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Jean-Luc Picard Understands Central Sensitization, Do You?
By: Sean Gill, MA SPT, MSc PT (in progress, class of 2022)

Biospsychosocial assessment meme

 

If you can’t already tell, I was a big fan of Star Trek growing up...While you may or may not find my play on the wise words of Jean-Luc Picard funny, they do illustrate the clinically challenging reality that musculoskeletal (MSK) pain can be driven by more than just physical factors.

Yet, as physiotherapists (a future one in my case), how do we navigate the strange new world of pain’s complexity when assessing and treating clients with persistent pain?

(Don’t worry, the Star Trek puns are over now…)

Or, more specifically, how do you yes I’m talking to YOU – account for central pain mechanisms in your practice? If you find this question bewildering, don’t worry, you are not alone!

This is the subject of Carolyn Vandyken and Sinead Dufour’s latest webinar-turned-course, How to Measure and Treat Central Sensitization in the Clinic.

Carolyn and Sinead bring together a host of experts (themselves, plus Jilly Bond, Dr. Judith Thompson, and Martin Rabey) with both clinical and academic expertise to discuss current research on central sensitization and provide guidance on clinical practice in the areas of pelvic pain, low back pain, and general assessment/treatment of nociplastic pain.

I’ve had the pleasure of completing the course and would like to share some of the wisdom and inspiration I took from it.

 

What is Central Sensitization (CS)?

 

Definition of Central Sensitization

Why should I care about central sensitization?

Did you know that features of central sensitization have been documented in a variety of pain conditions physiotherapists are involved in treating?  

These include:

  • fibromyalgia
  • osteoarthritis
  • rheumatoid arthritis
  • upper extremity tendinopathies
  • headache
  • pelvic pain
  • idiopathic lower back pain 
  • whiplash-associated disorders 
  • complex regional pain syndrome 
  • and more.

Furthermore, central sensitization predicts poor treatment outcomes, likely because clinicians tend to assume that nociceptive mechanisms are the key pain experience drivers in these conditions. As Carolyn says in the course: "If you’re not screening for central sensitization YOU WILL MISS IT!"

 

So, where do we go from here?

First, we need to recognize that a one-size-fits-all approach to central sensitization doesn’t make sense. There is significant variation in the presence, magnitude, and underlying contributors to central sensitization in clients with persistent pain.

For some clients, psychosocial factors may play a significant role in their pain. For others, cognitive factors around body awareness or injury-related beliefs may be at play. If we don’t systematically assess these factors we will often end up with (more) incomplete pain profiles for our clients. This can lead us to focus exclusively on treating biomechanical pain factors, often with limited effect.

So, recognizing that individual assessment is critical, what tools do we need to reliably and systematically assess central sensitization in a truly biopsychosocial way?

 

Assessment Framework for a Biopsychosocial Approach

Caroyln, Sinead, and their team provide a clearly articulated and scientifically-grounded approach to assessing persistent pain using a biopsychosocial model.

 

Assessment Framework for a Biopsychosocial Approach

They do not suggest that psychosocial factors are somehow more important than mechanical ones but advocate for a combined approach that incorporates both. They provide guidance on both the art (soft skills) and science (physical assessment, validated outcome measures) involved in a biopsychosocial approach to persistent pain.

 

Rethink Your Intake and Subjective Assessment

The art of listening is crucial to delivering effective physiotherapy treatment. If you’re not already, start asking clients questions like:

“What do you think is going on with your back?”

“What do you think should be done for your back?”

“Why do you think you still hurt?”

“What would it take for you to get better?”

“Where do you see yourself in 3 years in regard to your back?”

As Carolyn and the other presenters tell us, you will be amazed by the information you gain when you inquire directly about clients’ beliefs about their pain (sorry, I couldn’t resist the urge to rhyme there….). Not everyone will share this information with you unless you ask directly. And when you do, listen carefully to what they say.

 

Use Clinical Outcome Measures

Carolyn draws on Nijs et al. (2019) Algorithm for the clinical recognition of central sensitization pain, in structuring her clinical assessment of persistent pain.

Clinical Outcome Measures

In a nutshell, you follow the framework, using information from your intake, initial assessment, and outcome measures, to determine if central sensitization is likely a significant component in a client’s pain profile.

