Persisting Pain and Central Sensitisation

GP PLZ sessionJune 2016

Common MSK conditions...with a twist...

• 20% of all Primary Care Consultations are MSK• 3-4 per surgery

• 60% of those Consultations will involve Persisting Pain• 2 of those seen as above

• What is ‘common’ in MSK Medicine?

Pain

MSK Pain – a new paradigm

Sensitisation

Peripheral CentralDysregulated

• Reduced sensory threshold• Tissue changes• Crossover signalling

• Psychological changes• Increased excitatory

neuropeptide signalling

• Down regulation of inhibitory pathway

FibroChronic Fatigue

Restless Legs

IBS

Irritable Bladder

Myofascial Pain

Primary Dysmenorrho

ea

Migraines

Tension Headache

s

TMJD

Central Sensitisation

State

Predisposing factorsStress

Poor Sleep

Cultural & Health Beliefs

Personality Type

Social environment

What’s the ‘cure’?

Lifestyle adaptation

Education & Reassurance

Bio

Socio

Psycho

Bio

• Identify the peripheral trigger• ‘where’s it hurt?’

• Diagnose the pathology• Sprain, tear, inflammation

• Arrange investigations• Bloods & Scans• ‘Just to be safe’

• Use of pharmaceuticals• Escalating doses• Polypharmacy• Injections

• Focus on their being ‘something wrong’• Referrals to secondary care• Second opinions

Drug options• CAN work (and dramatically so)• Careful selection• Limited trial – no response, don’t continue

• Amitriptyline/Nortriptyline• GABA analogues (promote GABA mediated inhibitory pathway)• SSRIs (Citalopram, Fluoxetine, Sertraline)• SNRIs (Venlafaxine, Duloxetine)• Tramadol (works centrally ?via GABA mediated pathways)

NSAIDs – only for short term if certain inflammatory processOpiates – limited trial, unlikely to provide benefit above key listed drugs

Bio

Injections• Need to be certain that inflammatory process is main driver• Careful selection• Can worsen symptoms – one trial only

Bio

Investigations

• May need to judiciously exclude other pathologies• RA & CTD can be the ‘great pretenders’

• Basic inflammatory & immune screen• TATT screen• Avoid MRI if possible• Very sensitive and likely to pick up incidental findings• Costly• Reinforces ‘techno-medical’ paradigm

Bio

Psycho-social approach

Need a system!

Get the buy-in(most time intensive)

Transfer responsibility

Guide towards goals

• Screen carefully• Education• Score systems• Appropriate support• Confidence

• Graded exercise• Hobbies &

distractions• Mindfulness but

not autofocused

• Persisting Pain is an experience generated by a dysregulated nervous system• It can manifest regionally or globally• Some people are pre-prepared for this dysregulation• Cycle of persistence is driven by newly learned pathways, fed by ongoing experience• Once biological harm is excluded then approach must be towards relearning pathways• Need to retrain the brain to re-regulate the nervous system• Only person who can do this is the patient, supported by social network• Thus the patient has to come to accept the process and take ownership• Role of the GP is to do judicious screen, identify the process and point the patient in the

right direction• Best evidence supports:

• Activity (graded according to ability)• Hobbies and distractions• Education and acceptance of the process• Mindfulness and CBT techniques

Questions?