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Central sensitization 1
No Brain, No PainHerkenning van centrale sensitisatie
in de manueel therapeutische praktijk
Mira Meeus, Kelly Ickmans, Margot De Kooning, Iris Coppieters, Jo Nijs
Central sensitization 2
PainProtection mechanismSubjective complex perceptionDifferent components, no consistent relation
→ Acute painCause / nociception
→ Chronic painSuffering and Behaviour
Central sensitization 3
Acute painPain receptors
Nociceptive neurons & Wide-Dynamic Range (WDR)
neurons in dorsal horn
Thalamus
Cortical regions
Cortical output
Central sensitization 4
Acute painMostly nociception:
◦A-delta fibres: fast◦C-fibres: slow,
high threshold
5Inwendige 2013-2014
Central sensitization 7
If pain still persistsIn chronic musculoskeletal disorders????
→ lack of distinct localisation→ lack of tissue damage
No longer adaptive function≠ prolonged acute pain
◦ Fibromyalgia, Chronic Fatigue Syndrome◦ Whiplash Associated Disorders ◦ Aspecific chronic low back pain
Central sensitization 8
Chronic painNociceptive mechanisms
CHRONIC PAIN
Non-nociceptive mechanisms
CNS: “Body still in danger” Nociceptive system changes
Peripheral and central hypersensitivity
probably not:no tissue damageno spatial localisation
Central sensitization
Chronic painWidespread, no distinct localisationNo source of nociceptionTherapy resistant, bad recovery
Central hypersensitivity or sensitization
9
Central sensitization 10
central sensitization
normal situation
Central sensitization
Central sensitization
= Hyperexcitability CNS = Hypersensitivity for all mechanic stimuli
AllodyniaGeneralized hyperalgesia
Referred painChronic pain
12
Central sensitization 13
Symptoms of central sensitizationNijs et al. Manual Therapy 2010;15:135-141.
Central sensitization
Central Sensitization
Neuroplasticity: Habituation & sensitization
prolonged or strong stimulation
= Functional & chemical changes:
- More receptors- Ion channels longer open- Expansion involved regions- …
Efficacy signal trandsduction ↗↗14
Central sensitization 15
Central Sensitization: plasticity
Central sensitization 16
Central Sensitization: mechanisms
1. Overactivation bottom-up system:↗ nociceptive transmission
Meeus & Nijs, 2007Nijs & Van Houdenhove 2008Yarnitsky et al. 2010
Central sensitization 17
Overactive bottom-up
Central sensitization
CS: Wind-up
18
C-fibres:- prolonged discharge- ubiquitous distribution- 1/3” temporal summation
Central sensitization 19
Central sensitization 20
central sensitization:
Wind-up ↗
normal situation
21Inwendige 2013-2014
22Central sensitization
CS: Wind-up → LTP
2.
3.
1.
4.
5.
LTPCS
Once CS, not necessarily dependent anymore of
nociceptive activity.
Central sensitization 23
Central SensitizationHyperexcitability of dorsal horn (DH) neurons:
↑ spontaneous activity↑ receptive fields↑ stimulus responses↑ sensitivity for all mechanic stimuli
AllodyniaHyperalgesia
Widespread pain
Central sensitization 24
Wind-up & Central Sensitization?
Also in No sourceHealthy of nociception?individuals?
Central sensitization 25
Central Sensitization: plasticity
Central sensitization 26
Central Sensitisation: mechanisms
Meeus & Nijs, 2007Nijs & Van Houdenhove 2008Yarnitsky et al. 2010
Changes in top-down pathways:
Inhibitory
Facilitatory
Central sensitization
CS: Impaired pain inhibition
Descending inhibitory pathways in dorsolateral funiculus:
◦Inhibitory substances (serotonin, opioids, etc.) in synapses in dorsal horn
Experimental block or lesions of pathways
→ equivalent of CS
27
Central sensitization
CS: Impaired pain inhibitionSpinal block inhibition
expansion receptive fields hypersensitivity faster Wind-up
Þ Presynaptic activity not essential for CSÞ CS by failing endogenous pain inhibition
28
central sensitization
normal situation
Central sensitization 30
CS: Impaired pain inhibition
Conditioned pain modulation
Daenen et al. 2013: effect CPM on TS in WAD
Central sensitization 32
Conditioned pain modulation
Diffuse noxious inhibitory control or CPM:
◦CFS (Meeus et al 2008): ↘◦WAD (Daenen et al 2013): ↘◦FM (Julien et al. 2005, Staud et al. 2003, …) ↘◦RA (Leffler et al. 2002) =◦ …
Central sensitization 33
CS: Impaired pain inhibition
Exercise induced analgesia
8
20 x
6
Chronic WAD
PPTForce [N]
Van Oosterwijck et al. 2012
EIA 3/12/13 36
Descheemaeker et al. In Progress
Fibromyalgia
Lannersten and Kosek 2010
Shoulder myalgia & Fibromyalgia
EIA 3/12/13 37
38
Fibromyalgia (Lannersten & Kosek, 2010).
