Welcome back to the Healing Pain Podcast with Eva Huysmans

We are exploring how to explain central sensitization to patients using pain neuroscience education with physiotherapist, Eva Huysmans. Eva graduated with a Master’s Degree in Physiotherapy and is in the middle of her PhD work. She is working on a randomized controlled trial investigating the effect of perioperative pain neuroscience education for patients undergoing surgery for lumbar radiculopathy. To date, Eva has co-authored over twenty peer-reviewed publications and a manual on pain neuroscience education for the clinician. Next to her research activities, she’s working as a physiotherapist in the University Hospital in Brussels, where she helps people cope with chronic pain. During this episode, you’ll learn how to recognize central sensitization in clinical practice.

How do you objectively evaluate central sensitization? Why are people with central sensitization not the only ones who need pain neuroscience education? All about the introduced term, nociplastic pain. Finally, where does pain neuroscience education fit into a treatment program and how should it be delivered? She has created manuals for clinicians to use pain neuroscience education. As part of this episode, she is providing you with a free download of a pain neuroscience education slide deck that you can use with your patients. To download this slide deck for free, all you have to do is text the word, 169DOWNLOAD, to the number, 44222 or IntegrativePainScienceInstitute.com/169Download. Let’s learn all about central sensitization with Eva Huysmans.

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How To Explain Central Sensitization To Patients Using Pain Neuroscience Education With Physiotherapist Eva Huysmans

Eva Huysmans, thanks for joining me on the show. It’s great to have you here.

It’s my pleasure to be here. I’m looking forward to this one.

I know you do some great work in the realm of pain science. A topic we’re talking about is central sensitization and an important topic both for practitioners who are treating pain as well as people who are learning more about pain and discovering what the potential cause of their pain is. Central sensitization continues to be built out in the literature. To start us off, tell us what central sensitization is.

For many clinicians, it’s already clear what it is, but I will explain it simply for more patients. It’s a hypersensitivity that is due to changes that occur in the central nervous system. People who are experiencing central sensitization often have, for example, disproportionate pain. They also can be sensitive to other stimuli noises or even smells, etc. It’s a generalized hypersensitivity which is often linked to chronic pain problems.

There are aspects of peripheral sensitization that come into play as well.

Peripheral sensitization is also seen in acute disorders. For example, when you sprain your ankle, you will see that the whole region around the sprain will get sensitive. That’s a sensitization that we have to protect those tissues to make sure they can heal in a good way and as fast as possible. It’s an important thing. We also see these peripheral changes in the nervous system in central sensitization. On top of that, you will have the central adaptations that are going on in these patients.

That’s an excellent introduction. Thanks for that because it helps inform the rest of the show. If there’s someone who has chronic pain, it helps them start to think differently about their pain and reframe their pain away from being a musculoskeletal problem toward being a challenge of the nervous system. As people reading this are saying, “I have someone with back pain,” there’s probably someone with fibromyalgia, someone with CRPS. What types of conditions and chronic pain syndromes has central sensitization been associated with?

Fibromyalgia is the most known one together with chronic fatigue syndrome. For example, chronic whiplash-associated disorders, you see central sensitization as non-sprain type. You would see in chronic low back pain that it’s only a subgroup of patients who are showing dominant central sensitization. Irritable bowel syndrome is different but also characterized by the central sensitization mechanism. That’s an answer to your question more or less.

It’s seen in a number of different chronic pain syndromes which is helpful for people. You mentioned and described central sensitization. If the audience read this and they say, “I heard you talk about central sensitization. I’m still not quite sure what it is,” would you describe it in a different way to a patient if you’re working with them in the clinic?

