Research Review By Dr. Ceara Higgins©

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Date Posted:

February 2016

Study Title:

Balancing “hands-on” with “hands-off” physical therapy interventions for the treatment of central sensitization pain in osteoarthritis

Authors:

Girbés EL, Meeus M, Baert I, Nijs J

Author's Affiliations:

Department of Physical Therapy, University of Valencia, Spain; Pain in Motion Research Group, Belgium; Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium; Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium; Department of Human Physiology, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Belgium; Department of Rehabilitation Sciences, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Belgium.

Publication Information:

Manual Therapy 2015; 20: 349-352.

Background Information:

Osteoarthritis (OA) has been identified as one of the main causes of pain, disability, and loss of quality of life in the elderly population. Most often, practitioners treating individuals with OA employ a biomedical model of pain, which assumes a direct link between the amount of tissue damage in the joints or tissues and the amount of pain experienced by the patient (4). However, it is common for a discordance to be seen between the degree of structural joint damage and the level of symptoms experienced by patients with chronic OA-related pain (1). In a subset of patients with chronic OA-related pain, central sensitization has been identified as their dominant pain mechanism (7) and identification of patients in this subset can be helpful to allow clinicians to tailor their applied interventions and improve patient outcomes (10).

The purpose of this paper was to stimulate clinicians to achieve equilibrium between hands-on and hands-off interventions in patients with osteoarthritis-related pain dominated by central sensitization.

Summary:

Central sensitization (CS) in patients with OA seems to be driven by peripheral joint pathology (2), making it important to work to reduce peripheral nociceptive input and CS by finding equilibrium between hands-on treatments applied to the local site of pain and treatments aimed at addressing the sensitization aspect of the condition (most of which are ‘hands-off’) (5). This is best addressed by musculoskeletal therapists or clinicians who are in the position to deliver this individualized and combined approach to patients with chronic OA-related pain.

Although patient education is recommended in most current evidence-based guidelines for OA management, this education generally focuses on biomedical information. This approach has demonstrated limited efficacy in decreasing pain and disability (9, 11) and can also induce fear and reinforce patients’ belief in a patho-anatomical source of pain, leading (potentially) to more pain (3).

Pain Neuroscience Education:

Pain Neuroscience Education (PNE), a cognitive-based educational intervention, has been proposed as a more effective way to educate patients with chronic OA-related pain, as well as other types of chronic pain (8, 12). PNE aims to help patients reconceptualise their pain in order to desensitize the CNS and reduce pain and disability. Level A evidence supports its use for changing pain beliefs and improving health status in patients with CS pain (8).

Intregrating PNE with other treatment approaches:

Although PNE has been shown to be more effective when used in conjunction with other physical therapy interventions, there can be practical problems with combining these treatments. Clinicians used to working with the biomechanical model of pain may utilize a ‘find it and fix it’ model, which can reinforce the notion of the joint as the single cause of OA-related pain. This contradicts the PNE message, which de-emphasizes the idea of a specific tissue being the sole cause of pain. Based on current research, the authors suggest that OA patients should be educated about both the peripheral and central effects of manual therapy. Most importantly in a PNE context, joint mobilization has been shown to cause temporal activation of descending inhibitory pain mechanisms (13). This allows the manual therapist to use joint mobilization to help the patient gain movement and activate endogenous analgesic effects that have been found to be dysfunctional in chronic OA-related pain (6). OA patients also need to understand that:
  1. Central analgesic effects related to joint mobilization are short-lived;
  2. CS is unlikely to be resolved by a single modality (12); and
  3. other techniques may be required to desensitize the patient and help control their pain.
In addition, the common use of pain relief as an outcome measure for manual therapy as well as frequent references to pain during manual treatment can also create a conflict with the PNE message, which advocates functional gains over resolution of symptoms. The authors suggest replacing the use of the word ‘pain’ with less frightening terms such as ‘symptoms’ or ‘loss of function’ in order to avoid patient confusion and provide a uniform message to patients.

It is also important to consider the order of interventions when planning treatment. Logically, PNE should be applied before manual therapy. Explaining to a chronic OA patient how their pain system has become sensitized before presenting them with desensitizing techniques makes the most sense. This can also help to change how patients think about their pain, which can result in decreased fear of pain and promote better adherence to treatments such as manual therapy.

Clinicians must also consider the potential problem of cognitive and educational barriers when using PNE in some patient populations. In patients with low educational attainment or cognitive difficulty, it can be more difficult to ensure patients have understood and internalized the PNE message. Also, elderly patients may have a pre-established faith in biomedical information, making it potentially more difficult to reconceptualise their pain through PNE.

Clinical Application & Conclusions:

The PNE method has been shown to be effective in treating chronic OA-related pain, especially when used in conjunction with manual therapy. However, there may be some practical problems facing clinicians when using these methods together in clinical practice. Future research should compare the combined use of PNE and manual therapy to other current approaches (ex. medication and/or modalities) for the treatment of chronic OA-related pain.

For now, evidence-informed clinicians should continue to educate their patients on the nature of pain, concepts such as ‘hurt versus harm’, how sensitization may develop and be addressed via techniques that are complimentary to our manual and/or exercise interventions.

Study Methods:

This is a professional issue paper, so no formal study methods were outlined.

Additional References:

  1. Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC Musculoskelet Disord 2008; 9: 116.
  2. Graven-Nielsen T, Wodehouse T, Langford RM, et al. Normalization of widespread hyperesthesia and facilitated spatial summation of deep-tissue pain in knee osteoarthritis patients after knee replacement. Arthritis Rheum 2012; 64(9): 2907-2916.
  3. Greene DL, Appel AJ, Reinert SE, et al. Lumbar disc herniation: evaluation of information on the internet. Spine 2005; 30(7): 826-829.
  4. Haldeman S. North American Spine Society: Failure of the pathology model to predict back pain. Spine 1990; 15(7): 718-724.
  5. Jull G, Moore A. Hands on, hands off? The swings in musculoskeletal physiotherapy practice. Man Ther 2012; 17(3): 199-200.
  6. Kosek E, Ordeberg G. Lack of pressure pain modulation by heterotopic noxious conditioning stimulation in patients with painful osteoarthritis before, but not following, surgical pain relief. Pain 2000; 88(1): 69-78.
  7. Lluch E, Torres R, Nijs J, et al. Evidence for central sensitization in patients with osteoarthritis pain: a systematic literature review. Eur J Pain 2014; 18(10): 1367-75. doi: 10.1002/j.1532-2149.2014.499.x. Epub 2014 Apr 3.
  8. Louw A, Diener I, Butler DS, et al. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil 2011; 92(12): 2041-2056.
  9. Louw A, Diener I, Butler DS, et al. Preoperative education addressing postoperative pain in total joint arthroplasty: review of content and educational delivery methods. Physiother Theory Pract 2013; 29(3): 175-194.
  10. Malfait AM, Schnitzer TJ. Towards a mechanism-based approach to pain management in osteoarthritis. Nat Rev Rheumatol 2013; 9(11): 654-664.
  11. McDonald S, Hetrick S, Green S. Pre-operative education for hip or knee replacement. Cochrane Database Syst Rev 2004; (1):CD003526.
  12. Nijs J, Paul van Wilgen C, Van Oosterwijck J, et al. How to explain central sensitization to patients with “unexplained” chronic musculoskeletal pain: practice guidelines. Man Ther 2011; 16(5): 413-418.
  13. Schmid A, Brunner F, Wright A, et al. Paradigm shift in manual therapy? Evidence for a central nervous system component in the response to passive cervical joint mobilization. Man Ther 2008; 13(5): 387-396.