of years despite the fact that majority of patients with chronic pain suffer every day. Efficacious and reliable therapeutic intervention is still unavailable despite the tremendous economic burden imposed on healthcare to treat many diseases associated with chronic pain.

Peripheral modulation of chronic visceral pain.

Chronic visceral pain is a complex and often a serious burden on patients' life. It is strongly implicated in the etiology of many diseases, which often are complicated by co-morbid depression and other psychiatric disorders, all of which pose significant health risks. Understanding the mechanisms of nociception is an important step in treating pain-associated chronic diseases. The inflammatory process that is often associated with nociception produces a number of mediators, which activate nociceptors by interacting with ligand-gated ion channels, activation of different signal transduction pathways or by sensitizing primary afferent neurons located within the dorsal root ganglia (DRG). Primary afferents studied in vitro or in vivo are well-accepted models to examine various nociceptive and anti-nociceptive signals in peripheral nervous system. This review focuses on the recent work in the area of peripheral modulation of chronic pain at the level of visceral primary afferent neurons. Many studies intended to develop a coherent framework for a better understanding of heterogeneity of nociceptive neurons functioning as a gate for pain transmission and novel therapeutic tool for pain relief. Specifically, recent studies from the author's research group helped to define the role of ATP-sensitive purinergic and vanilloid-sensitive TRPV1 receptors in DRG-mediated nociceptive pathways. Tropic and physiological changes associated with chronic visceral pain indeed are mediated through different pathways; therefore, designing new and specific anti-nociceptive therapies will have a major impact on quality of life in patients by significantly reducing pharmacological and therapeutic interventions.

Neural reorganization associated with visceral pain.

Functional pain syndromes, including such common disorders as irritable bowel syndrome (within the field of gastroenterology); chronic pelvic pain (in gynecology); interstitial cystitis/painful bladder syndrome (in urology); fibromyalgia (in rheumatology) and others cross multiple disciplines affecting more than 20% of the population worldwide and are more common in women. Inflammation is not a common pathophysiological pathway for a number of chronic (including functional) diseases. One of the possible explanations for this phenomenon is the neuronal reorganization associated with pain transmission (nociception), but the mechanisms of the crosstalk are unclear. Moreover, clinical presentations of functional syndromes often lack a specific pathology in the affected organ but may respond to a visceral cross-sensitization in which increased nociceptive input from an inflamed organ (i.e., uterus) sensitizes neurons that receive convergent input from an unaffected organ (i.e., colon or bladder). This mini-review focuses on the novel mechanisms for possible therapeutic interventions associated with the visceral pain primarily focusing on visceral nociceptors located within primary afferent neurons of dorsal root ganglia. Since there are observed gender differences in prevalence of functional diseases, it is proposed that estrogen may modulate nociceptor sensitization. Understanding these gender differences and neuronal reorganization associated with visceral pain will be the basis of translational efforts to modulate viscerally mediated mechanisms or functional disorders with ultimate goal to develop new therapies to treat functional disorders.

Visceral nociception and functional diseases.

This mini-review summarizes the different pain-associated diseases and potential mechanisms that may help to achieve a deeper understanding of gender differences presented in clinical aspects of the functional syndromes. Chronic visceral pain is the most common complication of many functional disorders that do not have a defined pathophysiological cause. Functional pain syndromes include common disorders such as Irritable Bowel Syndrome (Gastroenterology), Interstitial Cystitis/Painful Bladder Syndrome (Urology), Fibromyalgia (Rheumatology), and Chronic Pelvic Pain (Gynecology) and cross multiple medical disciplines. Patients suffering from functional diseases may progress to cognitive decline and depression through neuroplastic changes not only at the level of central nervous system but also in the periphery. Pain pathways are activated in virtually all human diseases and only a thorough understanding of the mechanism implicated in the functional, painful disorders can truly contribute to more efficient therapeutic interventions.

Visceral pain modulation in female primary afferent sensory neurons.

