Kroniske smerter kan ofte ikke alene tilskrives fysiske skader på kroppen, men stammer ofte fra forandringer i vores nervesystems måde at fortolke signaler på. Med andre ord er nervesystemet øget følsomt og fastholdt i at beskytte et område, selvom en eventuel vævsskade er helet så godt som muligt. Det kan medføre, at vores naturlige alarmsystem reagerer for ofte, for hårdt og uden nogen åbenlys årsag.
Af Lene Pilegaard
Artiklen blev bragt i magasinet sund-forskning – juni/juli 2019
Artiklen handler om smertesensibilisering og for bedre at kunne forstå, hvor kompleks smertesensibilisering er, skal vi omkring den grundlæggende forståelse af, hvad smerte egentlig er.
Smerte er fantastisk
Vores alarmsystem er ganske fantastisk og udviklet gennem millioner af år. Alarmsystemet sender via sensorer konstant beskeder til hjernen om de ændringer, der sker i vores krop. Hjernen bearbejder disse informationer, uden at vores bevidsthed er involveret. Yderligere har det ”automatiske alarmsystem” indbygget en backup funktion: Vores synssans, lugtesans, høresans og smagssansen, det proprioceptive system og den vestibulære sans, som kombineret er med til at forhindre vores krop i at komme til skade og sørge for, at vi ”overlever”.
Smerte er en bevidst oplevelse – smerte kan ikke eksistere uden for vores bevidsthed, og der findes ingen smertereceptorer, smertesensorer, smertenerver, smerteveje eller et smertecenter” i hjernen.
Hvad er smerte?
Smerte er en evolutionær og genial udviklet mekanisme, som simplificeret kan betegnes som en advarsel om, at der er noget galt, og du er i fare – det er et signal om, at du skal gøre noget eller holde op med at gøre noget for at kunne overleve en fare eller at undgå at komme yderligere til skade. Vi kunne ikke have overlevet som art, hvis ikke vi havde denne sans.
Mange er overbevist om, at vi har smertenerver eller smertesensorer og et ”smertecenter” i hjernen. Det er ikke tilfældet! Der findes ingen smertesensorer eller smertenerver i kroppen. Alle signaler sendes via neuroner igennem det perifere nervesystem til det centrale nervesystem, som består af rygmarven og hjernen.
Man skelner mellem det centrale og det perifere nervesystem.
Det centrale nervesystem (CNS) består af rygmarven og hjernen. Alt andet hører til det perifere nervesystem. (PNS)
Hjernen ”oversætter og tolker” signaler fra kroppen ud fra den nuværende sammenhæng, og disse signaler bliver evalueret samtidigt og sammenkoblet med tidligere erfaringer, forventninger, minder, følelser og tanker. Hjernen bedømmer, om impulserne skal associeres med fare, og om der dermed skal føles smerte.
Udfordringen for hjernen er at sammensætte en så pålidelig og fornuftig oversættelse af alle disse input, baseret ud fra alle de informationer den får, sammenholdt med den kæmpe mængde information, der i forvejen er lagret i hukommelsen. Det vil derfor altid være en helt personlig og subjektiv bedømmelse og tolkning af signaler og en forklaring på, at identiske skader på to forskellige personer kan tolkes vidt forskelligt af disse personer. Så når lægen siger, at det umuligt kan passe, at du har så ondt, som du fortæller, med begrundelsen, at han kender til en anden patient, der fejler det samme, som ikke har nær så ondt, så har han ikke forstået det grundlæggende i, hvordan vores smertemekanisme fungerer!
Nocer = betydning fra latin: At gøre ondt
Nociception er defineret af IASP (International Association of the Study of Pain): Aktiviteter, der afkoder skadelige stimuli.
Nociception
Selve processen med, at sensorer fra det perifere nervesystem sender signaler til det centrale nervesystem, kaldes for ”nociception”, og det er reelt ”forsendelse og modtagelse af besked om fare”.
