Peripheral mechanisms of neuropathic pain – involvement of lysophosphatidic acid receptor-mediated demyelination
© Ueda; licensee BioMed Central Ltd. 2008
Received: 18 February 2008
Accepted: 01 April 2008
Published: 01 April 2008
Recent advances in pain research provide a clear picture for the molecular mechanisms of acute pain; substantial information concerning plasticity that occurs during neuropathic pain has also become available. The peripheral mechanisms responsible for neuropathic pain are found in the altered gene/protein expression of primary sensory neurons. With damage to peripheral sensory fibers, a variety of changes in pain-related gene expression take place in dorsal root ganglion neurons. These changes, or plasticity, might underlie unique neuropathic pain-specific phenotype modifications – decreased unmyelinated-fiber functions, but increased myelinated A-fiber functions. Another characteristic change is observed in allodynia, the functional change of tactile to nociceptive perception. Throughout a series of studies, using novel nociceptive tests to characterize sensory-fiber or pain modality-specific nociceptive behaviors, it was demonstrated that communication between innocuous and noxious sensory fibers might play a role in allodynia mechanisms. Because neuropathic pain in peripheral and central demyelinating diseases develops as a result of aberrant myelination in experimental animals, demyelination seems to be a key mechanism of plasticity in neuropathic pain. More recently, we discovered that lysophosphatidic acid receptor activation initiates neuropathic pain, as well as possible peripheral mechanims of demyelination after nerve injury. These results lead to further hypotheses of physical communication between innocuous Aβ- and noxious C- or Aδ-fibers to influence the molecular mechanisms of allodynia.
Chronic pain should be considered to be a disease rather than just a symptom, because it is one of most common reasons for hospital visits. Although recent advances in molecular biology techniques, and the subsequent discoveries of key molecules involved in pain production, have clearly contributed to better understanding acute pain [1–4], the molecular mechanisms underlying chronic pain remain to be fully clarified.
Chronic pain, or specifically neuropathic pain, is quite different from other types of pain, such as nociceptive (or physiological) or inflammatory pain, because it is irreversible, even when the underlying cause has been rectified . For this reason, the proper diagnosis and early treatment are often difficult. Moreover, neuropathic pain commonly occurs as a secondary symptom in diseases, such as diabetes, cancer, and herpes zoster infection, or as a side effect of chemotherapeutic treatments [3, 5–7]. Neuropathic pain is often characterized by stimulus-independent persistent pain or abnormal sensory perception of pain, such as allodynia (pain perception upon the innocuous tactile stimuli) and hyperalgesia (exaggerated pain sensations by mildly noxious stimuli) [3, 8]. To treat chronic pain, we must first understand the initial and sustained molecular events in experimental animal models. Because the central mechanisms of sustained molecular events, which are closely related to memory in the brain, have been described in elsewhere in detail [9, 10], this review focuses on peripheral mechanisms of initial events from nociceptors to the spinal dorsal horn.
Approaches to study plasticity in nociceptor endings
Neuropathic pain occurs as a consequence of complex sensory dysfunction and may differ depending on the type of insult and the individual patient. Furthermore, due to the dynamic nature of the pain system, signs and symptoms of neuropathic pain change over time. Injury to peripheral nerves causes functional and biochemical changes at the site of injury, as well as to other areas of the affected nerve, and later to higher order neurons in the spinal cord and brain [3, 8–12]. Nociceptor endings cause a generator potential, which leads to an action potential in polymodal C and mechanothermal Aδ fibers [1, 13]. These action potentials are then conducted to higher centers in the central nervous system (CNS) via neurotransmitter release and are accompanied by a variety of responses, including withdrawal reflexes, conscious perception of pain, and emotional effects. The pain signal, on the other hand, drives the descending noradrenergic and serotonergic pain-inhibitory systems from the lower brain stem to the spinal dorsal horn . Therefore, chronic neuropathic pain is a result of problems in ascending pain transmission or descending pain-inhibitory system.
