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Mira Meeus
- 1. No Brain, No Pain Herkenning van centrale sensitisatie in de manueel therapeutische praktijk Central sensitization 1 Mira Meeus, Kelly Ickmans, Margot De Kooning, Iris Coppieters, Jo Nijs
- 2. 2 Pain Protection mechanism Subjective complex perception Different components, no consistent relation → Acute pain Cause / nociception → Chronic pain Suffering and Behaviour Central sensitization
- 3. 3 Acute pain Pain receptors Nociceptive neurons & Wide-Dynamic Range (WDR) neurons in dorsal horn Thalamus Cortical regions Cortical output Central sensitization
- 4. Central sensitization 4 Acute pain Mostly nociception: ◦ A-delta fibres: fast ◦ C-fibres: slow, high threshold
- 7. Central sensitization 7 If pain still persists In 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
- 8. Central sensitization 8 Chronic pain Nociceptive mechanisms CHRONIC PAIN Non-nociceptive mechanisms CNS: “Body still in danger” Nociceptive system changes Peripheral and central hypersensitivity probably not: no tissue damage no spatial localisation
- 9. Chronic pain Widespread, no distinct localisation No source of nociception Therapy resistant, bad recovery Central hypersensitivity or sensitization 9Central sensitization
- 12. Central sensitization = Hyperexcitability CNS = Hypersensitivity for all mechanic stimuli Allodynia Generalized hyperalgesia Referred pain Chronic pain 12Central sensitization
- 13. Symptoms of central sensitization Nijs et al. Manual Therapy 2010;15:135-141. Central sensitization 13
- 14. Central Sensitization Neuroplasticity: Habituation & sensitization prolonged or strong stimulation = Functional & chemical changes: - More receptors - Ion channels longer open - Expansion involved regions - … Efficacy signal trandsduction ↗↗ 14Central sensitization
- 15. Central Sensitization: plasticity Central sensitization 15
- 16. Central Sensitization: mechanisms 1. Overactivation bottom-up system: ↗ nociceptive transmission Meeus & Nijs, 2007 Nijs & Van Houdenhove 2008 Yarnitsky et al. 2010 Central sensitization 16
- 18. CS: Wind-up 18Central sensitization C-fibres: - prolonged discharge - ubiquitous distribution - 1/3” temporal summation
- 20. central sensitization: Wind-up ↗ normal situation Central sensitization 20
- 22. 22 Cen tral sen sitiz atio n CS: Wind-up → LTP 2. 3. 1. 4. 5. LTPCS Once CS, not necessarily dependent anymore of nociceptive activity.
- 23. Central Sensitization Hyperexcitability of dorsal horn (DH) neurons: ↑ spontaneous activity ↑ receptive fields ↑ stimulus responses ↑ sensitivity for all mechanic stimuli Allodynia Hyperalgesia Widespread pain Central sensitization 23
- 24. Wind-up & Central Sensitization? Central sensitization 24 Also in No source Healthy of nociception? individuals?
- 25. Central Sensitization: plasticity Central sensitization 25
- 26. Central Sensitisation: mechanisms Meeus & Nijs, 2007 Nijs & Van Houdenhove 2008 Yarnitsky et al. 2010 Changes in top- down pathways: Inhibitory Facilitatory Central sensitization 26
- 27. 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 27Central sensitization
- 28. CS: Impaired pain inhibition Spinal block inhibition expansion receptive fields hypersensitivity faster Wind-up Presynaptic activity not essential for CS CS by failing endogenous pain inhibition 28Central sensitization
- 30. CS: Impaired pain inhibition Central sensitization 30
- 31. Conditioned pain modulation Daenen et al. 2013: effect CPM on TS in WAD
- 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 32
- 33. CS: Impaired pain inhibition Central sensitization 33
- 34. Exercise induced analgesia 8 20 x 6 Central sensitization 34
- 35. Chronic WAD PPT Force [N] Van Oosterwijck et al. 2012 Central sensitization 35
- 36. EIA 3/12/13 36 Descheemaeker et al. In Progress Fibromyalgia
- 37. Lannersten and Kosek 2010 Shoulder myalgia & Fibromyalgia EIA 3/12/13 37
- 38. 38 Fibromyalgia (Lannersten & Kosek, 2010).
- 39. Central Sensitization: plasticity Central sensitization 39
- 40. Central Sensitisation: mechanisms Meeus & Nijs, 2007 Nijs & Van Houdenhove 2008 Yarnitsky et al. 2010 Changes in top- down pathways: Inhibitory Facilitatory Central sensitization 40
- 41. catastrophizing kinesiophobia somatization stress depression CS: Cognitive eomotional sensitization Zusman, 2002 Central sensitization 41
- 42. Psychosocial factors Yellow flags Poor prognosis Related to brain changes Lloyd et al. 2008, George et al. 2007, Flor et al. 2002, Gracchev et al. 2002,2003 Central sensitization 42
- 43. 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
- 44. Central sensitization 44 pain Overactive pain neuromatrix Moseley, 2003
- 45. 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
- 49. Neuropathic pain Haanpää 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
- 51. 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
- 52. 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
- 53. Criterion 2: Diffuse pain distribution? One of the following options: Widespread pain Large pain area with a non-segmental distribution Pain varying in (anatomical) location Bilateral pain / mirror pain (i.e. symmetrical pain pattern) Hemilateral pain
- 54. Criterion 3: Hypersensitivity of non- musculoskeletal senses? ◦ Smell ◦ Light ◦ Sound ◦ Touch ◦ Drugs ◦ Cold / heat
- 55. Central Sensitization Inventory Measuring 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 only Cutoff = 40 Mayer et al. Pain Practice 2012; Neblett et al. Journal of Pain 2013
- 56. 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
- 57. 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
- 58. catastrophizing kinesiophobia somatization stress depression Cognitive emotional sensitization Characteristic for chronic pain in general rather than central sensitization pain? How quantifying?
- 59. Assessing central pain processing Central sensitization 59
- 60. Assessing central pain processing Exercise induced analgesia Central sensitization 60
- 61. Assessing central pain processing Conditioned Pain Modulation 0 1 2 3 4 5 6 7 8 9 PPT voor PPT na CON FM Central sensitization 61
- 62. Treatment response CS 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