Jessica Van Oosterwijck

In the mind or in the brain? Scientific evidence for central sensitisation in chronic fatigue syndrome

Eur J Clin Invest 2011

Treatment of central sensitization in patients with ‘unexplained’ chronic pain: what options do we have?

Introduction: Central sensitization accounts for chronic ‘unexplained’ pain in a wide variety of disorders, including chronic whiplash-associated disorders, temporomandibular disorders, chronic low back pain, osteoarthritis, fibromyalgia, chronic fatigue syndrome and chronic tension-type headache among others. Given the increasing evidence supporting the clinical significance of central sensitization in those with unexplained chronic pain, the awareness is growing that central sensitization should be a treatment target in these patients. Areas covered: This article provides an overview of the treatment options available for desensitizing the CNS in patients with chronic pain due to central sensitization. It focuses on those strategies that specifically target pathophysiological mechanisms known to be involved in central sensitization. In addition, pharmacological options, rehabilitation and neurotechnology options are discussed. Expert opinion: 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, 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. 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.

Rehabilitation of chronic whiplash: treatment of cervical dysfunctions or chronic pain syndrome?

Chronic whiplash-associated disorders (WAD) remains a challenging condition for clinicians. There is substantial evidence for the presence of various cervical dysfunctions (e.g., increased cervical muscle tone and impaired cervical movement control), but their contribution to the complex clinical picture of subjects with chronic WAD seems rather limited. There is consistent evidence for increased responsiveness of the central nervous system in those with chronic WAD, and central pain processing is likely to play a crucial role in the transition from an acute whiplash trauma towards chronic WAD. The manuscript explains how our current understanding of chronic WAD can be used to steer the content of conservative interventions and how treatment of cervical dysfunctions in patients with chronic WAD should account for the processes involved in chronicity. It is recommended to prevent sensorimotor incongruence, target cognitive–emotional sensitization, and apply a cognitive behavioral therapy-guided exercise program.

Lack of Endogenous Pain Inhibition During Exercise in People With Chronic Whiplash Associated Disorders: An Experimental Study

UNLABELLED A controlled experimental study was performed to examine the efficacy of the endogenous pain inhibitory systems and whether this (mal)functioning is associated with symptom increases following exercise in patients with chronic whiplash-associated disorders (WAD). In addition, 2 types of exercise were compared. Twenty-two women with chronic WAD and 22 healthy controls performed a submaximal and a self-paced, physiologically limited exercise test on a cycle ergometer with cardiorespiratory monitoring on 2 separate occasions. Pain pressure thresholds (PPT), health status, and activity levels were assessed in response to the 2 exercise bouts. In chronic WAD, PPT decreased following submaximal exercise, whereas they increased in healthy subjects. The same effect was established in response to the self-paced, physiologically limited exercise, with exception of the PPT at the calf which increased. A worsening of the chronic WAD symptom complex was reported post-exercise. Fewer symptoms were reported in response to the self-paced, physiologically limited exercise. These observations suggest abnormal central pain processing during exercise in patients with chronic WAD. Submaximal exercise triggers post-exertional malaise, while a self-paced and physiologically limited exercise will trigger less severe symptoms, and therefore seems more appropriate for chronic WAD patients. PERSPECTIVE The results from this exercise study suggest impaired endogenous pain inhibition during exercise in people with chronic WAD. This finding highlights the fact that one should be cautious when evaluating and recommending exercise in people with chronic WAD, and that the use of more individual, targeted exercise therapies is recommended.

A Modern Neuroscience Approach to Chronic Spinal Pain: Combining Pain Neuroscience Education With Cognition-Targeted Motor Control Training

Chronic spinal pain (CSP) is a severely disabling disorder, including nontraumatic chronic low back and neck pain, failed back surgery, and chronic whiplash-associated disorders. Much of the current therapy is focused on input mechanisms (treating peripheral elements such as muscles and joints) and output mechanisms (addressing motor control), while there is less attention to processing (central) mechanisms. In addition to the compelling evidence for impaired motor control of spinal muscles in patients with CSP, there is increasing evidence that central mechanisms (ie, hyperexcitability of the central nervous system and brain abnormalities) play a role in CSP. Hence, treatments for CSP should address not only peripheral dysfunctions but also the brain. Therefore, a modern neuroscience approach, comprising therapeutic pain neuroscience education followed by cognition-targeted motor control training, is proposed. This perspective article explains why and how such an approach to CSP can be applied in physical therapist practice.

Kinesiophobia and maladaptive coping strategies prevent improvements in pain catastrophizing following pain neuroscience education in fibromyalgia/chronic fatigue syndrome : an explorative study

ABSTRACT Many patients with chronic fatigue syndrome(CFS) and/or fibromyalgia(FM) have little understanding of their condition, leading to maladaptive pain cognitions and coping strategies. These should be tackled during therapy, for instance by pain neurophysiology education (PNE). Although positive effects of PNE are well-established, it remains unclear why some patients benefit more than others. This paper aims at exploring characteristics of patients responding poor to PNE to further improve its effectiveness. Data from two RCT’s were pooled to search for baseline predictors. Subjects (n = 39) suffering from CFS/FM, as defined by the American College of Rheumatology, underwent PNE treatment. The Pain Catastrophizing Scale (PCS); Pain Coping Inventory (PCI); and Tampa Scale of Kinesiophobia (TSK) were defined as outcome measures. There was a significant negative relationship between baseline TSK and the change in both PCS total score (r = −0.584; p < 0.001) and PCS rumination (r = −0.346; p < 0.05). There was a significant negative relationship between the change in PCS total score and baseline PCI worrying (r = −0.795; p < 0.001) and retreating (r = −0.356; p < 0.05). FM/CFS patients who tend to worry allot about their pain and with high levels of kinesiophobia are likely to experience less reductions in catastrophizing following PNE. It seems that PNE alone is insufficient to reduce catastrophic thinking regarding pain, and supplementary treatment is needed.

10 Evaluatie en behandeling van patiënten met chronische whiplashgeassocieerde aandoeningen

» Chronische whiplashgeassocieerde aandoeningen (WAD) worden gekenmerkt door een verhoogde algemene pijngevoeligheid, overgevoeligheid voor licht, geluid en geuren, concentratiestoornissen, vermoeidheid en slaapstoornissen. Er is momenteel voldoende wetenschappelijk bewijs dat niet de aanwezige cervicale functiestoornissen, maar wel veranderingen in de centrale pijnverwerkingsmechanismen het complexe klinische beeld van chronische WAD kunnen verklaren. Voor de fysiotherapeut is het belangrijk de klinische uitingen van centrale sensitisatie te herkennen en de cognitief-emotionele factoren die het proces kunnen onderhouden, op te sporen. De therapeutische aanpak zal zich al in het beginstadium richten op het gunstig beinvloeden van de cognitief-emotionele risicofactoren ter preventie van centrale sensitisatie c.q. het tot rust brengen van het overgevoelige centrale zenuwstelsel. In dit hoofdstuk bespreken we het proces van centrale sensitisatie bij patienten met chronische WAD. Verder lichten we toe hoe centrale sensitisatie klinisch kan worden herkend en geven we een aantal richtlijnen voor de behandeling van patienten met WAD.