Time for a closer embrace

Decades of denial
We have known about central sensitisation (CS) for at least 20 years, since Patrick Wall, Clifford Woolf and others published seminal papers suggesting that some pain and altered sensory states may be due to synaptic and membrane excitability changes in the central nervous system and not necessarily due to processes in tissues. This should have been a great relief to health professionals, but attempts to introduce the notion into rehabilitation, especially the manual therapy world (Butler 1994; Gifford and Butler 1997) were met with slow acceptance and often derision. I can recall introducing it in a conference in Scandinavia in the early 90s with the following speaker saying “well that’s well and good but we have to get on with the treatment”, and so the next session was on muscle stretching. “You are turning into a counsellor” was another comment. Many prominent physiotherapists and anatomists still deny the state and the current level of integration in most undergraduate and postgraduate programmes appears little more than lip service. Central sensitisation underpins modern biopsychosocial holistic management, yet we have a long way to go to integrate it. It deserves core curriculum status. A hot off the press review article by Clifford Woolf (2010) makes me believe that there may be a growing knowledge gap between science and practice.

Admitting that there is more to the story
For health practitioners to take on central sensitisation, they usually need to accept that the old peripheral story is not complete. A trigger point may have little to do with issues in the soft tissues, the palpably tender C2-3 nothing to do with processes around the joint, and the irritated gut only partly related to the gut, but are now known to be more due to a central nervous system which has lost the ability to “feature extract” from input and defaults quickly to a pain construction. The pathophysiology of this state is now well described. See Latremoliere (2009) and Woolf (2010) for updates. Of course this can be a challenge – many successful practitioners have a lot of clinical mileage at stake and large investments in continuing education. While many readers of these notes will have embraced it, most of the rehabilitation community is yet to integrate it.

A word from a big picture expert
Gordon Waddell (1998) summed it up nicely when defending modern holistic biopsychosocialism “it is all very well to say that we use science and mechanical treatment within a holistic framework, but it is too easy for that framework to dissolve in the starry mists of idealism. We all agree in principle that we should treat people and not spines, but then in daily practice we get on with the
business of mechanics.”

“But what about chronic knee OA and OA hips that respond to hip replacement?”
The hard core biomedicalists often bring this out as evidence of the tissue base of chronic pain. Of course, these are peripheral diseases which are often amenable to peripherally directed management. But even here, the degree of pain does not match radiological finding or degree of inflammation, suggesting a central mechanism as well (Bradley, Kersch et al. 2004). In OA knees (Arendt-Nielsen, Nie et al. 2010) and OA hips, there is impaired central inhibitory controls. This key feature of central sensitisation will improve with hip replacement (Kosek and Ordeberg 2000). This and other data summarized by Woolf (2010) strongly suggests central sensitisation should be a consideration in all acute and chronic pain states.

Bums into gear
This NOInotes is unashamedly all about getting readers to update, reconsider and read the Woolf update – here you can read all about CS in rheumatoid arthritis, osteoarthritis, TMJ disorders, fibromyalgia, headache, miscellaneous musculoskeletal disorders, post surgical pain, irritable bowel syndrome etc. etc.

Central sensitisation is treatable, though currently predominantly by medication. The NNT (number of people need to treat to get one with 50% pain relief) in fibromyalgia for a drug like pregabelin is around 6 (Russell 2006). This simply reinforces the fact that the conservative forces of management need to get their bums into gear, review current paradigms and get CS evidence based management strategies including neuroscience education (Butler and Moseley 2003), graded activity and exercise, imagery, mindfulness, and appropriate manual therapies out there and heard. Central sensitisation is so liberating in the clinic – the relentless and often disappointing searches for sources of nociception in the clinic becomes less important and it supports the critical notion that functional restoration can processed even in the presence of pain.

And there is a little bit of muted satisfaction seeing the research emerge which supports the importance of central sensitisation in all acute and chronic pain states.

References
Arendt-Nielsen, L., H. Nie, et al. (2010).:”Sensitization in patients with painful knee osteoarthritis.” Pain 149: 573-581.
Bradley, L. A., B. C. Kersch, et al. (2004).”Lessons from fibromyalgia : abnormal pain sensitivity in knee osteoarthritis” Novartis Found Symp 260: 258-270.
Butler, D. S. and L. S. Moseley (2003). Explain Pain. Adelaide, Noigroup Publications.
Butler, D. S. (1994). The upper limb tension test revisited. Physical Therapy of the Cervical and Thoracic Spines. R. Grant. New York, Churchill Livingstone.
Gifford, L. and D. Butler (1997). “The integration of pain sciences into clinical practice.” The Journal of Hand Therapy 10: 86-95.
Kosek, E. and G. Ordeberg (2000).”Lack of pressure pain modulation by hetereoptic noxious conditioning stimulation in patietnns with painful osteoarthritis before but not following surgical pain relief.” Pain 88: 69-78.
Latremoliere, A. and C. J. Woolf (2009).”Central Sensitization: a generation of pain hypersensitivity by central neural plasticity.” The Journal of Pain 10: 895-926.
Russell, I. J. (2006).”Fibromyalgia syndrome: Approach to management” Bull Rheum Dis 45: 1-4.
Waddell, G. (1998). The Back Pain Revolution. Edinburgh, Churchill Livingstone.
Woolf, C. J. (2010).”Central sensitization: Implications of the diagnosis and treatment of pain.” Pain (in press).

Last month’s notes on women rule
Thanks for your overwhelming and most comprehensive thoughts last month on why women rule. Here are a few of your thoughts in no particular order..

Our brains are ‘wired’ differently
Women can think outside the box
Women are more emotive by nature and men are more mechanical
Women might struggle with fly fishing
An upbringing with art, music and creativity may play a part
Women like to fix things verbally while men prefer to do it manually
We should consider tone of voice, touch, perfume or aftershave
Women are generally superior in general when it comes to talking, networking, sharing, discussing, socialising and communicating than men. (From a man).

Another legendary NOI instructor
Tim Beames is officially the equal baldest member of the NOI teaching faculty. He has been teaching with NOI since 2006 and has recently gained his Masters in Pain: Science and Society at Kings College London in 2010 under the legendary truffle thief, Mick Thacker.

Tim has an interest in nerve injuries and is researching the correlation of neurological assessment techniques in rugby players. Clinically he works in private practice as a physiotherapist treating patients with complex pain presentations using both traditional and more novel treatment techniques. He gets invited to speak at various conferences around Europe and aims to bring a better understanding of pain and the interaction of biological, psychological and social elements with an individual’s pain experience to patients, clinicians and the public.

Beames in name and beames in nature he landed in Australia earlier this week to take a look around the country over summer, teach a couple of courses and be there in the flesh to shake his fist as the dual for the ashes (cricket) continues.

Tim next teaches:
Neurodynamics and the Neuromatrix in Brisbane, AU (Dec 3-4)
Graded Motor Imagery in Adelaide, AU (Dec 10)
Enquire here..

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One Response to “Time for a closer embrace”

  1. Peter Horton Says:

    I would like to read the emails and comments that were sent to you in response for this note on CS. Is there an easy way for me to access these comments?
    I have trouble gatting my patients to believe this concept and I am looking at other ways to integrate it. Thanks guys for your good work!!
    -Pete in northern california

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