The identification of mechanisms or key molecules related to hyperalgesia and allodynia in neuropathic pain could be elucidated by studies using antisense oligos, RNA interference (RNAi), or transgenic (KO) mice lacking specific genes. However, these approaches present difficulties, such as: 1) intrathecal treatments with antisense oligo or RNAi cannot specify whether the action site is on sensory fibers or the spinal cord, although some studies have demonstrated dorsal root ganglion (DRG)-specific down-regulation [15, 16]; 2) the availability of specific KO mice is limited, and functional compensation during development and growth may modify the roles of the genes involved; and 3) the availability of conditional KO mice is even more limited. Considering this, as an initial attempt to survey key molecules responsible for neuropathic pain, we have developed novel nociception tests to measure algogenic-induced paw flexion (APF) .
Pharmacological plasticity in neuropathic hyperalgesia
Our laboratory has developed a highly sensitive and minimally stressful nociception test (APF test) in mice . In this test, the mouse is held in a hammock-type cloth sling, which is suspended from a bar, and nociceptive responses (in force) that are induced by intraplantar injection of a receptor ligand or algogenic substance can be measured. The APF test has proven to be advantageous for the study of in vivo pain signal transduction at peripheral nerve endings and has enabled the characterization of pain induction through nociceptors on C- or Aδ-fibers. In vivo signal transduction can be studied through the use of pharmacological methods using intraplantar treatments with various inhibitors and intrathecal pretreatments with antisense oligodeoxynucleotide (AS-ODN). The AS-ODN treatments are intended to determine whether the action site of compounds (i.pl.) reside on nociceptor endings or on non-neuronal peripheral cells.
Pharmacological studies have shown that the nociceptive fibers are responsible for various algogenics actions, which can be divided into three groups . Neonatal pretreatment of capsaicin degenerates unmyelinated C fibers, polymodal nociceptive fibers [18–20]. Spinal antagonism, using receptor antagonists for substance P (SP) or glutamate, is another way to characterize nociceptive fibers. The use of neonatal capsaicin-sensitivity and spinal antagonism enabled us to pharmacologically categorize algogenic-induced nociceptive flexor responses into three groups : 1) subcutaneous (s.c.) capsaicin-pretreatment and/or intrathecal (i.t.) pretreatment with NK1-type SP receptor antagonist abolished nociceptive responses to bradykinin (BK), SP, and histamine (His), which are representative chemical mediators; 2) ATP-induced responses were abolished with pretreatments of neonatal capsaicin (s.c.) or NMDA receptor antagonist (i.t.), but not by NK1 antagonist (i.t.); 3) PGI2 receptor agonist-induced responses were not affected by neonatal capsaicin, but were abolished by the NMDA antagonist. Therefore, we proposed that C-fibers could be further divided into two groups: peptidergic type 1 (SP-containing) and non-peptidergic type 2 (P2X3 receptor-expressing) C-fibers. This proposal is similar to the schematic model proposed by Snider & McMahon , who report two groups of C-fibers with differential gene (or protein) expression. This sub-classification of C-fibers is anatomically supported elsewhere ; only 3% of P2X3 receptor-positive neurons co-existed with SP in rat DRG neurons. Our proposal suggested a third group (type 3) of nociceptive fibers that may be related to myelinated A(δ) fibers, as opposed to C fibers .