The variations in symptoms and pain perception across the menstrual cycle in a large percentage of women diagnosed with functional syndromes such as Irritable Bowel Syndrome (IBS), Painful Bladder Syndrome (PBS), and Chronic Pelvic Pain (CPP), suggests the involvement of modulation of sex steroid hormones. Our recent studies have shown that estrogen modulation of visceral inputs of primary afferent nociceptors, located in the afferent primary sensory neurons of the dorsal root ganglia (DRG), accounts for the observed changes in nociception. Patients with CPP frequently experience pain from several organs. For patients with IBS, the most common co-morbid diagnoses include PBS and CPP. Pain is strongly associated with these diseases and the lack of awareness of their pathology is further illustrated by the fact that the average time between the onset of pain and the diagnosis is three to ten years. CPP patients may initially only have pain in the pelvis, but a multitude of mechanisms involving the peripheral and central nervous systems can lead to development of painful sensations in other adjacent organs; examples include lower colonic pain associated with IBS, and other viscera, such as the endometrium. In addition to the central regulation of pain, it is important to understand new pathways in which sex steroid hormones, such as estrogen, affect visceral nociception peripherally.

Physically disconnected non-diffusible cell-to-cell communication between neuroblastoma SH-SY5Y and DRG primary sensory neurons.

BACKGROUND: Cell-cell communication occurs via a variety of mechanisms, including long distances (hormonal), short distances (paracrine and synaptic) or direct coupling via gap junctions, antigen presentation, or ligand-receptor interactions. We evaluated the possibility of neuro-hormonal independent, non-diffusible, physically disconnected pathways for cell-cell communication using dorsal root ganglion (DRG) neurons. METHODS: We assessed intracellular calcium ([Ca(2+)]) in primary culture DRG neurons that express ATP-sensitive P2X3, capsaicinsensitive TRPV1 receptors modulated by estradiol. Physically disconnected (dish-in-dish system; inner chamber enclosed) mouse DRG were cultured for 12 hours near: a) media alone (control 1), b) mouse DRG (control 2), c) human neuroblastoma SHSY-5Y cells (cancer intervention), or d) mouse DRG treated with KCl (apoptosis intervention). RESULTS: Chemosensitive receptors [Ca(2+)](i) signaling did not differ between control 1 and 2. ATP (10 µM) and capsaicin (100nM) increased [Ca(2+)](i) transients to 425.86 + 49.5 nM, and 399.21 ± 44.5 nM, respectively. 17ß-estradiol (100 nM) exposure reduced ATP (171.17 ± 48.9 nM) and capsaicin (175.01±34.8 nM) [Ca(2+)](i) transients. The presence of cancer cells reduced ATP- and capsaicin-induced [Ca(2+)](i) by >50% (p<0.05) and abolished the 17ß-estradiol effect. By contrast, apoptotic DRG cells increased initial ATP-induced [Ca(2+)](i), flux four fold and abolished subsequent [Ca(2+)](i), responses to ATP stimulation (p<0.001). Capsaicin (100nM) induced [Ca(2+)](i) responses were totally abolished. CONCLUSION: The local presence of apoptotic DRG or human neuroblastoma cells induced differing abnormal ATP and capsaicin-mediated [Ca(2+)](i) fluxes in normal DRG. These findings support physically disconnected, non-diffusible cell-to-cell signaling. Further studies are needed to delineate the mechanism(s) of and model(s) of communication.

Estrogen modulation of visceral nociceptors.

A large body of literature supports the idea that estrogen modulates nociceptive responses in pelvic pain syndromes; however, whether this hormone is pro- or anti-nociceptive remains unresolved. The dorsal root ganglion (DRG) is an important site of visceral afferent convergence and cross-sensitization. Within the context of our hypothesis visceral nociception and nociceptor sensitization appear to be regulated by purinergic P2X3 and vanilloid TRPV1 receptors and 17ß-estradiol modulates DRG neuron response to ATP (P2X agonist) and capsaicin (TRPV1 agonist) suggesting that visceral afferent nociceptors are modulated by estrogen in the DRG. 17-ß estradiol (E2), the most common form of estrogen, acts on functional properties of P2X3 and TRPV1 receptors in DRG neurons in vitro. The localization of estrogen receptors (ER) in DRG neurons and the attenuation of ATP/capsaicin-induced intracellular calcium concentration [Ca2+]i strongly suggest that E2 modulates visceral pain processing peripherally. Moreover, E2 appears to have different actions on nociceptive signaling depending on the input. Based on our data we propose that E2 can gate primary afferent response to increase or decrease nociception.