I would do it in a simple way that is understandable for the patient that is sitting in front of me. You get a patient with a medical background then you can go more in detail. Central sensitization is characterized by a number of physiological changes that can get complex because even clinicians and researchers don’t know it all. For some parts of the whole discussion with the pain neuro matrix, we don’t know whether there is a neuro matrix or it’s something else or it’s a lot more complex. It can get complex when you want to explain it in detail. That’s not what you want to do with a patient. The main thing is that patients should understand that there’s more than the biomedical parts to pain so that you frame everything in a biopsychosocial framework. What we would do is use metaphors and everything like daily life examples and often examples from the patients themselves to explain parts of the mechanism. In the end, they would be able to get a large picture of central sensitization. We tried to deal with a low key to explaining that there’s hypersensitivity and that it’s due to lockdown mechanisms that are controlled in one place in the spine. You also have the brain which is involved and we explained that like a computer that is processing all the inputs that are coming in, that could even start doing things by itself and then you get the whole mechanisms. That’s how we tried to explain it smoothly.

For the practitioners who are learning about central sensitization or want to dive into a little bit more on a systems level. If you looked at the human body on a systems level, which systems does the central sensitization affect? The better way to frame it is which systems it does not affect because it may affect many different types of systems, but the ones that we start to look at with regard to chronic pain or the major ones.

I don’t know how much in detail that you want to go, but we are looking at the neurological system. Not only the neurons but also glial, they seem to be involved. You have everything which is centrally-located but then also in the periphery. We’re also looking at the sensors, the receptors, which aren’t from your central nervous system but there are also changes occurring the peripheral sensitization. Your receptors get sensitized over there. When you have a case of nociceptive pain, then you will look at the peripheral tissues like a muscle. That’s not what we specifically will talk about in pain neuroscience education, it’s focused on the nervous system. It goes together with endocrinological pathways, immunology. It’s a broad perspective but all the musculoskeletal system is what you almost leave out of the story.

I want to come back. It’s an important point and I appreciate you bringing that up. In general, when we’re looking at central sensitization, it affects the central nervous system, the peripheral nervous system, the digestive system, which we know is home to our immune system. It may affect the immune system both in the gut. You mentioned glial cells which act as immune cells in the central nervous system. Your immune system is primed in some way both centrally and peripherally.

You mentioned endocrine, so there’s HPA axis dysfunction that’s happening, which is another central component that drives peripheral hormones. Hormones are related. You mentioned the bio-psycho-social model and the psychosocial aspect. You start to think of how it affects mood. Anxiety, depression, irritation, anger, irritability, all those are components. Let’s talk about the musculoskeletal system, which is interesting because I always feel the musculoskeletal system can be the way in through the back door, which people don’t think about. Why do we leave that out of many types of pain neuroscience education perspectives?

That’s originated in the fact that pain neuroscience education was created for the chronic pain patients which comes into your practice with a body chart full of complaints. You don’t have any biomedical or biomechanical reasons for this pain. They had a number of investigations done in hospitals and they couldn’t find anything, but they have a huge amount of pain. That is how people started to explain the pain. It’s originated with Louis Gifford who started doing this and found something. The musculoskeletal system is not that important anymore in these people. It’s because we cannot find this musculoskeletal origin for the pain that we want to focus on the nervous system. It’s important when you first see your patients define whether if this is a patient who is dominantly characterized by the central sensitization, pain type or nociplastic pain instead of nociceptive pain. In some patients, you can have nociceptive pain still going on but they might be dominantly nociplastic pain. It’s a different story. You should incorporate a musculoskeletal system in your story that you’re telling the patients.

It depends on the patient but when you have someone in front of you who is completely a nociplastic pain case and there are no nociceptive inputs at that moment of time, I don’t think you should focus on the musculoskeletal parts. Although, they can feel they have real musculoskeletal complaints like stiffness in their muscles or they can feel their spine is blocked or anything. It’s a key to explain to them where it’s coming from and that’s not there locally. What you said, it can be the way in some people. The chronic whiplash-associated disorders start with an acute injury and then it goes to central sensitization and nociplastic pain. In the end, they cannot see anything on the MRI and they keep on having complaints. There’s a shift. That’s the importance of seeing a continuum and not as something that occurs from day-to-day.

I want to come back to that topic of the musculoskeletal system and tweeze that out a little bit more and get in the weeds of that. I want to back up a carline because you mentioned both nociplastic pain as well as nociceptive pain. Can you explain the difference between the two? Is one occurring before the other? 

