By January 24, 2013 Read More →

Classification of Central Sensitisation, Nociceptive Pain and Peripheral Neuropathic Pain

Keith Smart and colleagues have published a number of articles, over the past year or two, in relation to classification of Central Sensitisation, Nociceptive Pain and Peripheral Neuropathic Pain.

I think their findings are very useful in the clinical setting to guide us in our decision making.

Recent articles ,published in Manual Therapy in 2012,  identified the following signs/symptoms predictive of:

Central Sensitisation:

  • Disproportionate, non-mechanical, unpredictable pattern of pain provocation in response to multiple/non-specific aggravating/easing factors.
  • Pain disproportionate to the nature and extent of injury or pathology.
  • Strong association with maladaptive psychosocial factors (e.g. negative emotions, poor self-efficacy, maladaptive beliefs and pain behaviours).
  • Diffuse/non-anatomic areas of pain/tenderness on palpation.
  • This cluster was found to have high levels of classification accuracy (sensitivity 91.8%, 95% confidence interval (CI): 84.5-96.4; specificity 97.7%, 95% CI: 95.6-99.0).

Peripheral Neuropathic Pain:

  • Pain referred in a dermatomal or cutaneous distribution.
  • History of nerve injury, pathology or mechanical compromise.
  • Pain/symptom provocation with mechanical/movement tests (e.g. Active/Passive, Neurodynamic) that move/load/compress neural tissue.
  • This cluster was found to have high levels of classification accuracy (sensitivity 86.3%, 95% CI: 78.0-92.3; specificity 96.0%, 95% CI: 93.4-97.8; diagnostic odds ratio 150.9, 95% CI: 69.4-328.1).

Nociceptive Pain:

  • Pain localised to the area of injury/dysfunction.
  • Clear, proportionate mechanical/anatomical nature to aggravating and easing factors.
  • Usually intermittent and sharp with movement/mechanical provocation
  • May be a more constant dull ache or throb at rest.
  • Absence of:
    • Pain in association with other dysesthesias.
    • Night pain/disturbed sleep.
    • Antalgic postures/movement patterns.
    • Pain variously described as burning, shooting, sharp or electric-shock-like.
  • This cluster was found to have high levels of classification accuracy (sensitivity 90.9%, 95% CI: 86.6-94.1; specificity 91.0%, 95% CI: 86.1-94.6).

Please see the references for more information.

References:

Smart KM, Blake C, Staines A, Thacker M, Doody C.  Mechanisms-based classifications of musculoskeletal pain: part 1 of 3: symptoms and signs of central sensitisation in patients with low back (± leg) pain. Man Ther. 2012 Aug;17(4):336-44.

Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classifications of musculoskeletal pain: part 2 of 3: symptoms and signs of peripheral neuropathic pain in patients with low back (± leg) pain. Man Ther. 2012 Aug;17(4):345-51.

Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classifications of musculoskeletal pain: part 3 of 3: symptoms and signs of nociceptive pain in patients with low back (± leg) pain. Man Ther. 2012 Aug;17(4):352-7.

Posted in: Clinical Reasoning, Pain

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Sessional Academic at Curtin University. The views expressed on this blog are his own.

5 Comments on "Classification of Central Sensitisation, Nociceptive Pain and Peripheral Neuropathic Pain"

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  1. Bharath says:
    November 22, 2013 at 6:23 am

    Mark, isnt burning, shooting, electric pain manifestation also a part of central sensitisation? Does this mean a proportionate or rather specific to the injury involved in nociceptive natured unlike the central sensitisation where it is disproportionate? So the symptoms can be same but the manifestation differs right?

  2. Bharath says:
    November 22, 2013 at 6:33 am

    The reason i asked the above question is beause the nerve too undergoes changes (AIG? those nodes that are formed which starts sending danger signals. cant remember the exact name of it)and these keep firing like a peripheral neuropathic pain (PNP). In this case wont it be more of a peripheral neuropathic pain or say central sensitisation-CS (well offcourse with other symptoms mentioned under CS.
    How can we then classify a shooting, burning as nociceptive pain??
    Thanks mate.

  3. Mark Gibson says:
    November 22, 2013 at 11:30 am

    Hi Bharath,

    Thanks for the comments. I hope this will answer the questions above:

    1. The first issue I have with Smart et al’s classification is that when you look into the science of pain we typically have only Nociceptive, Inflammatory and Pathological (Neuropathic and Dysfunctional) described as the types of pain. Central Sensitisation (and Peripheral Sensitisation) are classified as mechanisms of the above listed pains. So I don’t like that CS is classified as a type of pain by Smart et al. Having said that I don’t disagree with their criteria for it.

    2. Central Sensitisation is a common mechanism associated with neuropathic pain. Hence, many of the symptoms of neuropathic pain would be the same as those with central sensitisation.

    3. Smart et al’s classification of nociceptive pain uses wording that confused me for a while and I thought that they were describing nociceptive pain as having burning, shooting, sharp or electric-shock-like qualities. That was until it finally occurred to me that they had listed those criteria under the heading of “absence of” (see the post above). i.e. the patient with nociceptive pain should have an “absence of pain variously described as burning, shooting, sharp or electric-shock-like” qualities. You are correct that those symptoms are much more characteristic of neuropathic pain/central sensitisation. For example if you look at the DN4 Questionnaire for Neuropathic pain (google search should turn up a free PDF if you don’t have a copy) you will see that the subjective qualities of Neuropathic pain based on this questionnaire are symptoms such as: Numbness, pins and needles, tingling, burning, electric shock like etc.

    I reckon I probably need to adjust the post to point that out. As I said it had me perplexed for a good few months!

    I hope this helps clarify your questions. If not let me know.

    Thanks for participating and following the blog.

    Cheers
    Mark