Expression of P2X3 and TRPV1 receptors in primary sensory neurons from estrogen receptors-α and estrogen receptor-ß knockout mice.

In women, pain symptoms and nociceptive thresholds vary with the reproductive cycle, suggesting the role of estrogen receptors (ERs) in modulating nociception. Our previous data strongly suggest an interaction between ERs and ATP-induced purinergic (P2X3) as well as ERs and capsaicin-induced vanilloid (TRPV1) receptors at the level of dorsal root ganglion (DRG) neurons. In this study, we investigated the expression of P2X3 and TRPV1 receptors by western blotting and immunohistochemistry in lumbosacral DRGs from wild type, ERα, and ERß knockout mice. We found a significant decrease for both P2X3 and TRPV1 in ERαKO and ERßKO. This phenomenon was visualized in L1, L2, L4, and L6 levels for P2X3 receptors and in L1, L2, and S2 levels for TRPV1 receptors. This tan interaction between P2X3/TRPV1 and ERs expression in sensory neurons may represent a novel mechanism that can explain the sex differences in nociception observed in clinical practice. The DRG is an important site of visceral afferent convergence and cross-sensitization and a potential target for designing new anti-nociceptive therapies.

Estrogen and Visceral Nociception at the Level of Primary Sensory Neurons.

Clinical studies suggest the comorbidity of functional pain syndromes such as irritable bowel syndrome, painful bladder syndrome, chronic pelvic pain, and somatoform disorders approaches 40% to 60%. The incidence of episodic or persistent visceral pain associated with these "functional" disorders is two to three times higher in women than in men. One of the possible explanations for this phenomenon is estrogen modulation of viscerovisceral cross-sensitization. While a central site of this modulation has been shown previously, our studies suggest a peripheral site, the dorsal root ganglion (DRG). Estrogens have remarkably wide range of functions including modulation of voltage-gated calcium channels (VGCCs) and purinoreceptors (P2Xs). Significantly, inflammation dramatically alters purinoception by causing a several fold increase in ATP-activated current, alters the voltage dependence of P2X receptors, and enhances the expression of P2X receptors increasing neuronal hypersensitivity. Gonadal hormones are thought as indispensable cornerstones of the normal development and function, but it appears that no body region, no neuronal circuit, and virtually no cell is unaffected by them. Thus, increasing awareness toward estrogens appears to be obligatory.

Estradiol attenuates the adenosine triphosphate-induced increase of intracellular calcium through group II metabotropic glutamate receptors in rat dorsal root ganglion neurons.

Estradiol attenuates the ATP-induced increase of intracellular calcium concentration ([Ca(2+)](i)) in rat dorsal root ganglion (DRG) neurons by blocking the L-type voltage gated calcium channel (VGCC). Because ATP is a putative nociceptive signal, this action may indicate a site of estradiol regulation of pain. In other neurons, 17ß-estradiol (E(2)) has been shown to modulate L-type VGCC through a membrane estrogen receptor-group II metabotropic glutamate receptor (mGluR(2/3)). The present study investigated whether the rapid estradiol attenuation of the ATP-induced increase in [Ca(2+)](i) requires mGluR(2/3). Previously we showed that DRG (L(1)-S(3)) express ERα, P2X(3), and mGluR(2/3) receptors. DRG were acutely dissociated by enzyme digestion and grown in short-term culture for imaging analysis. DRG neurons were stimulated twice, once with ATP (50 µM) for 5 sec and then again in the presence of E(2) (100 nM) or E(2) (100 nM) + LY341495 (100 nM), an mGluR(2/3) inhibitor. ATP induced a transient increase in [Ca(2+)](i) (216.3 ± 41.2 nM). This transient increase could be evoked several times in the same DRG neurons if separated by a 5-min washout. Treatment with estradiol significantly attenuated the ATP-induced [Ca(2+)](i) increase in 60% of the DRG neurons, to 163.3 ± 20.9 nM (P < 0.001). Coapplication of E(2) and the mGluR(2/3) inhibitor LY341495 blocked the 17ß-estradiol attenuation of the ATP-induced [Ca(2+) ](i) transient (209.1 ± 32.2 nM, P > 0.05). These data indicate that the rapid action of E(2) in DRG neurons is dependent on mGluR(2/3) and demonstrate that membrane estrogen receptor-α-initiated signaling involves interaction with mGluRs.

