Central sensitization for physiotherapist

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Central sensitization for physiotherapist

  1. 1. A.THANGAMANI RAMALINGAM
  2. 2. OBJECTIVES
  3. 3.  Basics of Central sensitization(CS)  Neuro immunology  Recognition of CS  Implications for physiotherapy/therapist(assessment/management/g uidelines)  What Evidences say?
  4. 4. PAIN “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” ISAP (1979)  Pain is a noxious unwanted perception  “Pain is subjective, individual and modified by degrees of attention, emotional state and the conditioning of past experiences.” (Livingstone 1943)
  5. 5. PHYSIOLOGY OF PAIN Receptors A fibers – Localized and quick type of pain C fibers – Slow acting type of pain(Peripheral Nervous System) Spinal Cord (Substantia Gelatinosa) Spinothalamic Tracts (Lateral / Anterior) Thalamus Cerebral Cortex (Somatosensory Cortex) Influenced by Limbic system & Reticular formation
  6. 6. Nociceptive processing
  7. 7. Pain sensitization  Primary hyperalgesia or peripheral pain sensitization pain  Secondary hyperalgesia or central sensitization Unimodal/polymodal nociceptors
  8. 8. Central sensitization Top down mechanisms Bottom up mechanisms  Augmentation of responsiveness(Meyer et al 1995)  Altered sensory processing (Staud et al.,2007)  Malfunctioning of descending inhibitory system(Meeus et al., 2008)  Potentiation of neuronal synapses (zuho 2007)  Temporal summation of secondpain or windup(Nijis 2007)  Pro inflammatory cytokines(samad et al) Prostoglandin E2/cox-2 releasestressors
  9. 9. Issue –tactile allodynia/punctuate hyperalgesia/temporal summation/sensory after effects Increased sensitivity to various stimuli  Light  Touch Cold Heat Pressure or punctuate Chemical substances Electrical stimuli
  10. 10. Reductionist Rationalist
  11. 11. Neuro immunology
  12. 12. Neuro immunological response
  13. 13. Glial cells-neuro immunology Dr. Watkins, at the Headache Cooperative of the Pacific’s 2009 Winter Colloquium  Glial cell activation has been demonstrated in every clinically relevant animal model study to date, including that of peripheral nerve injury, bone cancer, multiple sclerosis (MS), spinal cord injury, herniated disks, low back pain, and migraine, noted Dr. Watkins, Professor of Psychology and Neuroscience at the University of Colorado at Boulder. “Targeting the glial cells and their proinflammatory products doesn’t make a patient analgesic, and it doesn’t suppress all pain sensitivity. It simply returns the pain to normal. It removes the abnormal pain,
  14. 14. NMDA Vs
  15. 15. MSD-neuro immunology Biomechanical injury/loading Altered electro physiology Change in neuro immune response
  16. 16. Conditions  Rheumatoid arthritis  OA  Temporo mandibular disorders  Fibromyalgia  Chronic neck and back pain-disc pathologies  Headache  Neuropathic pain  CRPS  Visceral pain hypersensitivity syndrome
  17. 17. Central sensitization syndromes  Co morbidity of conditions IBS/FM/CFS/CWP/headache /MSDs
  18. 18. Recognition of Central sensitization
  19. 19. Screening Using medical diagnosis History taking Clinical examination Analyzing the treatment responses
  20. 20. Using medical diagnosis History taking
  21. 21. Clinical examination
  22. 22. Analyzing the treatment responses
  23. 23. Clinical decision making  Diagnostic criteria  eg: 2010 PRELIMINARY DIAGNOSTIC CRITERIA (EXCERPT) CRITERIA Diagnostic criteria for fibromyalgia if the following 3 conditions are met: 1.Widespread pain index (WPI) ≥7 and symptom severity (SS) scale score ≥5 or WPI 3 - 6 and SS scale score ≥9. 2.Symptoms have been present at a similar level for at least 3 months. 3.The patient does not have a disorder that would otherwise explain the pain.  Biomarkers  Clinical testing of hyper algesia/allodynia