Nociceptive pain is occurring from an acute injury or from tissue damage. We would say that patients who are having dominantly nociceptive pain, their pain is proportionate to certain tissue damage that is occurring in their body or a certain condition, which is generating nociceptive inputs that are processed in the right way. That would be a prominently nociceptive pain. Nociplastic pain is the pain type which is characterized by central sensitization. That’s what we see more in chronic pain patients.

That’s a continuum, so it could be an injury that leads to nociplastic pain? 

It can be a continuum. Nociplastic pain can also occur without a nociceptive pain type or injury before.

Because it’s centrally mediated, things like emotions, thoughts, beliefs, those can be the driver. They’re beautiful and important distinctions to make for both people with pain as well as practitioners so they can start to weed that out. If I’m a practitioner, how do I clinically differentiate between nociceptive and nociplastic pain? 

First, you want to listen to your patient. It’s important to get the complete medical file of a patient if that’s possible so you can see whether there has been some imaging or stuff that you can look at what they did in the hospital or the doctor’s office. You can see the whole picture. Often, you have the impression that you can recognize central sensitization or nociplastic pain from the moment that a patient walks in your clinic. That’s not multicodes. You should do a proper investigation with your patient clinical examination. With the Pain in Motion group, we designed an algorithm for differentiating between nociceptive pain and nociplastic pain, which was published years ago.

In that algorithm, you would first look at whether the pain is these proportions so then you’re looking at pain intensity. Is this patient showing a higher pain intensity than what you would expect with a certain injury or condition that is going on in this patient? There is nothing on medical imaging or nothing in all the previous investigations. You also don’t find anything in your clinic with your clinical examination and the patient is still showing a lot of pain, then you’re sure that it’s disproportionate. If you have to say no, it’s not disproportionate, then you would already decide that it’s a nociceptive pain so no central sensitization. If you decide that the pain is indeed disproportionate, then you would have to look at the distribution of the pain.

We are not looking at pain intensity but the anatomical regions where the pain is occurring at that moment in the patient. If that’s a positive thing, you can conclude based on the algorithm that you’re sitting in front of a patient with dominantly central sensitization or nociplastic pain. If the pain is not diffused, then you would want to do a central sensitization inventory in the patients. If a patient scores above 40 or 40, then you can conclude again that it’s central sensitization dominantly. The central sensitization inventory is a questionnaire that was designed to assess symptoms of central sensitization. It’s good to tell. I use this algorithm personally in clinical practice, but I tend to not only use that algorithm but also listen to the stuff that the patient tells me additionally.

For example, hypersensitivity to different stimuli, sleep disturbances, some things in the diet. I try to get the whole picture and then the algorithm can help me to make my final decision whether it’s dominantly nociplastic pain. A small thing I want to add here is that before you would differentiate between nociceptive pain and nociplastic pain, you would want to have excluded neuropathic pain. That’s an important thing that you should first exclude. The most important way to do that is by looking at whether you’re paying distribution is neuroanatomically logical. Do some neurodynamic tests so it can be active or passively performed by the patient. That’s important to differentiate those before you go into nociceptive pain.

We have a good idea of what central sensitization is, how we can explain it to a patient, all the different types of various systems and the systems biology that is included in that. You went through the IASP mechanistic definitions of the three different types of pain, nociplastic, nociceptive and neuropathic pain, which is important. You talked a little bit about how to evaluate it from a clinical perspective and figure out if it’s nociplastic or nociceptive. All of our intent is going to start to go up and say, “How do we treat this now?” Pain Neuroscience Education has a number of high-powered studies proving its efficacy for fear, fear-avoidance, as well as helping people function better in life even with some things with regard to mood. Tell us what Pain Neuroscience Education is first for those who don’t know what it is?

It’s explaining what pain is to a patient. You would want to do this from a biopsychosocial perspective. That means that you’re going to talk about core conditions and beliefs. What we incorporate in pain or a sensitive cation or some specific things related to the patients or to the setting. We’ve called the whole package Pain Neuroscience Education but it’s not all pain neuroscience. It’s working or targeting your pain neuroscience. In perioperative patients, we will also talk about the decision to have surgery. What we try to do is use this information, this theoretical background that we as a start of the therapy for pain problems. That’s in a nutshell of Pain Neuroscience Education.

