Why treating chronic pain patients can be different

Recent research within neuroscience and psychology has offered new frameworks that may improve our understanding of how Osteopathic treatment works.  One such new framework is central sensitisation (CS), a concept originating from pain research within a laboratory setting, and this paper promotes its role and applications within a musculoskeletal clinical setting.  CS can rule the clinical kingdom in some patients with chronic musculoskeletal pain.

CS is defined as “an amplification of neural signaling within the central nervous system that elicits pain hypersensitivity” and “increased responsiveness of nociceptive neurons in the central nervous system to their normal or sub threshold afferent input” that occurs in chronic pain patients. Not all patients with musculoskeletal pain will go on to develop central sensitisation but a significant proportion do. Research has shown conditions such as low back pain, Achilles tendinopathy, osteoarthritis, tennis elbow and whiplash all involve CS and these are all conditions commonly seen by osteopaths.

CS is thought to act via a change in the way the brain processes sensory information meaning that there is no longer a clear nociceptive pain source (eg torn ligament, prolapsed disc) together with an altered (often increased) response to stimuli such as temperature, touch, stretch.  The patient feels “pain” in the areas activated by these stimuli, but with no peripheral nociception.  Cognitive-emotional factors such as pain catastrophising, stress or depression can increase pain and hyper-responsivity of the central nervous system, but with very little or no actual nociceptive inputs.  This may be familiar presentation to osteopaths.

The review paper discusses research which shows that chronic pain patients with central sensitisation have much higher pain severity and lower quality of life, and that CS influences treatment outcome in low back pain, whiplash, osteoarthritis and tendinopathy.  It is therefore important to identify patients with CS, but how can this be done in osteopathic practice? In the assessment (case history, clinical examination, other investigations) osteopaths aim to find a cause of pain that explains the patients symptoms.  For musculoskeletal pain, CS can be considered when i) pain experience is disproportionate to the assessment findings ii) pain distribution is diffuse and outside segmental area of primary nociception iii) Central Sensitisation Index (Mayer et al 2012) scoring more than 40/100.

Once CS is identified in a patient, the treatment plan needs to be determined. Treatment recommendations focus on three points and are all relevant to osteopathy.  Firstly to not treat only locally.  Manual techniques are still indicated but only provide short-term pain inhibition. However, we can consider how they can potentially influence central processing of pain and be of further benefit in CS.  Secondly some explanation of pain (alongside listening) can help reassure and improve the patient’s pain beliefs and coping strategies. Thirdly, active interventions alongside manual work: graded activity or exercises, graded exposure to pain-eliciting movements.

In conclusion, greater awareness and understanding of the influence of CS in chronic musculoskeletal patients is key to successful treatment and relevant to osteopathic practice.

Nijs, J., Goubert, D., & Ickmans, K. (2016). Recognition and Treatment of Central Sensitization in Chronic Pain Patients: Not Limited to Specialized Care. The Journal of orthopaedic and sports physical therapy, 46(12), 1024–1028. https://doi.org/10.2519/jospt.2016.0612 

Mayer, T. G., Neblett, R., Cohen, H., Howard, K. J., Choi, Y. H., Williams, M. J., Perez, Y., & Gatchel, R. J. (2012). The development and psychometric validation of the central sensitization inventory. Pain practice : the official journal of World Institute of Pain, 12(4), 276–285. https://doi.org/10.1111/j.1533-2500.2011.00493.x

Hazel Mansfield

January 2021

Hazel is an Osteopath of 15 years’ experience with a background in neuropsychology, and a renowned lecturer of osteopaths and other manual therapists at both undergraduate and post-graduate levels. 

Hazel studied Natural Sciences at Cambridge University, specialising in neuropsychology before training as an osteopath at the British College of Osteopathy in London.

She consults in private practice in Stockholm, with a special interest in back pain, stress, and using the best available knowledge to elevate standards of patient care.