  24. 24. Physiotherapy
  25. 25.  Behavioral pain measures Physiological measures EMG – muscle tension Heart rate Skin temperature EEG and brain imaging Self-report measures Visual Analog Scale(VAS) Graphic Rating Scale(GRS) Simple Descriptor Scale(SDS) Numerical Rating Scale(NRS) Faces Rating Scale(FRS) McGill Pain Questionnaire
  26. 26. Pain Rating Scales Pain Discomfort Scale MPQ
  27. 27. Sixteen Pain Behaviors-biopsychosocial assessment Rudy et al. Asymmetry Slow response time Guarded movement Limping Bracing Personal contact Position shifts Partial movement Absence of movement Eye movement Grimacing Quality of speech Pain statements Limitation statements Sounds Pain relief devices (under use)
  28. 28. Quantitative sensory testing (QST)  compare pressure pain threshold (PPT) values of myotomes, sclerotomes, and dermatomes corresponding to segments - algometer  two-point discrimination (TPD)- aesthesiometer  vibratory sensation  thermal pain threshold and tolerance  suprathreshold heat pain response.  DNIC-diffuse noxious inhibitory control assessment
  29. 29. Measurement of secondary hyperalgesia
  30. 30. CSI (test-retest reliability = 0.817; Cronbach's alpha = 0.879)
  31. 31. SCREENING TOOLS FOR NEUROPATHIC PAIN.  Leeds Assessment of Neuropathic Symptoms and Signs (LANSS)  Neuropathic Pain Questionnaire (NPQ)  Douleur Neuropathique en 4 questions (DN4)  pain DETECT  ID-Pain
  32. 32. Mechanisms-based classifications of musculoskeletal pain  'Disproportionate, non-mechanical, unpredictable pattern of pain provocation in response to multiple/non-specific aggravating/easing factors', 'Pain disproportionate to the nature and extent of injury or pathology‘  'Strong association with maladaptive psychosocial factors (e.g. negative emotions, poor self-efficacy, maladaptive beliefs and pain behaviours)‘  'Diffuse/non-anatomic areas of pain/tenderness on palpation'. This cluster was found to have high levels of classification accuracy (sensitivity 91.8%, 95% confidence interval (CI): 84.5-96.4; specificity 97.7%, 95% CI: 95.6-99.0).  Mechanisms-based classifications of musculoskeletal pain: part 1 of 3: symptoms and signs of centralsensitisation in patients with low back (± leg) pain.Smart KM1, Blake C Staines A, Thacker M Doody C Man Ther.2012 Aug;17(4):336-44. doi: 10.1016/j.math.2012.03.013. Epub 2012 Apr 23
  33. 33. Management
  34. 34. Guidelines 1. Assessment of pressure pain thresholds at sites remote from the symptomatic site; 2. Assessment of sensitivity to touch during manual palpation at sites remote from the symptomatic site; and 3. Assessment of pressure pain thresholds during and following exercise  Nijs J, Van Houdenhove B, Oostendorp R a B. Recognition of central sensitization in patients with musculoskeletal pain: Application of pain neurophysiology in manual therapy practice. Manual therapy [Internet]. Elsevier Ltd; 2010 Apr [cited 2014 Feb 24];15(2):135–41. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20036180
  35. 35. Education Face to face session Booklet/written – homework Application
  36. 36. Anterior cingulate cortex – responds to physical and emotional pain -EXERCISE
  37. 37. Biofeedback Gauthier et al. (1994) for headaches
  38. 38. Behavioral/Cognitive Approaches • Guided Imagery • Systematic desensitization • Reframing • Meditation • Stress management techniques – not as effective as other techniques • Thinking about the pain and expectations – Bandura et al. (1987)– an increase in endorphines with cognitive technique