Peripheral sensitization of sensory neurons.

INTRODUCTION: Defining the sites and mechanisms of nociception is an important step in understanding and treating pain. During inflammation, increased nociceptive input from an inflamed organ can sensitize neurons that receive convergent input from an unaffected organ, but the site of visceral cross-sensitivity is unknown. This study examined the cellular responses to ATP and substance P stimulation in sensory neurons innervating visceral organs. METHODS: Lumbosacral dorsal root ganglia (L6-S1) were cut into slices and processed for substance P receptor expression using immunocytochemistry. Primary culture of dorsal root ganglion (DRG) neurons was used for [Ca2+]i measurement by videomicroscopy. RESULTS: DRG neurons express substance P receptors. Both brief addition of low dose adenosine triphosphate (ATP, 5 microM) and substance P (10 microM) significantly increased subsequent ATP stimulation at the same neuron. DISCUSSION: Sensitization of the DRG neurons innervating the different organs may be through the release of nociceptive transmitters such as ATP and/or substance P within the ganglion. Together, these experiments will increase our understanding of the important modulatory role of peripheral sensitization in nociceptive transmission and suggest potential periphepheral sites for therapeutic intervention.

Visceral sensory neurons that innervate both uterus and colon express nociceptive TRPv1 and P2X3 receptors in rats.

In women, clinical studies suggest that functional pain syndromes such as irritable bowel syndrome, interstitial cystitis, and fibromyalgia, are co-morbid with endometriosis, chronic pelvic pain, and others diseases. One of the possible explanations for this phenomenon is visceral cross-sensitization in which increased nociceptive input from inflamed reproductive system organs sensitize neurons that receive convergent input from an unaffected visceral organ to the same dorsal root ganglion (DRG). The purpose of this study was to determine whether primary sensory neurons that innervate both visceral organs--the uterus and the colon--express nociceptive ATP-sensitive purinergic (P2X3) and capsaicin-sensitive vanilloid (TRPV1) receptors. To test this hypothesis, cell bodies of colonic and uterine DRG were retrogradely labeled with fluorescent tracer dyes micro-injected into the colon/rectum and uterus of rats. Ganglia were harvested, cryo-protected, and cut in 20-microm slices for fluorescent microscopy to identify positively stained cells. Up to 5% neurons were colon-specific or uterus-specific, and 10%-15% of labeled DRG neurons innervate both viscera in the lumbosacral neurons (L1-S3 levels). We found that viscerally labeled DRGs express nociceptive P2X3 and TRPV1 receptors. Our results suggest a novel form of visceral sensory integration in the DRG that may underlie co-morbidity of many functional pain syndromes.

Inflammation in the uterus induces phosphorylated extracellular signal-regulated kinase and substance P immunoreactivity in dorsal root ganglia neurons innervating both uterus and colon in rats.