Partial injury to peripheral nerves has been used to generate representative experimental animal models for neuropathic pain , where remarkable functional and molecular changes are observed. The injury-induced expression of Nav1.3 in large (A-fiber) DRG neurons  is thought to be one of the mechanisms underlying the hypersensitivity. We have also observed injury-induced appearance of TRPV1 and B1-type BK receptors in N52 (an A-fiber marker)-positive DRG neurons [15, 25]. Neuropeptides, such as galanin, neuropeptide Y (NPY), and pituitary adenylyl cyclase activating polypeptide (PACAP), which are normally expressed at low levels in sensory neurons, are dramatically increased in DRG neurons, including medium to large size neurons (A-fibers) [26–29]. Recently, a paper described reduced neuropathic pain in mice lacking PACAP . Nevertheless, the up-regulation of these neuropeptides is not always the mechanism intrinsic to neuropathic pain. NPY-null mice exhibit autotomy-like biting behaviors , augmentation of neuropathic pain is observed in NPY Y1 receptor-null mice , and i.t. injection of NPY inhibits neuropathic pain . Similarly, neuropathic pain is decreased in transgenic mice overexpressing galanin, and augmented in galanin receptor 1-null mice [33, 34]. On the contrary, some molecules, such as substance P [28, 35], Nav1.8, and Nav1.9, are down-regulated [36, 37]. These modifications may be generalized functional switches of C-fibers to A-fibers, as evidenced by the down-regulation of C-fiber mechanisms and the up-regulation of A-fiber mechanisms .
Sensory fiber-specific plasticity in neuropathic allodynia
Allodynia is the best target to investigate molecular mechanisms underlying neuropathic pain. In the APF test, hypoalgesia could be characterized through peptidergic C-fibers and A(δ)-hyperalgesia, another feature of neuropathic pain. This test mimics the physiological event where, upon exposure to noxious stimuli, chemicals are secreted in the vicinity of nerve endings to stimulate these nociceptive fibers. However, because the peripheral nerve terminals of innocuous Aβ fibers, which are thought to mediate allodynia, are covered by nonneuronal supporting cells, and protected from chemicals, different nociception tests are needed to characterize Aβ-fibers.
Matsumoto et al.  also confirmed frequency-specificity with a pharmacological study; neonatal capsaicin treatments to cause a damage of C-fibers eliminated LF-stimuli-induced nociceptive behavior, but not MF- or HF-stimuli-induced behaviors. These results suggest that nociceptive behavior from LF-stimuli is a result of C-fiber stimulation, while MF- or HF-stimuli-induced behavior is due to A-fiber stimulation. Furthermore, MF-stimulus to the finger results in sharp pain (prickly feeling), while HF-stimulus causes an unpleasant vibrating perception (light tickle).
Further pharmacological characterizations strengthened the validity of behavioral studies using Neurometer® [38, 44]. Both NK1 and NMDA receptor antagonists inhibited LF-stimuli-induced nociceptive responses; NMDA receptor antagonists inhibited MF-responses, while AMPA/kainate (non-NMDA) receptor antagonists specifically inhibited HF-induced behaviors (Fig. 1c), which is consistent with previous reports . The characteristics of pain behavior were consistent to those obtained with the measurement of neuron-specific phosphorylation of extracellular signal-regulated kinase 1/2 (p-ERK). Studies have shown that LF-stimuli induced neuronal p-ERK signals at the spinal dorsal horn (lamina I and II) were inhibited by NK1 and NMDA receptor antagonists, while MF-induced signals (lamina I) were specifically inhibited by the NMDA receptor. Moreover, HF stimuli resulted in no signal in the spinal cord. Thus, it seems likely that LF-stimuli causes C-fiber stimulation, while MF- or HF-stimuli causes nociceptive A(δ) or innocuous A(β)-fiber stimulation, respectively, in naïve animals and humans. It is unlikely that cutaneous application of high frequency (250 or 2000 Hz) electrical stimuli is capable of completely stimulating sensory fibers at the same frequency. Koga et al.  reported ~3 Hz C-fiber, ~22 Hz Aδ-fiber, and ~140 Hz Aβ-fiber responses after 5, 250, and 2000 Hz stimulation, respectively; these responses are similar to physiological levels .
Functional mechanisms influencing neuropathic allodynia
According to the previous hypothesis for neuropathic allodynia, nerve damage results in a retraction of C-fibers and allows for intrusion of A-fibers to the newly created space and loss of C-fiber pain transmission. This hypothesis was originally proposed with anatomical studies that demonstrated that nerve transection produces central sprouting of large fibers from deep laminae to lamina II [48, 49]. Although nerve injury-induced intrusion of Aβ-fibers to the superficial dorsal horn layers has not been well documented, this hypothesis received functional support through electrophysiological studies .
