Anxiety and central sensitisation (CS) but without CS pain?   January 1st, 2015

This is short case study with observations from the clinic which may raise interesting research questions. 

A 50 year old female attended for physiotherapy for left sided low back pain of rapid onset over the previous 10-14 days. She attributed the cause to a recent increase in weekly driving distances and in personal stress levels. Her concern was that she had become limited in her walking capacity due to back pain and she felt she needed to walk for 40 minutes daily for mental wellbeing. She was displaying some distress and was complaining of concurrent difficulty in coping with hormonal changes. She reported that she had not been experiencing pain prior to this episode except some tension discomfort in her neck and shoulders and sometimes in her jaw. However these had not caused her any concern.

It was possible from her history that she may have been experiencing some central sensitisation (CS) pain. Her score on the Central Sensitisation Inventory (Mayer et al. 2012Neblett et al. 2013) was 51, where a score of 40+ indicates a likelihood of CS pain. 
However, on physical examination, her left sided back and buttock pain presented with "mechanical" characteristics and was indicative of a nociceptive pain mechanism. There was no evidence of allodynia nor hyperalgaesia on palpation nor during movements. 
Further questioning revealed a long history of anxiety and significant childhood trauma. She reported poor sleep patterns, sensitivity to caffeine and wheat, fatigue, poor concentration and many of the items listed on the CSI. However her pain did not present as that of predominantly the CS pain mechanism. She scored 61 on the Trait Anxiety Inventory (where 40+ indicates high trait anxiety). 
Two treatments with manual therapy resolved her back pain and she returned to daily walking unhindered.

It seems she presented with nociceptive pain, and many of the general symptoms associated with CS pain but without the CS pain itself. It raises the observations that anxiety appears to significantly overlap with CS in its symptomology, that the central sensitivity syndromes (as described by Yunus 2008 and identified by the CSI) may exist in the absence of CS pain and that high trait anxiety may play a role in the aetiology of CS. 

Jacqui Clark  

2015 Pain in Motion

References and further reading: 

Mayer, T. G., Neblett, R., Cohen, H., Howard, K. J., Choi, Y. H., Williams, M. J., Perez, Y. and Gatchel, R. J. (2012) 'The Development and Psychometric Validation of the Central Sensitization Inventory.' Pain Practice, 12(4) pp. 276-285.

Neblett, R., Cohen, H., Choi, Y., Hartzell, M. M., Williams, M., Mayer, T. G. and Gatchel, R. J. (2013) 'The Central Sensitization Inventory (CSI): Establishing Clinically Significant Values for Identifying Central Sensitivity Syndromes in an Outpatient Chronic Pain Sample.' The Journal of Pain, 14(5), 5//, pp. 438-445.

Yunus, M. B. (2008) 'Central Sensitivity Syndromes: A New Paradigm and Group Nosology for Fibromyalgia and Overlapping Conditions, and the Related Issue of Disease versus Illness.' Seminars in Arthritis and Rheumatism, 37(6), 6//, pp. 339-352.