Clinically, are you using it with people with pain or does it have usefulness for other types of conditions and diagnoses?

It’s originated for people with chronic pain disorders. That’s what we see in research nowadays and that’s also where I’m doing research on, we try to apply Pain Neuroscience Education to other populations. I mentioned the perioperative patients. Those are still having pain. You also see some studies popping up in primary school children. They are going to give the content of Pain Neuroscience Education to those children. It’s a study by Adrian Lao. They measured whether the children were able to understand the content of Pain Neuroscience Education and whether their knowledge of pain science effectively improved. It would be interesting if they could do a longer follow-up study to see a large group of children whether they would develop less chronic pain issues later in life. That’s what you mean a tweak could give Pain Neuroscience Education as a preventive matter. At this moment, it’s important that we keep on doing. It’s for the populations where we know that there’s some evidence-based practice available.

Additionally to that, it’s important for us as researchers and as clinicians that we try to communicate the message that we want to communicate. We need a biopsychosocial perspective to everyone in our neighborhood and try to spread it as much as possible because one of the largest issues that we occur in practice is that people are resistant against getting therapy from a biopsychosocial perspective. That’s because in our society, we are still living in a biomedical or biomechanical framework. What we learn at school is the biomedical part. No one is teaching children at this point that when you have depression, you will have higher pain intensities. It’s important that the general population is also getting this message because otherwise, it will still be a restriction to our practice that we’re trained to do.

There are plenty of work to be done with the populations that we’re working with that have pain. It is interesting to see how it starts to roll out into perioperative and preoperative populations of acute pain. It’s interesting with the children. In that context, it’s being used more as a health prevention or health promotion, which if we had a long-term study to see where those groups less life to have chronic pain. It’s interesting to think about but you’re right, we don’t want to leave the millions of people by the wayside and run to prevention, so to speak. We want to help the people who have chronic pain cope and overcome in many ways the pain they’re experiencing. Where does Pain Neuroscience Education fit into? Let’s say a patient comes in with a prescription for physiotherapy twice a week for six weeks. How does a practitioner fit that into care? If they haven’t an hour for the evaluation and 30 minutes each treatment session, that’s somewhat typical in standard globally.

I will say how we do it here in Belgium and then I will say how many people can do it because there’s a practical issue with the timing of consultations in many countries. In our clinic, we have a chronic pain rehabilitation program, which is specific. We try to give a session of one-hour one-on-one pain neuroscience education at the beginning of therapy. It’s for chronic pain patients. When you are sitting in front of an acute pain patient, I don’t think they would need an hour of Pain Neuroscience Education. They even don’t need it but in certain situations, it can also be useful. In any case, I would give it at the start of your treatments because Pain Neuroscience Education is such a good way to mold your patients into the best perspectives to start rehabilitation, and that’s important to get them prepared, so they know what to expect.

It will be important to keep communicating the same message during the rest of your therapy plan. It’s not good to have a one-on-one session Pain Neuroscience Education. In the next session, you are going to do only manual therapy and you’re going to say to your patient, “I’m going to fix your back.” That’s not working. You can combine Pain Neuroscience Education with hands-on techniques like manual therapy. That’s perfectly fine, but then you should communicate why you are doing those manual techniques. We know from research that we can stimulate our nociceptive inhibition by doing manipulations.

That’s the way you want to communicate with a patient. They would understand it because they had a Pain Neuroscience Education before. In many clinical practices, you would only have 30 minutes with a patient each session, we take one hour for Pain Neuroscience Education. Another issue is that often the healthcare system or the healthcare insurances are not allowing you to give one whole session of education and not doing any hands-on techniques or any exercise training. You would have to do something active in your session with your patient. In that case, I would recommend trying to explain the key principle space and some simple metaphors to your patients before you start your treatments. You start your active treatments or hands-on treatments, whatever you want to do.

