A systematic literature review recently showed that approximately 30% of patients with osteoarthritis have central sensitization pain, implying that their pain is dominated by central factors (i.e. the increased hyperexcitability of the central nervous system) rather than peripheral (i.e. joint) factors. The next thing you want to know is: how does this affect the treatment for patients with osteoarthritis and central sensitization pain? 

The presence of central sensitization pain in osteoarthritis may erroneously lead clinicians to conclude that hands-on interventions (manual therapy) have no place in the patients’ management, and that hands-off interventions must be applied exclusively (i.e. treatment strategies that target the brain). However, osteoarthritis is something different than for instance fibromyalgia or even whiplash associated disorders. In osteoarthritis, there is clear evidence for peripheral involvement as well, no debate about that. This implies that clinicians needs to find the balance between treating the joints and the brain. 

Therefore, Enrique Lluch and colleagues have written a paper to encourage clinicians in finding an equilibrium between hands-on and hands-off interventions capable of desensitizing the central nervous system in patients with osteoarthritis-related pain dominated by central sensitization. The theoretical rationale for simultaneous application of manual therapy and pain neuroscience education is presented. Practical problems clinicians will have to deal with when combining these interventions are addressed, including:

• Targeting the brain without ignoring the joints for treating central sensitization pain in patients with osteoarthritis;
• The problem of the “conflicting” or “contradictory” messages when communicating with your patient about osteoarthritis pain and its treatment;
• The problem of the order of interventions: should manual therapy precede pain neuroscience education or vice versa?
• The problem of cognitive and educational barriers when applying pain neuroscience education to elderly people affected by chronic osteoarthritis-related pain.

Future studies should explore the combined effects of treatment strategies aiming to desensitize the central nervous system to examine whether they increase therapeutic outcomes against current approaches for chronic osteoarthritis-related pain. Enrique Lluch is currently undertaking such a randomized controlled trial at the University of Valencia, Spain.

If you would like to read more about the treatment of osteoarthritis and how to balance biomechanics with pain neuroscience, you can access this post.

Further reading: http://www.ncbi.nlm.nih.gov/pubmed/25169787

Enrique Lluch & Jo Nijs