  39. 39. How do placebos influence pain? Patient’s expectation about the effects of the treatment Airily (2008) study of differential effectives of placebo based on perceived cost ($.10 v. $2.50) http://www.npr.org/templates/story/story .php?storyId=87938032 Classical conditioning Patient’s may change behaviors Physiological changes which inhibit the experience of pain
  40. 40.  10khz medium frequency current has marked discrimination between motor and pain threshold  Clinically we use 2and 4khz equipments for therapy
  41. 41. Evidences
  42. 42. Neck/back pain  Weak pain days  CS α pain intensity  Strong pain days  CS α no of pain areas
  43. 43. Post operative cases DAY(m ean/sd ) 20HZS EN 2OHZ MOT 2OHZP AIN 50 HZSEN 50HZ MOT 50HZP AIN 100HZ SEN 100HZ MOT 100HZ PAIN NPRS GROC ONE 4.800 6.733 9.533 4.97 6.933 9.733 5.133 7.066 10.233 4.73 5.0 THREE 5.300 7.033 9.600 5.40 7.100 9.933 5.433 7.2000 10.233 3.43 5.63 SEVEN 5.333 7.166 9.700 5.43 7.300 10.03 5.566 7.433 10.366 2.40 5.96
  44. 44. Chronic back pain cases DAY(me an/sd) 20HZSEN 2OHZM OT 2OHZPAI N 50 HZSEN 50HZMO T 50HZPAI N 100HZSE N 100HZM OT 100HZPA IN NPRS one 4.4 6.25 10.8 4.75 6.6 11.2 4.75 6.6 11.5 5.05 thre e 4.55 6.5 11.5 4.8 6.6 11.3 5.2 7.3 12.1 4.0 five 5.05 6.8 11.8 5.10 7 12 5.3 7.2 12.4 3.6
  45. 45.  Response to 100 hz low frequency current on different groups
  46. 46. OA  Interventions such as cognitive- behavioral therapy and neuroscience education potentially target cognitive- emotional sensitization (and descending facilitation), and centrally acting drugs and exercise therapy can improve endogenous analgesia (descending inhibition) in patients with osteoarthritis.  Phys Ther. 2013 Jun;93(6):842-51. doi: 10.2522/ptj.20120253. Epub 2013 Feb 7. Pain treatment for patients with osteoarthritis and central sensitization. Lluch Girbés E1, NijsJ, Torres-Cueco R, López Cubas C
  47. 47. Activity dependent treatments in neuropathic pain Treadmill running Electrical stimulation  ,TR induced strong agonistic effects in relieving pain. TR reduced the levels of pro- nociceptive factors such as BDNF, NGF and GDNF in DRG.  Combination of ES and TR induced intermediate levels suggesting an optimal balancing of treatment effects.  ES enhanced motor and sensory reinnervation  ES speeded up expression of BDNF and GDNF in DRG ., and of BDNF and NT3 in the ventral horn. Exp Neurol.2013 Feb;240:157-67. doi: 10.1016/j.expneurol.2012.11.023. Epub 2012 Nov 30.Differential effects of activity dependent treatments on axonal regeneration and neuropathic pain after peripheral nerve injury.Cobianchi S1, Casals-DiazL, Jaramillo J, Navarro X
  48. 48. TENS Positive study Negative study  Frequency-dependent antihyperalgesic and analgesic effects in humans.  No long-lasting analgesic and antihyperalgesic effects of a single TES treatment  (TES(60Hz) > TES(100Hz)) • Anesth Analg.2010 Nov;111(5):1301-7. doi: 10.1213/ANE.0b013e3181e3697e. Epub 2010 Jun 8.The analgesic and antihyperalgesic effects of transcranial electrostimulation with combined direct and alternating current in healthy volunteers.Nekhendzy V, Lemmens HJ, Tingle M, Nekhendzy M, Angst MS.  Tens influence on centrally sensitized OAk patients may be augmented to the input of electrical stimuli.  Adverse therapy effect of tens.  To increase treatment effectiveness - identify a subgroup of symptomatic OAk patients, i.e., non- sensitized patients.  Trials.2012 Feb 21;13:21. doi: 10.1186/1745-6215-13- 21.Effect of tens on pain in relation to central sensitization in patients with osteoarthritis of the knee: study protocol of a randomized controlled trial.Beckwée D1, De Hertogh W, Lievens P, BautmansI, Vaes P.