During the treatment, keep on talking to your patient and try to give the right message. I don’t think you have to explain theoretical stuff during the rest of your treatments because if you’re doing exercise therapy, then the patient should focus on these exercises and all of what you’re telling. It wouldn’t be a great occasion to give theory to the patient but keep on communicating in the same perspective. Try to give another message during the rest of the therapy that you’re giving. The next session that your patient is coming, you can again do ten minutes of Pain Neuroscience Education and then you do the rest of the therapy.

Give your patients sometimes the opportunity to ask questions. When they ask questions, some clarity pop up and then you can explain them. In the end, you will be able to give the whole theoretical but then you spread it over several sessions. In our case, the big advantage is that we can prepare the patient first completely for mental and psychological viewpoints. They would have the right knowledge to go further with treatments. The next step in our treatment is stress management or activity management. When you’re going to do such things, then it’s important that the patient dealt the Pain Neuroscience Education background because otherwise, they wouldn’t understand why they have to do stress management or why they have to face their activities. That’s where it fits in a treatment.

Often, patients are coming to physical therapists and other practitioners who treat pain and they have seen multiple practitioners anywhere between 5 and 10. They feel that they have been stuck struggling for years, if not decades. The more they struggle, the more they sink and the smaller life gets and the more they try to flail around and find solutions to solve their pain. The more they feel that they’re stuck in one place with cement shoes and they’re not going anywhere. Do you find that an hour of Pain Neuroscience Education helps people drop that struggle a little bit and relax that there may be hope for them?

In some patients. I had many patients who were after the Pain Neuroscience Education session saying, “You’re the first one who understands my problems and who can give an explanation for everything that I’m feeling or what I have been complaining about in a big part of my life.” They often saw many practitioners before who were treating them locally. As we know, local treatments have the desire to fix in patients with dominantly central sensitization it shows. For some patients, one hour session Pain Neuroscience Education gives them an explanation and they feel reassured in their own situation because there’s finally someone who can talk to them and who can understand them.

That’s also important because from the biopsychosocial viewpoints. You would want to explain to the patients how important the conditions, feelings and emotions are in the whole story. Sometimes, patients start getting the impression that you see it. It’s all between your two ears. That’s not what you want to occur in a patient because that’s not what you are seeing. The patients are feeling a thing. They do not imagine the pain or anything. It’s important that you can stress the fact that pain is also a feeling, so that they start believing that if they feel angry, it’s something that they feel pain. It’s the same but feeling pain is annoying.

That’s what I try to explain to patients to make sure that they do not think that it’s all an imagined illness because they don’t want to hear that. That’s also not the effect. Some patients are not ready for your biopsychosocial story. They have been to many practitioners looking for an explanation for their complaints and then you are going to tell them that it’s all in their heads and central nervous system and they are not pleased with that because they can feel the pain in their back and legs and there must be something wrong over there. If they keep thinking in that perspective, then it’s sometimes hard to get them out and to get them along with your story. We can know that what we are saying is the best evidence nowadays, but it’s hard sometimes to explain that to a patient who has been told that there could be something wrong over there and there could be something wrong over there. When you are dealing with a patient that is thinking biomedically and biomechanically, then Pain Neuroscience Education might not be the best step in the first session.

I’m noticing that for some people, it can be a validating experience for them where that education seeps in as new learning, they’re interested, it’s eye-opening for them and it’s hopeful for them. There’s another group of patients where there’s much cognitive bias to overcome from years of societal conditioning and conditioning through the healthcare system that it can be tough to try to reframe change cognitions, add new learning on top of that. It’s interesting because as practitioners, we’re excited about Pain Neuroscience Education. All the different types of cognitive behavior therapies that came before it, there are over their averages of averages and there are always going to be groups and specific people that fall outside where you may say, “This might not be the approach for them to try to help me change their pain-related beliefs, which ultimately is what PNE does.” 