I hele vores krop er der sensorer, der konstant sender signaler til hjernen, og vores nervesystem består af kilometervis af nerver. Nerver består af ca. 50 % ligament, som gør dem ret stærke, og ca. 50 % neuroner. Nogle af disse neuroner informerer rygmarven og hjernen om aktivitet af sensorerne, og andre styrer muskler og svedkirtler.
Din krop har masser af disse sensorer spredt over det hele: led, muskler, ligamenter (ledbånd), bindevævet, hud osv. Disse mange sensorer sender konstant signaler til hjernen.
- Signaler registreres og videreføres via neuroner. Nogle vil reagere ved mekanisk stimuli – eksempelvis berøring, hvis der sker et brud, eller man skærer sig.
- Nogle reagerer på ændringer i temperaturen – både koldt og varmt.
- Andre reagerer på, om der sker kemiske forandringer enten ved:
-
- udefrakommende påvirkning (allergiske reaktioner på påvirkning af noget, man er overfølsom overfor.
-
- eller hvis der udløses kemiske reaktioner inde i selve kroppen, eksempelvis ved kropsvæsker eller mælkesyre.
Disse signaler er IKKE smertesignaler
- Smerte er noget ganske andet.
- Smerten dannes som en oplevelse i hjernen – 100 % af tiden – uden undtagelser.
- Dette betyder, at der kan være reelle faresignaler, endda mange, men at der stadig ingen smerte føles.
- Du kan have en skade og stadig ingen smerte føle.
Ovenstående kan blandt andet forklare, hvorfor sportsfolk, der får en skade under en konkurrence, fortsætter og først bagefter finder ud af, at de har en voldsom skade. Her kan blandt andet niveauet af adrenalin, serotonin og dopamin også have væsentlig indflydelse på, hvorfor der ikke føles smerte i en konkurrencesituation.
Hvad er forskellen på nociception og smerte?
Forskellen på nociception og smerte kan være svært at forstå. Grundreglen er, at smerte er det, man oplever, og nociception er det, vi kan måle. Eller sagt lidt mere simpelt: Nociception alene er hverken tilstrækkeligt eller nødvendigt for at vi kan opleve smerte. Derfor bør man ikke se smerte og nociception som to sider af samme sag, men derimod som to forskellige, men ofte sammenhængende, fænomener.
Sensibilisering – ændringer i nervesystemet
Kronisk skade og/eller smerte kan medføre ændringer i nervesystemet, hvor tolkningen af signaler fra det perifere nervesystem (”smertesignalet”) forstørres og forlænges. Resultatet er en tilstand af hypersensibilisering, hvor smerten fortsætter og endda kan fremkaldes ved helt ufarlige stimuli. Man ved ikke nok om dette i dag, men der forventes meget ny viden i de kommende år indenfor forskning i lige netop dette område.
Kroniske smertepatienter, der lider af sensibilisering, lider på hver deres individuelle måde, og både psykologiske såvel som fysiske faktorer har stor indflydelse på den subjektive oplevelse af smerte. Mennesker, der lider af kroniske smerter, kan nogle gange føle, at de er ved at blive skøre, fordi de rent intellektuelt ved, at en simpel berøring eller bevægelse ikke skal føles så smertefuld, som det er tilfældet ved hypersensibilisering. Andre gange er det fordi, mennesker i deres omgangskreds har særdeles svært ved at forstå, at en simpel berøring kan gøre SÅ ondt, og de kan tolke det som om, at det er smertepatienten, der er hypokonder eller overdriver, fordi de ikke har nok viden om og forståelse for tilstanden, som hypersensibiliseringen forårsager, hos den, der oplever de voldsomme smerter.
Diagnosticering af hypersensibilisering
Der er ikke nogen klare kriterier for diagnosticering af central sensibilisering. Der er ingen nem test eller tjekliste, der kan bekræfte det, for smerte er en helt personlig og subjektiv oplevelse, og ikke to mennesker kan have sammenlignelige skader og samme smerteoplevelse.
