Treatment of central sensitization in patients with chronic pain: time for change?

ABSTRACT

Introduction: Given our improved understanding of the role of central sensitization (CS) in many patients with chronic pain, it seems rational to account for CS during treatment.

Areas covered: First, the treatment rationale based on the complex mechanisms underlying CS in patients having chronic pain is presented. Second, emphasis is given to explaining the concept of CS when providing treatment, as well as why patients and clinicians should focus on long-term rather than short-term treatment effects. Third, possible pharmacological and non-pharmacological treatment options are discussed.

Expert opinion: Centrally acting drugs such as tricyclic compounds, serotonin-norepinephrine reuptake inhibitors, and α₂δ ligands each target mechanisms that are often dysfunctional in patients having chronic pain and CS, but decades of clinical practice and clinical trials have not resulted in satisfactory outcomes. This comes as no surprise; CS comprises complex psycho-neuro-immunological interactions, while each of the tested drugs targets one or two of those mechanisms from a purely biomedical viewpoint. Clinicians willing to take CS into account should design an individually tailored multimodal treatment plan comprising pain neuroscience education, cognition-targeted exercise therapy, sleep management, stress management, and/or dietary intervention.

KEYWORDS:

• Pain
• treatment
• exercise
• psychological
• self-management
• drug

Article highlights

• Chronic pain affects up to 30% of the Western population.

• Over the past decades, neuroscience has advanced our understanding about pain, including the role of central nervous system sensitization – more briefly termed central sensitization (CS).

• Clinicians should treat the patient as a biopsychosocial human being suffering from chronic pain, and take central sensitization into account when designing and delivering the treatment.

• Available evidence does not support the (standard) use of centrally acting drugs such as tricyclic compounds, serotonin-norepinephrine reuptake inhibitors, and α₂δ ligands in patients having chronic pain, even though they each target key mechanisms that are often dysfunctional in patients having chronic pain and central sensitization.

• Accounting for central sensitization implies explaining the concept of central sensitization, focusing on long-term rather than short-term treatment effects, and addressing its sustaining factors such as stress, sleep problems, physical inactivity, maladaptive cognitions, and/or dietary factors.

This box summarizes key points contained in the article.

Declaration of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This work is partially funded by the Berekuyl Academy Chair, funded by the European College for Lymphatic Therapy, the Netherlands, and awarded to J Nijs, Vrije Universiteit Brussel, Belgium. I Coppieters is a postdoctoral research fellow funded by the Applied Biomedical Research Program (TBM) of the Agency for Innovation by Science and Technology (IWT; B2aSic project, IWT-TBM no. 150180) and project funding of the Research Foundation Flanders (FWO; G007217), Belgium. A Malfliet, E Huysmans, and A Polli are PhD fellows funded by FWO. K Ickmans is a postdoctoral research fellow funded by the Research Foundation – Flanders (FWO).