How to explain central sensitization to patients with ‘unexplained’ chronic musculoskeletal pain: Practice guidelines

Abstract

Central sensitization provides an evidence-based explanation for many cases of 'unexplained' chronic musculoskeletal pain. Prior to commencing rehabilitation in such cases, it is crucial to change maladaptive illness perceptions, to alter maladaptive pain cognitions and to reconceptualise pain. This can be accomplished by patient education about central sensitization and its role in chronic pain, a strategy known as pain physiology education. Pain physiology education is indicated when: 1) the clinical picture is characterized and dominated by central sensitization; and 2) maladaptive illness perceptions are present. Both are prerequisites for commencing pain physiology education. Face-to-face sessions of pain physiology education, in conjunction with written educational material, are effective for changing pain cognitions and improving health status in patients with various chronic musculoskeletal pain disorders. These include patients with chronic low back pain, chronic whiplash, fibromyalgia and chronic fatigue syndrome. After biopsychosocial assessment pain physiology education comprises of a first face-to-face session explaining basic pain physiology and contrasting acute nociception versus chronic pain (Session 1). Written information about pain physiology should be provided as homework in between session 1 and 2. The second session can be used to correct misunderstandings, and to facilitate the transition from knowledge to adaptive pain coping during daily life. Pain physiology education is a continuous process initiated during the educational sessions and continued within both the active treatment and during the longer term rehabilitation program.

An exploration of the extent and nature of reconceptualisation of pain following pain neurophysiology education: A qualitative study of experiences of people with chronic musculoskeletal pain

“…Clinically, there may be merit in screening patients' understanding of their pain prior to PNE to identify unready patients and prime them with basic PNE messages beforehand to aim to facilitate change within the PNE session. The finding that reconceptualisation was partial after the single PNE session adds weight to the potential of follow up education to help continue the process [31]. Further investigation is warranted to explore the readiness of patients to take on board the messages of PNE.…”

An Over-the-Counter Central Sensitization Therapy: A Chronic Back Pain Registry Study of Pain Relief, Medication Use and Their Adverse Effects

“…In the case of 'central sensitization,' the normal habituation/sensitization process has been disrupted such that even normal 'afferent noise' can be sensed as being painful. As such, when long-standing acute pain hypersensitizes the CNS, it results in increased pain facilitation pathways and decreased inhibition pathways [32][33][34][35]. This results in pain that does not reduce over time (chronic) and therefore the sufferer is left in a persistent, sensitized state of pain.…”

“…Central sensitization is now well established as an integral factor in many chronic pain states, including the commonly occurring knee and back pain [32,34,35]. Since peripheral information plays a crucial role in central sensitization, the key to reversing central sensitization, and moving the system out of the pain state, also lies in providing new peripheral information [33].…”

“…But initiating an exercise regime is painful, and therefore it is a barrier to successful therapeutic activity [33], and this is compounded by the effect of chronic pain on the subjects' motivation [37]. There is some evidence that TENS can help reduce pain and hyperalgesia, while restoring healthy levels of central inhibition in patients with another clinical syndrome of central sensitization , fibromyalgia [38].…”

“…Complications such as discomfort from the tingling sensation, skin irritation from electrode gel and potential skin damage from electrical heating make prolonged TENS use inconvenient for long-term use. However, since sensory information constitutes only a fraction of all the 'afferent noise' that reaches the spinal cord [33], sensation-free neuromodulation has the potential to be used continuously for mitigating central sensitization. Given the sensation-free and contactless nature of the ActiPatch, it can be used to regulate peripheral afferent activity such that the CNS 'sees' an increase in nonsensory 'afferent noise' and, over time, raises the pain tolerance thresholds through the habituation process.…”