Man skelner mellem central og perifer sensibilisering
Central sensibilisering
Central sensibilisering er en tilstand, hvor nervesystemet påvirkes på grund af både udvikling og vedligeholdelse af en kronisk smertetilstand. Når der opstår central sensibilisering, gennemgår nervesystemet en proces, hvor det accelererer, bliver hyperaktivt og ender med at blive i en tilstand med høj aktivitet hele tiden. Denne vedvarende tilstand kan efterfølgende være med til at vedligeholde smertetilstanden, efter at den oprindelige skade er helet.
Central sensibilisering er også associeret med kognitive problemer såsom besvær med koncentration og dårlig korttidshukommelse. Central sensibilisering hænger også ofte tæt sammen med øget niveau af følelsesmæssig stress og lidelse – i særdeleshed angst. Eftersom nervesystemet er på konstant overarbejde, har det også indflydelse på følelserne og får meget ofte også indflydelse på ens selvopfattelse i relation til sygdommen og ændrede ”roller” og opførsel og opfattelsen af ens egen identitet.
Smerte ændrer i sig selv ofte, hvordan centralnervesystemet fungerer, så en person faktisk bliver mere følsom og oplever mere smerte ved mindre stimulus. Denne sensibilisering kaldes ”central sensibilisering” fordi den involverer ændringer i centralnervesystemet (CNS) – altså hjernen og rygmarven.
Inden for det psykologiske felt kan tidligere traumatiserende oplevelser, hvor smerte har spillet en rolle og vigtigheden af disse oplevelser, have stor indflydelse på, hvordan sensibiliseringen udarter sig. Ligeledes har den måde man tackler smerter på stor indflydelse, såvel som ens mentale tilstand. Det kan ændres fra situation til situation. Hukommelse og hjernens plasticitet spiller også en væsentlig rolle.
Perifer sensibilisering
Neuroner i en nerve er en god meddeler af signaler og kan ydermere også være med til at vedligeholde signalet til centralnervesystemet. Når der er et sted i kroppen er skadet, dannes der flere sensorer på det skadede sted. (C-fibers.) Nogle af disse sensorer kan påvirkes ved mekanisk stimuli, nogle ved mangel på blodgennemstrømning, andre ved påvirkning af stress neuropeptider (fx adrenalin). Hvis der er mange sensorer, der påvirkes i nerveenderne, vil det ”tænde” og sende alarmsignaler til hjernen.
En teori er, at hvis en nerve er skadet, vil hjernen konkludere, at der skal mere sensitivitet til for at du skal tage handling og derved ”overleve” faren og derfor vil der blive produceret flere sensorer (via DNA i neuronet) og tilføjet i nervemembranen.
Nervecellen kan blive lettere at stimulere, hvis forskellen mellem dens hvilemembranspotentiale og ”alt-eller-intet-punktet” reduceres. Den kortere ”buffer” mellem hvile- og aktionspotentiale betyder, at der skal mindre stimulus til, før nerven sender signaler videre i systemet.
Hvis en nervecelle i det perifere nervesystem er sensibiliseret, betyder det derfor, at stimuli af f.eks. hud, sene eller muskel lettere bliver transmitteret til centralnervesystemet. Dette er forklaringen på, at et sår gør ondt, når man trykker på det, da tærsklen for, hvornår ”tryk” opleves som smerte, er sænket. Dette kaldes for ”hyperalgesi” (hyper = mere, algesi = ondt)
Allodyni er når en person oplever smerter ved påvirkninger, som normalt ikke skulle være smertefulde. Kroniske smertepatienter oplever ofte smerte ved simpel berøring eller massage. I disse tilfælde sendes signalet via nociception på normal vis til hjernen, men eftersom hjernen er i en vedvarende tilstand af øget aktivitet, vil hjernen registrere indkommende signaler som værende voldsommere end det normalt burde.
Kroniske smerter er ikke kun i hjernen
Neuronernes signaler kan også gå den modsatte vej end op og forårsage helt andre effekter. Normalt må man gå ud fra, at signalet fra de perifere nerver nødvendigvis går op ad, idet signalerne til sidst skal ende i hjernen. Signaler kan også gå den modsatte vej og neuroner fungerer ligesom en slags dominobrikker; Signalet starter i en ende og forplanter sig hele vejen til den anden ende – og det går begge veje, når det gælder neuroner.