For that group, they may need more of an ACT approach, where it’s less about changing distorted cognitions about pain and more about behavior change in line with what they value in life and that may fit that person even more. It’s wonderful that we have so many tools to use and sometimes these tools can run side by side where you can do an hour of PNE, which everyone could benefit from in some way, even if it’s only partial reconceptualization of pain. If that’s not fitting and you’re seeing that they’re a little bit resistant and there’s not moving with that, then you move to something a mindfulness approach or an ACT approach that is a little bit different. Some of the research you’re doing, Eva, is fascinating and it’s going to help inform all of our practice and help people with pain. Tell us what’s new for you? What’s coming up in 2020 for you? What are you working on?

I’m about to publish, hopefully if it’s accepted, a review of the relationship between cognitive and emotional factors in healthcare utilization. That’s also what I want to look at in a population of patients that are going surgery for lumbar radiculopathy. We are running a large trial that provides the Pain Neuroscience Education perioperatively to those patients compared to a more biomedically-focused spec school approach. Based on these data, I want to look at whether changing pain conditions and beliefs about pain, which also results in lower healthcare utilization post-surgery. That’s hopefully what 2020 and 2021 will bring for me. I’m looking forward to it because it’s even more important to find changes in these patients on behavioral outcomes like healthcare use and return to work, which has a high socio-economical impact for the patients themselves but also for society.

You would look at pain and the conditions because there’s a consensus among pain researchers that pain might not be the holy grail that we’re looking for, but it might be more outcome slight quality of life and behavior functioning. That’s important that in the future, try to focus more on these outcomes as primary outcome measures instead of always looking at pain intensity. When you look at the patient being in clinical practice, that’s what you see. They might keep on experiencing pain, but they might be functioning way better quality of life and see that’s a lot more important than the fact that sometimes they have the intensity of 8 out of 10.

We want people’s quality of life to improve and when someone’s quality of life improves, their mood improves, everything tends to get better. I always say, in many ways, we’re putting the cart before the horse and we’re looking for pain relief than someone’s life gets better. I always talk to people, I’m like, “I want to see your life get better first. I want you to reengage gently, slowly and compassionately with some of the things that you love in life.” With that, oftentimes pain relief will be the outcome. Living a full life is what we’re looking for. As we move into 2020, we’ll keep our toes and fingers crossed to hopefully that great research you’re working on will be published. Please come back and talk to us about that research once you publish it. In the meantime, let everyone know how they can follow your work and learn more information about you.

Updates on my work and the work of my colleagues can be found on the website, www.PainInMotion.be. We are also very active on social media. I’m one with the social media managers of Pain in Motion. I’ll make sure that my research is shared on social media. You can find us on Facebook, Twitter and Instagram, @PainInMotion.

I want to thank Eva for joining us talking about central sensitization and Pain Neuroscience Education. Awesome information here whether you’re someone who has chronic pain or you’re a practitioner looking to serve your patients more. Make sure to follow Eva and all her colleagues’ work at the Pain in Motion website, it’s PainInMotion.be.

Important Links:

• Eva Huysmans
• IntegrativePainScienceInstitute.com/169Download
• Facebook – Pain In Motion
• Twitter – Pain In Motion
• @PainInMotion – Instagram
• www.PainInMotion.be
• @EvaHuysmans – Twitter

About Eva Huysmans

Eva Huysmans graduated in 2015 as a Master of Science in Rehabilitation Sciences and Physiotherapy at the Vrije Universiteit Brussel, Belgium. In November 2015, Eva started as a PhD researcher at both the department of Physiotherapy, Human Physiology and Anatomy and the department of Health Sciences.

She is working on the B²aSic project, which comprises a randomized controlled trial investigating the effect of perioperative pain neuroscience education and back school in patients undergoing surgery for lumbar radiculopathy. Within this project Eva is working on data concerning healthcare utilization and costs, return to work and pain cognitions.

To date Eva has (co-)authored over 20 peer-reviewed publications and a manual concerning Pain Neuroscience Education for clinicians. Next to her research activities, she is working as a physiotherapist in the University Hospital of Brussels with patients with chronic pain. Furthermore, she regularly gives lectures and courses for clinicians about biopsychosocial therapy options for several populations.