I’ve just been to the Neuro Orthopaedic Institute’s (NOI) Conference in Adelaide: “Neurodynamics and the Neuromatrix”. What a great conference – great mix of presenters – and delegates! Refreshing views, ideas and conference format while also presenting cutting edge research in an easily digestible way. All up, a really valuable conference in helping us to better understand the physiology of pain and the many functional and structural changes that occur throughout the CNS in chronic ‘pain states’.
Increasing recognition of this altered CNS function is leading to attempts to clinically diagnose and sub-classify patient presentations – it seems either into central sensitisation’ (CS) or ‘peripheral pain’ (PP) states. While acknowledging that there may be overlap between the two, the primary treatment approach offered to each group is quite different:
- CS indicates a cognitive behavioural approach and usually advice to remain active – perhaps within a graded activity programme. Studies have shown that they do somewhat learn to cope better with their pain and lead a more active life.
- PP patients assumedly continue to receive ‘usual practice’ – a veritable minefield of diverse manual and other therapeutic approaches often resulting in ‘failed interventions’ – and perhaps in time leading to a diagnosis of CS!
Clinically, disturbed spino-pelvic function is common to both states. PP always precedes CS – have PP long enough with its attendant barrage of altered sensorimotor input, and then the development of CS is inevitable!
Hence, we need to ask ourselves – Is CS on the incline because we are better at recognising it? Or is it also at the same time a reflection of how inept we have been at effective and meaningful interventions early in the history when our ‘window of opportunity’ in creating change is greatest?
How to better appreciate and understand ‘the source’ of pain – and stem the tide of ‘failed interventions’ – and ipso facto inevitably, apparent CS?
I suggest that in general, it is malfunction of the axial skeleton which is the clinically apparent ‘original driver’ which underlies most peripheral pain states – and also underlies ‘central sensitisation’ pain.
The dense innervation of these spatially ‘central’ tissues: facet joints, ligaments, fascia and muscles and even the disc means that they are potentially hard wired for ‘pain’. Small disturbances in function can evoke big changes in neuronal activity.
It is timely to remind ourselves that as far as the nervous system is concerned, we can conceive the peripheral nervous system as distal to the spinal cord and the ‘central nervous system’ as from the spinal cord to the brain. Both systems are absolutely functionally interdependent
Yet if we think functionally, we are inclined to think of the ‘periphery’ as the limbs. While spatially ‘central’, the spinal column, proximal limb girdles and head are also ‘peripheral’ as far as the nervous system is concerned.
Axial dysfunction doesn’t necessarily result in axial pain. It often does, and it is also behind many limb pain disorders – and it also underlies most CS
Changed afference to the CNS from disturbed function in the periphery results in changed neuro-motor behaviour in general – further leading to more CNS changes. A vicious cycle ensues.
If the ‘peripheral driver’ is not effectively ‘switched off’, the ‘peripheral pain’ and allied symptoms remain – and in time we can predict the onset of CS
In the beginning pain happens for a reason – receptors are activated in the ‘peripheral’ tissues which alert the being’s protection mechanism – simply signalling that all is not OK in the system. When these early warnings are not appropriately heeded and/or dealt with, the continuing ‘abnormal’ signal barrage from the periphery starts to be encoded by the CNS and the original simple messages begin take on a whole new meaning.
To better understand the various pain syndromes in our patients, we need to think about their genesis. Why function is disturbed such that these receptors are activated. If tissue function is not restored, abnormal afference continues
If you want to achieve better management outcomes in your patients, then be prepared to explore axial dysfunction and its link to many pain and associated symptom presentations. With a judicious approach, even those with CS can be significantly helped.
The Key Approach attempts to aid this exploration. Watch this space!