As a new graduate physiotherapist, I have learnt so much in my first two months of practice.
Finally, theory has been put into practice and I’ve been challenged when seeing a range of different people with different conditions every day.
It’s been satisfying to learn that I can confidently treat every person who walks through my door and make improvements to their pain and function.
For many of my clients, pain is the reason they come to see me: pain has become a factor restricting them from doing what they want to do.
In some cases, this pain is from a recent injury and for others it has been a gradual build up that has now become too much to bear. In most cases I can work with my clients to reduce their pain and eventually improve their function quite quickly.
However, something I’ve found myself questioning following some of my appointments, is why this process can be much slower for people with chronic pain. The answer lies in the process called central sensitisation.
What is central sensitisation?
In short, pain is your body’s warning system for preventing injury.
Nociception, or the sensation of pain, in your tissues sends a signal via the nervous system to your brain which creates a pain response.
Your brain then generates a response to the pain, such as pulling your hand away from a harmful stimulus, an emotional reaction to the pain, and an avoidance behaviour for the future. As you can see, this immediate pain response is usually very helpful.
However, for many conditions where pain persists long-term, your brain and nervous system become more sensitive to stimuli.
This can be to the point where actions that normally may not cause pain, will generate a pain response. The brain has become hyper-aware and protective of your tissues, wanting to avoid further injury or damage.
The issue arises when this increased sensitivity persists after the tissues have repaired themselves.
This heightened pain response to usually non-painful stimuli is the process called central sensitisation.
An Example Case:
John is a 40-year-old man who injured himself whilst lifting something heavy at work.
After half an hour, he left work as he found is very painful to bend in any direction or to stand up for more than five minutes.
After a few days off work and no improvement in his pain, John visits his local physiotherapist who diagnoses him with a disc prolapse in his lower back.
The physio gives him some massage on his back and advises him not to bend forward or lift anything heavy for 6 weeks while the injury heals.
John decides that he doesn’t need to return to the physio and instead will just wait for the injury to heal. Over the next six weeks, John avoids bending or moving his spine as much as possible.
However, after two months, John finds that it is still painful to bend forwards to tie his shoelaces or to carry two bags of groceries.
He is frustrated that his movement is not back to normal and that he still remains on light duties at work.
The most likely explanation for John’s pain is that there has been central sensitisation of his previous lower back injury.
This has now made normal activities, like tying shoelaces and carrying grocery bags, painful.
What does that mean for you?
The good news is that central sensitisation can be reversed. But as this often develops slowly, it can be a slow process of desensitisation as well.
Physiotherapists are able to help you decrease your levels of pain.
But what I find results in the best outcomes, is assisting my clients to return to activities they’re interested in – which in John’s case may be tying shoelaces and resuming full duties at work.
Setting goals for the future that are less centred around pain and more centred around your life and interests, helps you to stay motivated through what may seem like a lengthy process.
After initial goal setting, we will then work with you to retrain your brain to become less sensitive to different movements and actions.
This will often involve a combination of hands on treatment by the physio to assess and move the sensitive area, as well as exercises to do at home to further increase movement and strength.
What is important to know, is that throughout this process of desensitisation, exercises may enter slightly into your painful range, most likely into mild discomfort.
This is a critical step, as we need to teach the brain to understand that although we are feeling this pain response, that this movement won’t cause further damage or serious pain afterwards.
As time progresses, the movement will become less painful and more comfortable.
Then, your physiotherapist will continue to progress your movements and exercises so that with each progression, you’re moving closer and closer towards your full range of movement and strength, and therefore towards your long-term goals.
When thinking about clients who may come to see me with central sensitisation in the future, there are 3 key points that I would love for them to know:
- Central sensitisation is a complex phenomenon, involving a heightened pain response by your brain in your body. For many people with chronic pain, central sensitisation can develop and cause ongoing pain even once injuries have fully healed.
- Despite me talking about pain and your brain, I’m not saying that this pain is “all in your head” and I do understand you are feeling real pain.
- The process of recovery and rehabilitation will involve experiencing some discomfort in order to desensitise your brain and body. Luckily, you’ll be able to work alongside your physiotherapist throughout the process until you’re able to achieve your goal activities.
By Courtney Essex