  49. 49.  Acetaminophen, serotonin-reuptake inhibitor drugs, selective and balanced serototin and norepinephrine- reuptake inhibitor drugs, the serotonin precursor tryptophan, opioids, N-methyl-D-aspartate (NMDA)- receptor antagonists, calcium-channel alpha(2)delta (a2δ) ligands, ketamine ,pragabalin, duloxetine,transcranial magnetic stimulation. +  transcutaneous electric nerve stimulation (TENS), manual therapy and stress management each target central pain processing mechanisms in animals that – theoretically – desensitize the CNS in humans
  50. 50. Message/tips for therapist
  51. 51. Tips Treat acute pains at right times The pain tolerance –can be improved/cs is reversible Get the pain control first then go for exercise therapy Use pressures sensibly Use appropriate therapy windows when we use electro physical agents. Understand pain behaviours.
  52. 52. Pain can be triggered from normal tissues(secondary hyperalgesia),not necessarily psychogenic. Pain has a learned component and produces physical changes in CNS and musculoskeletal system. Education and learning(motor and cognitive) plays important role (AustJPhysiotherv45i2Shacklock) A multidisciplinary approach to care of chronic pain conditions is an absolute necessity ensure that whichever treatment protocol is utilized the treatments must not induce any pain for the patient
  53. 53. APPROACH to CS block or reduction of the nociceptive input from the injured areas specific pharmacological intervention on the cord mechanisms pharmacologic or psychologic interventions at supraspinal level descending modulatory system a multimodal physical therapy program a clinician should use caution with generically prescribing exercise to patients experiencing chronic pain. psychosocial characteristics, such as inappropriate beliefs about pain, pain catastrophizing, and/or depression may contribute to the mechanisms of central sensitization.
  54. 54. Why deep tissues are more frequently affected in chronic pain state? Mirror-image pain (pain or hyperalgesia in unaffected side or area) stress-induced hyperalgesia
  55. 55. To provide a comprehensive treatment for ‘unexplained’ chronic pain disorders characterized by central sensitization, it is advocated to combine the best evidence available with treatment modalities known to target central sensitization
  56. 56. References  Woolf CJ. Central sensitization : Implications for the diagnosis and treatment of pain. Pain [Internet]. International Association for the Study of Pain; 2011;152(3):S2–15. Available from: http://dx.doi.org/10.1016/j.pain.2010.09.030  Winkelstein B a. Mechanisms of central sensitization, neuroimmunology & injury biomechanics in persistent pain: implications for musculoskeletal disorders. Journal of electromyography and kinesiology : official journal of the International Society of Electrophysiological Kinesiology [Internet]. 2004 Feb [cited 2014 Feb 24];14(1):87–93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14759754  Nijs J, Van Houdenhove B, Oostendorp R a B. Recognition of central sensitization in patients with musculoskeletal pain: Application of pain neurophysiology in manual therapy practice. Manual therapy [Internet]. Elsevier Ltd; 2010 Apr [cited 2014 Feb 24];15(2):135–41. