Zusammenfassung
Die Interaktion von kardiovaskulären Dynamiken und der Schmerzwahrnehmung stellt eine bedeutsame Komponente der intrinsischen Schmerzregulation dar. Bei Gesunden provoziert ein akuter Schmerzreiz ein erhöhtes sympathisches Arousal, einhergehend mit einem Anstieg des mittleren arteriellen Blutdrucks. Arterielle Barorezeptoren registrieren solche phasischen Blutdruckveränderungen und projizieren diese Information zum dorsomedialen Nucleus tractus solitarii (dmNTS) im unteren Hirnstamm. Durch Verbindungen in weitere Hirnstammareale, aber auch in höhere kortikale Gebiete hat dies schließlich eine Regulation des Blutdrucks, aber auch die Modulation von Schlaf, Angst und Schmerz zur Folge. Bei Gesunden besteht daher eine inverse Beziehung von Blutdruck und Schmerzsensitivität, dieser Zusammenhang ist jedoch im chronischen Schmerz gestört. Es wird diskutiert, dass, bedingt durch Stress und Schmerzverhalten, klassische und operante Konditionierungsprozesse in einer Subgruppe von Patienten die Baroreflexsensitivität reduzieren und dadurch die Aktivität des dmNTS vermindern können. Das führt zur Reduktion der autonomen Regulationsfähigkeit und zu einer fehlenden intrinsischen Schmerzhemmung. Gleichzeitig wird die Funktion des Baroreflexes selbst durch kognitive und affektive Prozesse moduliert. In diesem Beitrag wird die Rolle des Baroreflexes als ein möglicher wichtiger Faktor in der Entstehung und Aufrechterhaltung von chronischem Schmerz dargestellt. Berücksichtigt werden dabei auch relevante Lernprozesse. Darauf aufbauend werden mechanismenbasierte individuelle Behandlungsansätze für Schmerzpatienten mit hypertoner Stressreaktivität kritisch diskutiert.
Abstract
The interaction of cardiovascular dynamics and pain perception is an important component of intrinsic pain regulation. In healthy subjects acute pain stimuli cause increased sympathetic arousal and increased mean arterial pressure. Arterial baroreceptors sense phasic blood pressure changes and relay the information to the lower brainstem via the dorsomedial nucleus tractus solitarius (dmNTS). Projections in the brainstem and also higher cortical areas result in elevation of blood pressure as part of the autonomic nervous system as well as modulation of sleep, anxiety and pain. In healthy subjects there is an inverse relationship between blood pressure and pain sensitivity but this relationship is impaired in chronic pain patients. Persistent stress, pain behavior and classical and operant conditioning mechanisms reduce baroreflex sensitivity (BRS) and dmNTS activity in a subgroup of patients. This leads to a decrease of autonomic regulatory function as well as reduced pain inhibition. Importantly, baroreflex function can be modulated by cognitive and affective processes. This article reviews the role of the baroreflex arc as a possible crucial factor in the development and maintenance of chronic pain. The importance of learning mechanisms is described. Mechanism-based individualized treatment approaches for patients with hypertensive stress reactivity are also critically discussed.
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T. Meller, F. Stiehm, R. Malinowski und K. Thieme geben an, dass kein Interessenkonflikt besteht.
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Meller, T., Stiehm, F., Malinowski, R. et al. Baroreflexsensitivität und chronischer Schmerz. Schmerz 30, 470–476 (2016). https://doi.org/10.1007/s00482-016-0150-5
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DOI: https://doi.org/10.1007/s00482-016-0150-5
Schlüsselwörter
- Blutdruck
- Hämodynamik
- Dorsomedialer Nucleus tractus solitarii
- Chronischer Schmerz
- Psychologische Schmerztherapie