Relation of substance P to pain transmission: neurophysiological evidence

Diverse Role of Biological Plasticity in Low Back Pain and Its Impact on Sensorimotor Control of the Spine

Pain is complex. It is no longer acceptable to consider pain solely as a peripheral phenomenon involving activation of nociceptive neurons. The contemporary understanding of pain involves consideration of different underlying pain mechanisms and an increasing awareness of plasticity in all of the biological systems. Of note, recent advances in technology and understanding have highlighted the critical importance of neuroimmune interactions, both in the peripheral and central nervous systems, and the interaction between the nervous system and body tissues in the development and maintenance of pain, including low back pain (LBP). Further, the biology of many tissues changes when challenged by pain and injury, as reported in a growing body of literature on the biology of muscle, fat, and connective tissue. These advances in understanding of the complexity of LBP have implications for our understanding of pain and its interaction with the motor system, and may change how we consider motor control in the rehabilitation of LBP. This commentary provides a state-of-the-art overview of plasticity of biology in LBP. The paper is divided into 4 parts that address (1) biology of pain mechanisms, (2) neuroimmune interaction in the central nervous system, (3) neuroimmune interaction in the periphery, and (4) brain and peripheral tissue interaction. Each section considers the implications for clinical management of LBP. J Orthop Sports Phys Ther 2019;49(6):389-401. doi:10.2519/jospt.2019.8716.

Increased CCN2, substance P and tissue fibrosis are associated with sensorimotor declines in a rat model of repetitive overuse injury

Key clinical features of cumulative trauma disorders include pain, muscle weakness, and tissue fibrosis, although the etiology is still under investigation. Here, we characterized the temporal pattern of altered sensorimotor behaviors and inflammatory and fibrogenic processes occurring in forearm muscles and serum of young adult, female rats performing an operant, high repetition high force (HRHF) reaching and grasping task for 6, 12, or 18 weeks. Palmar mechanical sensitivity, cold temperature avoidance and spontaneous behavioral changes increased, while grip strength declined, in 18-week HRHF rats, compared to controls. Flexor digitorum muscles had increased MCP-1 levels after training and increased TNFalpha in 6-week HRHF rats. Serum had increased IL-1beta, IL-10 and IP-10 after training. Yet both muscle and serum inflammation resolved by week 18. In contrast, IFNγ increased at week 18 in both muscle and serum. Given the anti-fibrotic role of IFNγ, and to identify a mechanism for the continued grip strength losses and behavioral sensitivities, we evaluated the fibrogenic proteins CCN2, collagen type I and TGFB1, as well as the nociceptive/fibrogenic peptide substance P. Each increased in and around flexor digitorum muscles and extracellular matrix in the mid-forearm, and in nerves of the forepaw at 18 weeks. CCN2 was also increased in serum at week 18. At a time when inflammation had subsided, increases in fibrogenic proteins correlated with sensorimotor declines. Thus, muscle and nerve fibrosis may be critical components of chronic work-related musculoskeletal disorders. CCN2 and substance P may serve as potential targets for therapeutic intervention, and CCN2 as a serum biomarker of fibrosis progression.

Substance P in nociceptive sensory neurons

Substance P is contained within a subpopulation of nociceptive primary sensory neurons that project to the superficial dorsal horn of the spinal cord. Stimulation of the peripheral processes of primary afferent fibres at intensities that activate A delta and C fibres elicits a pronounced release of substance P from the cat spinal cord in vivo. Experiments with the neurotoxins capsaicin and 5,6-dihydroxytryptamine have shown that substance P release from the spinal cord in vivo derives largely from afferent fibres. Intrathecal perfusion of the cat spinal cord with morphine abolishes the nerve-evoked release of substance P while capsaicin produces a dramatic increase in peptide release. Prolonged treatment of rats with capsaicin depletes substance P from the dorsal horn and results in reduced sensitivity to noxious peripheral stimuli. The duration of the somatic action potential recorded from cultured sensory neurons is known to be decreased by enkephalin and is prolonged by capsaicin. The acute effects of both morphine and capsaicin on substance P may be mediated by an interaction with voltage-sensitive ion channels on the sensory neuron. These observations suggest that nociceptive input to the dorsal horn can be regulated by drugs that interact directly with substance P-containing sensory terminals.