Behavioral studies (APF test) have determined a loss of peptidergic C-fiber responses after nerve injury [25, 35]. The down-regulation of C-fiber specific molecules, such as Nav1.8 and 1.9 [36, 37] and bradykinin B2 receptor , could be responsible for this type of neuropathic pain. The down-regulation of pain transmitter SP in the dorsal horn of spinal cord could be another mechanism [3, 35, 51]. Because SP precursor preprotachykinin (PPT)-null mice continued to exhibit neuropathic pain, the loss of peptidergic C-fiber function may not be significant stimuli to cause nociceptive behaviors. Alternatively, up-regulation of NK1 receptor expression in the spinal cord  may counteract the threshold change.
On the other hand, hypersensitization or allodynia upon innocuous stimulation has been studied. These studies demonstrated, in particular, the up-regulation of large-fiber-specific molecules [15, 24, 25, 27]. Although these changes may be responsible for neuropathic hyperalgesia, they cannot explain the mechanism of allodynia. The novel method using the Neurometer® clearly demonstrates Aβ-fiber stimulation-induced nociceptive flexor responses . Following partial sciatic nerve injury, LF-stimuli-induced behavioral responses were significantly inhibited in the EPF test, while MF-stimuli-induced responses were enhanced . These results are in accordance with studies using the APF test to determine that peptidergic C-fiber responses were lost, while Aδ-fiber responses were hypersensitized . It should be noted that similar injury-specific hypersensitization was also observed with HF-stimuli [38, 44], which should stimulate innocuous fibers in naïve mice. Consistent results were also observed when neuronal p-ERK signals were measured at the spinal dorsal horn . Most interestingly, HF-stimuli generated significant p-ERK signals at the spinal cord lamina I and II after nerve injury. Pharmacological characterization after the injury also verified the plasticity that HF-stimuli (Aβ)-induced spinal transmission is mediated by NMDA receptor, but not by non-NMDA receptor [44, 46].
Thus, functional changes following nerve injury suggest that two molecular events are taking place: communication between different sensory fibers and C-fiber retraction. Demyelination, and subsequent physical cross-talk, might be the mechanism responsible for neuropathic pain, because many demyelinating diseases accompany chronic pain, as with Guillain-Barre syndrome , Charcot-Marie-Tooth type I disease , and multiple sclerosis . Indeed, it has been reported that neuropathic pain develops as a result of aberrant myelination (splitting, detachment, and loss of myelin) in mice deficient in the myelin protein periaxin . However, little is known of the molecular events causing demyelination in the diseases that accompany neuropathic pain.
Lysophosphatidic acid (LPA) mimics nerve injury-induced neuropathic pain
A number of pharmacological studies suggest that lysophosphatidic acid (LPA) might cause neuropathic pain and demyelination following partial sciatic nerve injury. LPA is one of several lipid metabolites released after tissue injury, as well as from various cancer cells [57–59]. LPA receptors activate multiple signaling pathways and multiple G-proteins [60–64]. Direct stimulation of peripheral nociceptor endings by LPA, through LPA1 receptors, also suggests a role in nociceptive processes [65, 66]. Of particular note, receptor-mediated LPA signaling via Gα12/13 activates the small GTPase RhoA [63, 64, 67]. In the active state, Rho is translocated to the plasma membrane and thereby relays extracellular signals to multiple downstream effectors, including Rho-kinase or ROCK, which can be inhibited by the pyridine derivative compound, Y-27632. Inhibition of the Rho pathway can also be accomplished by selective ADP-ribosylation of RhoA, using Clostridium botulinum C3 exoenzyme (BoTN/C3). The involvement of Rho-ROCK system in neuropathic pain mechanisms was initially demonstrated by i.t. injections of BoTN/C3 prior to peripheral nerve injury in mice, which blocked the development of hyperalgesia . LPA receptors and LPA receptor gene expression activates Rho in peripheral nerves [69–71], which suggests that LPA receptors might pathophysiologically activate Rho in neuropathic pain states of peripheral nerve injury. An interesting study illustrated that LPA inhibits the filopodia of growth cones . LPA could be involved in C-fiber retraction, which is a hypothesis supporting functional changes induced by neuropathic pain. Together, these findings present LPA as an attractive signaling molecule in the development of neuropathic pain.