The PainDETECT questionnaire helps to determine whether the pain is predominantly neuropathic. Then you consider whether the client’s pain experience is disproportionate in terms of pain history, hypersensitivity, and psychosocial factors.  

Martin Rabey facilitates an excellent discussion amongst the experts on how to reliably assess pain hypersensitivity in the clinic (including the role of quantitative sensory testing). They discuss populations including lower back pain and pelvic pain (let’s be real, there are different considerations when testing hypersensitivity on a knee vs. a vagina…).  

Do YOU own a pressure algometer?

Pressure Algometer

Do you need one? If you’re not sure, this is the place to find out.

Carolyn and Antony Lo came up with the acronym SAD CLLIFSS to capture key psychosocial factors and outcome measures to assess them.

Assessment Needs to Include Psychosocial ScreeningOk, so let’s say you start handing out psychosocial screening questionnaires? What do you do with the results? Carloyn, Sinead, and the team each provide insight on how to use questionnaires to further guide physical therapy treatment.

 

Painting a Proper Picture of Pain 

Sorry about the alliteration folks….I just can’t help myself….

To sum things up, your physical and subjective assessments plus your pain and psychosocial questionnaires provide a well-rounded picture of your client’s situation. You can even represent this visually to help plan your intervention.

Picture of Pain

And you may not always start with the biggest bubble. Your clinical reasoning will help inform where you begin. But regardless, one of the key messages from the course is that pain education, tailored to your client’s specific needs, must be central to your approach. 

And, if you’re thinking something like ‘This all sounds great, but it’s very abstract’, TAKE THE COURSE! It includes 3 carefully analyzed case studies – each from a different practitioner – that illustrate the real-world application of a biopsychosocial model to clients with complex histories of lower back pain, tailbone pain, and pelvic girdle pain. 

 

Closing Thoughts

I’m not being paid to write this blog but still, I jumped at the opportunity to write it (and…Maggie did give me free access to the course). I am fascinated by the work that Carolyn, Sinead, Judy, Jill, and Martin are doing. Writing the blog has given me the opportunity to further digest the course content and reflect on its relevance for my soon-to-be clinical practice (and my deeper understanding of intergalactic philosophy). I highly encourage anyone interested in learning more about how to assess and treat persistent pain to take it. Whether you have a special interest in general musculoskeletal pain, lower back pain, or pelvic girdle pain, you won’t regret it!

 

The link to the course is below, along with one to all of Carolyn’s courses on Embodia, and those hosted on her company’s website, Reframe Rehab. I’ve also included the reference list from the course, along with a couple of extras from my own research. Enjoy!

 

References

Beales D et al. Masterclass: A pragmatic approach to pain sensitivity in people with musculoskeletal disorders and implications for clinical management for musculoskeletal clinicians. Musculoskelet Sci Pract. 2021 Feb;51:102221. doi: 10.1016/j.msksp.2020.102221. Epub 2020 Jul 18. 

Caneiroa JP, Bunzli S, O’Sullivana P. Beliefs about the body and pain: the critical role in musculoskeletal pain management. Braz J Phys Ther. 2021 Jan-Feb; 25(1): 17–29. Published online 2020 Jun 20. doi: 10.1016/j.bjpt.2020.06.003.

Carlesso, Law, L. F., Wang, N., Nevitt, M., Lewis, C. E., & Neogi, T. (2022). Association of Pain Sensitization and Conditioned Pain Modulation to Pain Patterns in Knee Osteoarthritis. Arthritis Care & Research (2010), 74(1), 107–112. https://doi.org/10.1002/acr.24437

Cocks, T. (2021, Mar 31). Why therapists need a philosophy of pain. https://www.noigroup.com/noijam/why-therapists-need-a-philosophy-of-pain/

Hannibal, & Bishop, M. D. (2014). Chronic stress, cortisol dysfunction, and pain: a psychoneuroendocrine rationale for stress management in pain rehabilitation. Physical Therapy, 94(12), 1816–1825. https://doi.org/10.2522/ptj.20130597

Holopainen R et al. Physiotherapists’ perceptions of learning and implementing a biopsychosocial intervention to treat musculoskeletal pain conditions: a systematic review and metasynthesis of qualitative studies. Pain. 2020 Jun;161(6):1150-1168. doi: 10.1097/j.pain.0000000000001809. 