In women, clinical studies suggest that pain syndromes such as irritable bowel syndrome and interstitial cystitis, which are associated with visceral hyperalgesia, are often comorbid with endometriosis and chronic pelvic pain. One of the possible explanations for this phenomenon is viscerovisceral cross-sensitization, in which increased nociceptive input from an inflamed pelvic organ sensitizes neurons that receive convergent input to the same dorsal root ganglion (DRG) from an unaffected visceral organ. Nociception induces up-regulation of cellular mechanisms such as phosphorylated extracellular signal-regulated kinase (pERK) and substance P (SP), neurotransmitters associated with induced pain sensation. The purpose of this study was to determine, in a rodent model, whether uterine inflammation increased the number of pERK- and SP-positive neurons that received input from both the uterus and the colon. Cell bodies of colonic and uterine DRG were retrogradely labeled with fluorescent tracer dyes microinjected into the colon/rectum and into the uterus. Ganglia were harvested for fluorescent microscopy to identify positively stained neurons. Approximately 6% of neurons were colon specific and 10% uterus specific. Among these uterus- or colon-specific neurons, up to 3-5% of DRG neurons in the lumbosacral neurons (L1-S3 levels) received input from both visceral organs. Uterine inflammation increased the number of pERK- and SP-immunoreactive DRG neurons innervating specifically colon, or innervating specifically uterus, and those innervating both organs. These results suggest that a localized inflammation activates primary visceral afferents, regardless of whether they innervate the affected organ. This visceral sensory integration in the DRG may underlie the observed comorbidity of female pelvic pain syndromes.

The same dorsal root ganglion neurons innervate uterus and colon in the rat.

The purpose of this study was to determine whether primary sensory neurons that innervate the uterus receive convergent input from the colon. To test this, in the rat, cell bodies of colonic and uterine dorsal root ganglia were retrogradely labeled with fluorescent tracer dyes microinjected into the colon/rectum and bilaterally into the uterine horns. Ganglia were harvested, cryoprotected and cut into 20 microm slices to identify positively stained cells for fluorescent microscopy. Up to 5% of neurons were colon-specific or uterus-specific, and 10-15% of labeled ganglion neurons innervate both viscera in the L1, L2, L6 and S1-S3 levels. These results suggest a novel form of visceral sensory integration in the dorsal root ganglion that may underlie comorbidity of many functional pain syndromes.

Estradiol stimulates progesterone synthesis in hypothalamic astrocyte cultures.

The brain synthesizes steroids de novo, especially progesterone. Recently estradiol has been shown to stimulate progesterone synthesis in the hypothalamus and enriched astrocyte cultures derived from neonatal cortex. Estradiol-induced hypothalamic progesterone has been implicated in the control of the LH surge. The present studies were undertaken to determine whether hypothalamic astrocytes derived from female neonatal or female postpubertal rats increased production of progesterone in response to an estradiol challenge. Estradiol induced progesterone synthesis in postpubertal astrocytes but not neonatal astrocytes. This estradiol action was blocked by the estrogen receptor antagonist ICI 182,780. Previously we had demonstrated that estradiol stimulates a rapid increase in free cytosolic Ca(2+) ([Ca(2+)](i)) spikes in neonatal cortical astrocytes acting through a membrane estrogen receptor. We now report that estradiol also rapidly increased [Ca(2+)](i) spikes in hypothalamic astrocytes. The membrane-impermeable estradiol-BSA construct also induced [Ca(2+)](i) spikes. Both estradiol-BSA and estradiol were blocked by ICI 182,780. Depleting intracellular Ca(2+) stores prevented the estradiol-induced increased [Ca(2+)](i) spikes, whereas removing extracellular Ca(2+) did not prevent estradiol-induced [Ca(2+)](i) spikes. Together these results indicate that estradiol acts through a membrane-associated receptor to release intracellular stores of Ca(2+). Thapsigargin, used to mimicked the intracellular release of Ca(2+) by estradiol, increased progesterone synthesis, suggesting that estradiol-induced progesterone synthesis involves increases in [Ca(2+)](i). Estradiol treatment did not change levels of steroid acute regulatory protein, P450 side chain cleavage, 3beta-hydroxysteroid dehydrogenase, and sterol carrier protein-2 mRNAs as measured by quantitative RT-PCR, suggesting that in vitro, estradiol regulation of progesterone synthesis in astrocytes does not depend on transcription of new steroidogenic proteins. The present results are consistent with our hypothesis that estrogen-positive feedback regulating the LH surge involves stimulating local progesterone synthesis by hypothalamic astrocytes.

Estrogen receptor-alpha mediates estradiol attenuation of ATP-induced Ca2+ signaling in mouse dorsal root ganglion neurons.