Central sensitization 39
Central Sensitization: plasticity
Central sensitization 40
Central Sensitisation: mechanisms
Meeus & Nijs, 2007Nijs & Van Houdenhove 2008Yarnitsky et al. 2010
Changes in top-down pathways:
Inhibitory
Facilitatory
Central sensitization 41
catastrophizing
kinesiophobia
somatization
stress
depression
CS: Cognitive eomotional sensitization
Zusman, 2002
Central sensitization 42
Psychosocial factorsYellow flagsPoor prognosisRelated to brain changes
Lloyd et al. 2008, George et al. 2007, Flor et al. 2002, Gracchev et al. 2002,2003
Catastropizing
Catastrophizing ≈ increased activity in brain areas related to:
◦ anticipation of pain, ◦ attention to pain (ACC), ◦ emotional aspects of pain ◦ and motor control. (Gracely, 2003)
Central sensitization 43
Central sensitization 44
pain
Overactive pain neuromatrix
Moseley, 2003
Catastropizing
- Prediction pain intensity in CFS: ± 20% (Meeus et al. 2012)
- Related to CPM (Weissman-fogel et al. 2008)
- Related to TS (Goodin et al. 2013)
CATASTROPHIZING PREDICTS ENDOGENOUS PAIN MODULATION
Central sensitization 45
Nociceptive pain
Neuropathic pain
Central sensitization
Neuropathic pain
Central sensitization
Neuropathic painHaanpää et al. Pain 2011
Non-neuropathic central sensitization pain
evidence abnormality / damage nervous system
≠ evidence abnormality / damage nervous system
medical cause ≠ medical cause
neuroanatomically logical neuroanatomically illogical
burning, shooting, or pricking ≠ burning, shooting, or pricking
sensory dysfunction is neuroanatomically logical
↑sensitivity at segmentally unrelated sites
Nociceptive pain
Central sensitization
Musculoskeletal pain
Disproportionate pain experience?
no Central Sensitization
Diffuse pain distribution?
Central Sensitization Inventory ≥ 40 ?Central Sensitization
YES
YES
YES
NO
NO
NO
no Central Sensitization
Central Sensitization
Criterion1: Disproportionate pain?
Severity of pain and related disability disproportionate to the nature and extent of injury or pathology
Examples:◦ chronic neck pain, no structural lesions on cervical scans,
segmentally unrelated pain areas and severe disability◦ knee osteoarthritis, too early for surgery, widespread
pain & severe disability
Criterion 2: Diffuse pain distribution?
One of the following options:Widespread painLarge pain area with a non-segmental
distribution Pain varying in (anatomical) locationBilateral pain / mirror pain (i.e. symmetrical pain
pattern)Hemilateral pain
Criterion 3: Hypersensitivity of non-musculoskeletal senses?
◦Smell ◦Light◦Sound ◦Touch ◦Drugs ◦Cold / heat
Central Sensitization InventoryMeasuring hypersensitivity to various stimuli:
◦ Certain smells, such as parfums, make me feel dizzy and sick◦ When I go to bed, my legs feel uncomfortable and restless◦ Stress enhances my physical symptoms◦ I am sensitive to bright light
Part A onlyCutoff = 40
Mayer et al. Pain Practice 2012; Neblett et al. Journal of Pain 2013
Musculoskeletal pain
Disproportionate pain experience?
no Central Sensitization
Diffuse pain distribution?
Central Sensitization Inventory ≥ 40 ?Central Sensitization
YES
YES
YES
NO
NO
NO
no Central Sensitization
Central Sensitization
Additional signs and symptoms
Abnormal therapeutic response Abnormal pain timeline Sleeping difficulties Memory- and concentration difficulties Fatigue Muscle weakness Phantom swelling Impaired tactile localization Dyskinaesthesia
catastrophizing
kinesiophobia
somatization
stress
depression
Cognitive emotional sensitization
Characteristic for chronic pain in general rather than central sensitization pain? How quantifying?
Central sensitization 59
Assessing central pain processing
Central sensitization 60
Assessing central pain processingExercise induced analgesia
Central sensitization 61
Assessing central pain processingConditioned Pain Modulation
PPT voor PPT na0
1
2
3
4
5
6
7
8
9
CONFM
Treatment responseCS possibly NOT at treatment initiation BUT during rehabilitation
◦ Post-exertional malaise
◦ Pain increase following hands-on treatment
◦ Poor treatment progress
◦ Symptoms expand to non-segmental related areas
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