Main CJ, George SZ. Psychologically informed practice for management of low back pain: future directions in practice and research. Phys Ther. 2011 May;91(5):820-4. doi: 10.2522/ptj.20110060. Epub 2011 Mar 30. PMID: 21451091

 Meints SM, Edwards RR. Evaluating Psychosocial Contributions to Chronic Pain Outcomes. Prog Neuropsychopharmacol Biol Psychiatry. Author manuscript; available in PMC 2018 Dec 20. Published in final edited form as: Prog Neuropsychopharmacol Biol Psychiatry. 2018 Dec 20; 87(Pt B): 168–182. Published online 2018 Jan 31. doi: 10.1016/j.pnpbp.2018.01.017.

 Nijs J et al. Sleep Disturbances in Chronic Pain: Neurobiology, Assessment, and Treatment in Physical Therapist Practice. Phys Ther. 2018 May 1;98(5):325-335. doi: 10.1093/ptj/pzy020.

Nijs J et al. Treatment of central sensitization in patients with chronic pain: time for change? July 2019. Expert Opinion on Pharmacotherapy 20(9995):1-10. DOI:10.1080/14656566.2019.1647166

Pack. (n.d.). The slow medicine approach to chronic pain. Physiotherapy Theory and Practice, ahead-of-print(ahead-of-print), 1–9. https://doi.org/10.1080/09593985.2021.1970295

Tatta J, Nijs J, Elma Ö, Malfliet A, Magnusson D. The Critical Role of Nutrition Care to Improve Pain Management: A Global Call to Action for Physical Therapist Practice. Physical Therapy, 2022;, pzab296, https://doi.org/10.1093/ptj/pzab296.

 Vandyken C, Hilton S. Physical Therapy in the Treatment of Central Pain Mechanisms for Female Sexual Pain. Sex Med Rev. 2017 Jan;5(1):20-30. doi: 10.1016/j.sxmr.2016.06.004. Epub 2016 Aug 3..

Wallden, & Nijs, J. (2021). Applying the understanding of central sensitization in practice. Journal of Bodywork and Movement Therapies, 27, 723–730. https://doi.org/10.1016/j.jbmt.2021.04.004.

Wallden, & Nijs, J. (2021). Before & beyond the pain – Allostatic load, central sensitivity and their role in health and function. Journal of Bodywork and Movement Therapies, 27, 388–392. https://doi.org/10.1016/j.jbmt.2021.04.003

Dr. Sinéad Dufour
PT, PhD

Dr. Sinéad Dufour is Assistant Clinical Professor in the Faculty of Health Science at McMaster University. She teaches and conducts research in both the Schools of Medicine and Rehabilitation Science. She completed her MScPT at McMaster University (2003), her PhD in Health and Rehabilitation Science at Western (2011), and returned to McMaster to complete a post-doctoral fellowship (2013). Her current research interests include: conservative approaches to manage pelvic floor dysfunction, pregnancy-related pelvic-girdle pain, and interprofessional collaborative practice models of service provision to enhance pelvic health.

Sinéad stays currently clinically through her work as the Director of Pelvic Health Services at The World of my Baby (the WOMB) in Milton, Ontario.

Carolyn Vandyken
BHSc (PT)

Carolyn is the co-owner of Reframe Rehab, a teaching company engaged in breaking down the barriers internationally between pelvic health, orthopaedics and pain science. Carolyn has practiced in orthopaedics and pelvic health for the past 34 years. She is a McKenzie Credentialled physiotherapist (1999), certified in acupuncture (2002), and obtained a certificate in Cognitive Behavioural Therapy (CBT) in 2017.

Carolyn received the YWCA Women of Distinction award (2004) and the distinguished Education Award from the OPA (2015). Carolyn was recently awarded the Medal of Distinction from the Canadian Physiotherapy Association in 2021 for her work in pelvic health and pain science.

Carolyn has been heavily involved in post-graduate pelvic health education, research in lumbopelvic pain, speaking at numerous international conferences and writing books and chapters for the past twenty years in pelvic health, orthopaedics and pain science.

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