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20036180  Nijs J, Wilgen CPV, Oosterwijck JV, Ittersum MV, Meeus M. How to explain central sensitization to patients with “ unexplained ” chronic musculoskeletal pain : Practice guidelines. Manual Therapy [Internet]. Elsevier Ltd; 2011;16(5):413–8. Available from: http://dx.doi.org/10.1016/j.math.2011.04.005  Smart KM, Blake C, Staines A, Doody C. Self-reported pain severity , quality of life , disability , anxiety and depression in patients classified with “ nociceptive ”, “ peripheral neuropathic ” and “ central sensitisation ” pain . The discriminant validity of mechanisms-based classifications of low back ( Æleg ) pain. Manual Therapy [Internet]. Elsevier Ltd; 2012;17(2):119–25. Available from: http://dx.doi.org/10.1016/j.math.2011.10.002  Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classifications of musculoskeletal pain : Part 3 of 3 : Symptoms and signs of nociceptive pain in patients with low back ( Æleg ) pain. Manual Therapy [Internet]. Elsevier Ltd; 2012;17(4):352–7. Available from: http://dx.doi.org/10.1016/j.math.2012.03.002  Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classifications of musculoskeletal pain : Part 2 of 3 : Symptoms and signs of peripheral neuropathic pain in patients with low back ( Æleg ) pain. Manual Therapy [Internet]. Elsevier Ltd; 2012;17(4):345–51. Available from: http://dx.doi.org/10.1016/j.math.2012.03.003  18. Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms- based classifications of musculoskeletal pain : Part 1 of 3 : Symptoms and signs of central sensitisation in patients with low back ( Æleg ) pain. Manual Therapy [Internet]. Elsevier Ltd; 2012;17(4):336–44. Available from: http://dx.doi.org/10.1016/j.math.2012.03.013  Kumar SP. Physical Therapy and Central Sensitization : Are We Explaining to Patients with “ Unexplained ” Pain ? Journal de Physique (main title). 2013;41–5.  48. Review L. Central Sensitization In Urogynecological Chronic Pelvic Pain: A Systematic Literature Review. Pain Physician. 2013;291–308.  49. Mcclintic AM, Garcia JB, Gofeld M, Kliot M, Kucewicz JC, Loeser JD, et al. Intense focused ultrasound stimulation can safely stimulate inflamed subcutaneous tissue and assess allodynia. The Lamp. 2014;2(1):1–9.  50. Dodick D, Silberstein S, Jefferson T. Central Sensitization Theory of Migraine : Clinical Implications. Society. 2006;  51. Farasyn A, Meeusen R. Effect of Roptrotherapy on Pressure-Pain Thresholds in Patients with Subacute Nonspecific Low Back Pain. ReVision. 2007;15(1):41–54.  52. Munglani R. Neurobiological Mechanisms Underlying Chronic Whiplash Associated Pain : The Peripheral Maintenance of Central Sensitization. ReVision. 8:169–79.  53. Dickenson AH. The Pharmacology of Central Sensitization. Imprint. 2002;10(1):35–43.  54. Salter MW. The Neurobiology of Central Sensitization. Journal of Musculoskeletal Pain. 10(1):23–33.  55. Whiplash JOF, Disorders R. Central Sensitization in Chronic Whiplash and Related Musculo- skeletal Disorders. Journal of Whiplash & Related Disorders. 1998;64–6.  Mayer TG, Neblett R, Cohen H, Howard KJ, Choi YH, Williams MJ, et al. The Development and Psychometric Validation of the Central Sensitization Inventory. Pain Practice. 2012;12(4):276–86.  Winkelstein BA. Mechanisms of central sensitization , neuroimmunology and injury biomechanics in persistent pain : implications for musculoskeletal disorders. Electromyography. 2004;14(1):87–93.  Meeus M, Nijs J. Central sensitization : a biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clinical Rheumatology. 2007;465–73.  Staud R. Is It All Central Sensitization ? Role of Peripheral Tissue Nociception in Chronic Musculoskeletal Pain. Arthritis & Rheumatism. 2010;448–54.  Watkins LR, Maier SF. GLIA : A NOVEL DRUG DISCOVERY TARGET FOR CLINICAL PAIN. Discovery. 2003;2(December).  Predicting outcome of TENS in chronic pain_ a prospective, randomized, placebo controlled trial.pdf.

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