A mechanism underlying gender-related differences in pain perception may be estrogen modulation of nociceptive signaling in the peripheral nervous system. In rat, dorsal root ganglion (DRG) neurons express estrogen receptors (ERs) and estrogen rapidly attenuates ATP-induced Ca2+ signaling. To determine which estrogen receptor mediates rapid actions of estrogen, we showed ERalpha and ERbeta expression in DRG neurons from wild-type (WT) female mice by RT-PCR. To study whether ERalpha or ERbeta mediates this response, we compared estradiol action mediating Ca2+ signaling in DRG neurons from WT, ERalpha knockout (ERalphaKO), and ERbetaKO mice in vitro. ATP, an algesic agent, induced [Ca2+]i transients in 48% of small DRG neurons from WT mice. 17beta-Estradiol (E2) inhibited ATP-induced intracellular Ca2+ concentration ([Ca2+]i) with an IC50 of 27 nM. The effect of E2 was rapid (5-min exposure) and stereo specific; 17alpha-estradiol had no effect. E2 action was blocked by the ER antagonist ICI 182,780 (1 microM) in WT mouse. Estradiol coupled to bovine serum albumin (E-6-BSA), which does not penetrate the plasma membrane, had the same effect as E2 did, suggesting that a membrane-associated ER mediated the response. In DRG neurons from ERbetaKO mice, E2 attenuated the ATP-induced [Ca2+]i flux as it did in WT mice, but in DRG neurons from ERalphaKO mice, E2 failed to inhibit the ATP-induced [Ca2+]i increase. These results show that mouse DRG neurons express ERs and the rapid attenuation of ATP-induced [Ca2+]i signaling is mediated by membrane-associated ERalpha.

A membrane estrogen receptor mediates intracellular calcium release in astrocytes.

Appreciating the physiology of astrocytes and their role in brain functions requires an understanding of molecules that activate these cells. Estradiol may influence astrocyte functions. We now report that estrogen altered intracellular calcium concentration ([Ca(2+)](i)) in neonatal astrocytes that expressed estrogen receptor (ER) mRNA in vitro. Western blotting revealed both ERalpha and ERbeta proteins in both the nuclear fractions and plasma-membrane fractions. Application of 17beta-estradiol (20 nm) to fura 2-loaded astrocytes in vitro stimulated [Ca(2+)](i) in 75% of astrocytes with an EC(50) of 12.7 +/- 3.1 nm. This rapid action of estradiol was blocked by the ER antagonist, ICI 182,780. The membrane-impermeable estradiol-BSA induced a [Ca(2+)](i) flux that was statistically similar to estradiol. Removal of extracellular Ca(2+) did not alter the effect of estradiol, but phospholipase C inhibitor U73122 (10 microm) and 2-aminoethoxydiphenyl borate (5 microm), an inhibitor of the inositol-1,4,5,-trisphosphate-gated intracellular Ca(2+) channel, significantly decreased the estradiol-induced [Ca(2+)](i) flux. Estradiol was unable to induce [Ca(2+)](i) flux in thapsigargin-depleted cells. These results indicate that estradiol mediates [Ca(2+)](i) flux in astrocytes through a membrane-associated ER that activates the phospholipase C pathway.

Oestrogen modulates cholecystokinin: opioid interactions in the nervous system.

Responses of the nervous system to introceptive and extroceptive inputs depend upon the state of the brain. Oestrogen has the ability to modulate brain state and dramatically alter interactions among neural circuits to influence an organism's responses to given stimuli. Cholecystokinin (CCK) and endogenous opioid peptides (EOP) have a wide and parallel distribution in the nervous system. Their reciprocal interactions regulate a diverse physiology including reproduction, cortical function and nociception. The actions of CCK and EOP are diametrically opposed, in many regions. For example, when opioids inhibit reproductive behaviour or nociception, CCK facilitates. Because oestrogen is a powerful regulator of the expression of CCK and EOP, we examined whether oestrogen-state also modulated the interactions of these neuropeptides. In this paper we present new data and review previous work that demonstrates oestrogen modulation of functional CCK-opioid interactions that regulate reproductive behaviour, cortical function and nociception.