NK-1 receptor immunoreactivity in distinct morphological types of lamina I neurons of the primate spinal cord

In cat and monkey, lamina I cells can be classified into three basic morphological types (fusiform, pyramidal, and multipolar), and recent intracellular labeling evidence in the cat indicates that fusiform and multipolar lamina I cells are two different types of nociceptive cells, whereas pyramidal cells are innocuous thermoreceptive-specific. Because earlier observations indicated that only nociceptive dorsal horn neurons respond to substance P (SP), we examined which morphological types of lamina I neurons express receptors for SP (NK-1r). We categorized NK-1r-immunoreactive (IR) lamina I neurons in serial horizontal sections from the cervical and lumbar enlargements of four monkeys. Consistent results were obtained by two independent teams of observers. Nearly all NK-1r-IR cells were fusiform (42%) or multipolar (43%), but only 6% were pyramidal (with 9% unclassified). We obtained similar findings in three monkeys in which we used double-labeling immunocytochemistry to identify NK-1r-IR and spinothalamic lamina I neurons retrogradely labeled with cholera toxin subunit b from the thalamus; most NK-1r-IR lamina I spinothalamic neurons were fusiform (48%) or multipolar (33%), and only 10% were pyramidal. In contrast, most (approximately 75%) pyramidal and some (approximately 25%) fusiform and multipolar lamina I spinothalamic neurons did not display NK-1r immunoreactivity. These data indicate that most fusiform and multipolar lamina I neurons in the monkey can express NK-1r, consistent with the idea that both types are nociceptive, whereas only a small proportion of lamina I pyramidal cells express this receptor, consistent with the previous finding that they are non-nociceptive. However, these findings also indicate that not all nociceptive lamina I neurons express receptors for SP.

Transgenic mice over-expressing substance P exhibit allodynia and hyperalgesia which are reversed by substance P and N-methyl-D-aspartate receptor antagonists

A transgenic mouse has been developed which, during development, over-expresses nerve growth factor under the control of a myelin basic protein promoter. These animals display an ectopic network of substance P-containing sensory fibers in the white matter of the spinal cord. To study the functional significance of this model to nociception, these mice were studied in a test measuring the latency to tail withdrawal from a noxious radiant heat stimulus. Baseline reaction times were significantly less in transgenic mice, suggesting thermal allodynia. A mechanical stimulus was then applied to the tip of the tail at either 450 g or 1400 g for 2 s and tail withdrawal readings were taken for another 10 min. In control mice, the 450 g stimulus was without effect, suggesting that it is normally innocuous. In transgenic mice, this stimulus induced a transient decrease in withdrawal latency at 1 min. Thus, transgenic mice exhibited mechanical allodynia. The 1400 g stimulus decreased withdrawal latency in both transgenic and control mice. However, the response was greater in transgenic mice, indicating that they exhibited mechanical hyperalgesia. The neurokinin-1 receptor antagonist CP-96,345, but not the inactive stereoisomer CP-96,344, administered subcutaneously 30 min before the 450 g stimulus, blocked the stimulation-induced allodynia in transgenic mice, and revealed a transient antinociception in transgenic and control mice. Ketamine, an N-methyl-D-aspartate receptor antagonist, given intraperitoneally 10 min before 450 g stimulation, blocked the allodynia in transgenic mice. These results indicate that these transgenic mice display hyperalgesia and allodynia, and that these nociceptive responses are reversed by substance P and N-methyl-D-aspartate receptor antagonists.

Neurokinin B is a preferred agonist for a neuronal substance P receptor and its action is antagonized by enkephalin

Receptor specificity of the substance P-related peptides neurokinin A and neurokinin B was studied in the isolated guinea pig ileum. Substance P and the recently discovered neurokinins elicit contraction of the ileum both directly through action on a muscle cell receptor and indirectly through stimulation of a neuronal receptor, leading to release of acetylcholine, which causes muscle contraction via muscarinic receptors. Two specific assay procedures for the function of the neuronal receptor were developed. The muscular receptor was inactivated either by desensitization with the selective agonist substance P methyl ester or by receptor blockade with the selective antagonist [Arg6, D-Trp7,9, Me-Phe8]substance P-(6-11) hexapeptide. Both procedures revealed that the neuronal receptor is clearly distinct from the muscular receptor, since it exhibits different agonist specificity and is insensitive to antagonists of the muscular receptor. Neurokinin B was found to be the most potent agonist (EC50 = 1 nM) for the neuronal receptor. Furthermore, [D-Ala2, Met5]enkephalinamide inhibited in a naloxone-sensitive manner the effect of neurokinin B mediated via the neuronal receptor. These results suggest that the different mammalian tachykinins can play specific physiological roles by virtue of their distinct receptor specificities.

Hyperalgesia produced by intrathecal substance P and related peptides: desensitization and cross desensitization

The hyperalgesic effect of intrathecally administered substance P (SP), physalaemin, eledoisin and eledoisin-related peptide (ERP) was investigated in the rat tail flick test. Hyperalgesia produced by SP (2.5-15 micrograms, 1.9-11 nmol) was maximal 10-20 min after injection, lasted 30 min and was dose-related. The effect was mimicked by all of the peptides examined. The rank order of potency was physalaemin greater than SP greater than eledoisin greater than ERP. Desensitization to the hyperalgesic effect of SP was produced by three repeated intrathecal injections. Rats desensitized to SP no longer responded to physalaemin or ERP, indicating cross-desensitization. Phentolamine continued to produce hyperalgesia following such desensitization. The demonstration of a hyperalgesic effect for SP provides further support for a role for SP in nociceptive transmission. The receptor mediating this effect appears to be a SP-P subtype. Cross-desensitization between peptides suggests an action on the same receptor.