Hyperalgesi opstår når et bestemt smertefuld stimuli opleves mere smertefuld end det burde. Et eksempel kunne være, at man støder ind i noget med en kropsdel, og som normalt ikke skulle afstedkomme de helt store voldsomme smerteanfald, men får en person, der lider af hyperalgesi, til at opleve denne påvirkning som ekstrem smertefuld. Der kan også være sensibilisering over for lys, lyde eller dufte.
Dette skift i retninger af signaler sker hele tiden i hjernens neuroner og er en helt normal proces, men når det drejer sig om de perifere nerver, kan det have overraskende virkninger. Når signaler går den modsatte vej i neuronerne, udløses der en række kemiske substanser i enden af neuronet, hvor end det så måtte være.
I første omgang er disse kemiske substanser med til at igangsætte en helingsproces: Signalerne foranlediger, at der startes en masse andre funktioner i kroppen, og processen startes med, at der udløses forskellige kemiske substanser, der hver især er delelementer i en helings- og oprydningsproces på det skadede sted.
Blandt andet enzymer går i gang med at fjerne og rydde op i celler og væv, der dannes måske inflammation, og der sker øget blodgennemstrømning et sted, hvor der er sket skade. Så når der sendes signaler den modsatte vej, er det en ganske logisk og fantastisk proces.
Men når signaler også går den modsatte vej, kan der ske ting, der måske ikke altid er forståelige og hensigtsmæssige. (F.eks. kan en beskadiget nerve i ryggen forårsage, at der kommer hævelse i foden.)
På den korte bane er det for det meste ikke noget problem, når signalerne går den modsatte vej, men når en tilstand har stået på i længere tid og hvis der f.eks. er kronisk inflammation et sted, kan det resultere i, at vævet det pågældende sted forandres; bliver enten ”sumpet” og ”klægt” eller ”hårdt” og der kan dannes en form for arvæv.
Der er selvfølgelig en årsag til inflammation, men når det bliver kronisk, er det et problem for vævet, idet der sendes konstante signaler retur og der igangsættes processer for at helingen kan gå i gang.
Complex Regional Pain Syndrome (CRPS eller Komplekst Regionalt Smertesyndrom – tidligere blev det også kaldt Refleksdystrofi), er en af de mest alvorlige og voldsomme typer af kropssmerter og kan forekomme efter en skade eller et traume på en kropsdel. Det kan være en lille skade, som for eksempel et bistik, der forårsager lidelsen. Store områder på den ramte kropsdel bliver ulideligt smertefulde og praktisk talt umulige at røre – et vindpust kan være svært at holde ud.
Som ved andre former for kroniske smerter gik mange eksperter ud fra, at hovedårsagen til problemet lå i patienternes hjerner. Men man har for nyligt opdaget, at CRPS-patienternes blod havde et særligt immunstof kaldet ”autoimmunstof’”. Det er muligt, at dette immunstof forårsager smerte ved at binde sig til periferisk væv og få sansenerverne til at ”skyde forkert” – selvom den nøjagtige måde det sker på, ikke rigtig er forstået endnu.
Vi venter på ny forskning
Kroniske smerter er ikke kun i hjernen. Abnorm perifer nerveaktivitet eller perifer immun aktivering (CRPS) har sandsynligvis medindflydelse på mange kroniske smerte
Kroniske smerter er ikke kun i hjernen
Neuronernes signaler kan også gå den modsatte vej end op og forårsage helt andre effekter. Normalt må man gå ud fra, at signalet fra de perifere nerver nødvendigvis går op ad, idet signalerne til sidst skal ende i hjernen. Signaler kan også gå den modsatte vej og neuroner fungerer ligesom en slags dominobrikker; Signalet starter i en ende og forplanter sig hele vejen til den anden ende – og det går begge veje, når det gælder neuroner.lidelser, og der får vi forhåbentlig mange flere forklaringer, når forskningen fremover finder flere svar.
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