Indeed, a single i.t. injection of LPA produced marked mechanical allodynia and thermal hyperalgesia that persisted for at least 7–8 days before returning to baseline levels at day 13 . Sphingosine 1-phosphate (S1P), which signals through S1P receptors and shares similar signaling pathways with LPA receptors , did not produce mechanical allodynia after i.t. injections in mice. These findings, therefore, highlight the specificity of LPA. Further studies have shown that LPA-induced thermal hyperalgesia and mechanical allodynia could be blocked by BoTN/C3 (i.t.) and Y-27632 . In addition, LPA decreased the peptidergic , but not non-peptidergic C-fiber responses, but markedly increased A(δ)-fiber responses in the APF test, which strongly suggests that LPA mimics partial sciatic nerve injury by causing neuropathic pain .
Ex vivo studies of LPA-mediated demyelination
Involvement of LPA1-signaling in nerve injury-induced neuropathic pain
LPA acts through G-protein-coupled LPA receptors, designated LPA1, LPA2, LPA3, and LPA4, each exhibiting different G protein interactions [63, 64]. However, only the lpa1 receptor gene is expressed in both DRG neurons and dorsal root . LPA1-null mice reversed LPA-induced demyelination, as well as mechanical allodynia . Furthermore, LPA1 receptor-mediated demyelination was evidenced by down-regulation of myelin-associated proteins, such as MBP and peripheral myelin protein 22 kDa (PMP22), in the dorsal root after LPA injection or peripheral nerve injury. These changes were identical to nerve injury changes resulting in neuropathic pain. Indeed, LPA1-null, reversed nerve injury-induced neuropathic pain and demyelination, as well down-regulation of myelin proteins and up-regulation of A-fiber Cavα2δ-1 and spinal PKCγ .
Nerve injury-induced de novo LPA biosynthesis
LPA as an initiator of nerve-injury-induced neuropathic pain
Neuropathic pain behavior at day 14 was absent after pretreatment with AS-ODN for LPA1, but not with later treatments that started at day 7 post-injury . Neuropathic pain was also blocked when BoTN/C3 was administered within 1 h post-injury. A time-course study using Ki-16425, a short-lived LPA1 antagonist  revealed that LPA1 receptor signaling was found to terminate within 3 h following injury (Lin and Ueda et al., unpublished data). These findings suggest that de novo-produced LPA after nerve injury might initiate various mechanisms of neuropathic pain through the LPA1 receptor .
Working hypothesis for LPA1 signaling initiating neuropathic pain
Neuropathic pain is thought to become worse with time, if not appropriately treated. This present review proposes initial mechanisms at the level of peripheral nerves following nerve injury. The development of agents to block enhanced pain transmission is an important therapeutic direction for research. It would be important to target the crosstalk between noxious and innocuous fibers after demyelination to cure or prevent neuropathic pain. Sustained mechanisms could occur at the spinal and supraspinal levels. Plasticity or reorganization of neural networks in pain and pain-inhibitory pathways could make treatment more problematic. Pain induces pain in a vicious circle. Complete blockade of the plasticity responsible for neuropathic pain at the initial stage and at the peripheral level might be an appropriate strategy.
I thank Makoto Inoue, Ryousuke Fujita, and Misaki Matsumoto for kind help in preparing this manuscript. This study was supported by Special Coordination Funds of the Science and Technology Agency of the Japanese Government and Grant-in-Aid from the Ministry of Education, Science, Culture and Sports of Japan and Human Frontier Science Program.
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