One of the newer ideas that is gaining better understanding in the pain community is the concept of pain centralization. This is the general category that a lot of other pain problems fall under. The most common condition is Fibromyalgia, but other conditions such as TMJ, irritable bowel syndrome and some tension headaches are similar. The main characteristic is that the disturbance is processed differently by the brain, and a diffuse increase to pain fiber stimulation then occurs. There are an altering of levels of neurotransmitters affecting pain transmission.
The key finding in all the conditions characterized by centralized pain states is a significant increased sensitivity to sensory stimuli. Chronic pain is often found in multiple regions of the body over a period of time. Multiple other types of symptoms also occur including fatigue, sleep difficulties, mood changes and memory problems. Symptoms are often triggered by a stressful event, such as an infection, brain injury or trauma. Multiple discrete areas of pain are found, and can be present with other diseases such as rheumatoid/osteoarthritis and hyper-laxity conditions like Ehlers-Danlos or Marfans Syndromes.
These conditions are a continuum of pain problems starting from acute peripheral pain to chronic centralized diffuse pain. It affects from 2-8% of the population, and is about twice as common in females. There is a strong familial correlation and it can be worsened with stress and anxiety.
New Understanding of Centralized Pain
Research has now shown there are definite abnormalities present in these patients. Functional MRI scans have shown an increased connectivity in regions of the brain that sense pain signals and decreased activity in areas that inhibit signals. Along with this is a change in the balance of neurotransmitters, those that facilitate pain reception including Substance P, Glutamate, Serotonin, and Nerve Growth Factor are elevated. Those transmitters that inhibit pain are decreased, such as Norepinephrine and GABA.
Treatment of these conditions is difficult. Nothing works in everyone; it is a matter of using multiple strategies. Medications that have have proven effective include some antidepressants like tricyclic’s, cymbalta and cyclobenzaprine, and seizure medications like gabapentin and lyrica. Tramadol, low dose naltrexone and cannabinoids have shown modest benefits, but they aren’t typically as effective. What absolutely does not work and sometimes makes things worse are opioids. Other beneficial treatments with strong evidence include aerobics, strength training and cognitive behavioral therapy. There is little benefit from acupuncture, massage, chiropractic and manual therapy, and most injections including trigger points.
In a lot of chronic pain conditions, a common thread is emerging. There appears to be a short circuit in the brain and the volume control for pain sensitivity is turned to high. Normal signals become overly amplified in the brain and are considered painful. The normal ability of the brain to inhibit pain signals for the periphery is also decreased. The brain then becomes stuck in a state of hypersensitivity. The new directions of research is to find ways to correct the changes seen in these centralized pain states.