Patient-friendly summary
If you read nothing else
Bottom line
Manual therapy might help prevent chronic pain if used right, but needs understanding of central sensitisation.
Moderate evidenceNot everyone agrees
This paper suggests manual therapy can be effective for chronic pain but challenges the approach by emphasizing the importance of understanding central sensitisation.
Best fit for
Body regions
How it works
- 1Peripheral nociceptor stimulationInjury or damage causes pain sensors to send signals to the spinal cord.
- 2Central sensitisationThe spinal cord and brain become extra sensitive to these pain signals, amplifying the pain.
- 3Ongoing painThe sensitised central nervous system keeps the pain going even after the injury has healed.
Study Summary
Background
This paper addresses a critical gap in understanding how acute musculoskeletal injuries can progress to chronic widespread pain and fibromyalgia (FM). Despite manual therapists frequently treating patients with FM using techniques like trigger point injections and joint manipulation, there was limited theoretical framework for these approaches. The transition from localized acute pain to chronic widespread pain involves complex changes in how the central nervous system processes pain signals, but manual therapy practice hadn't fully incorporated this knowledge.
What They Did
The authors conducted an in-depth review of basic science and clinical research to develop a theoretical framework for manual therapy in patients with chronic widespread pain and FM. They examined the neurophysiology of central sensitization, where pain pathways in the spinal cord and brain become hypersensitive. The review explored three key ways manual therapy might influence pain chronicity: preventing chronicity in acute cases, treating local problems while accounting for central sensitization, and addressing inappropriate pain beliefs and behaviors.
What They Found
Central sensitization involves hyperexcitability of spinal cord neurons, malfunctioning of brain-based pain inhibitory systems, and altered sensory processing. The process can be triggered by ongoing nociceptive input from peripheral tissues and sustained by inappropriate pain beliefs, stress system dysfunction, and sensory-motor conflicts. In patients with established central sensitization, even minor injuries can perpetuate the chronic pain state. Exercise that's too vigorous or manual techniques that increase pain can worsen central sensitization.
However, appropriate interventions including pain education, gentle manual therapy below the pain threshold, stress management, and low-intensity exercise with recovery periods may help prevent or manage chronic widespread pain.
What This Means
Manual therapists need to fundamentally change their approach based on whether patients have acute pain or chronic widespread pain with central sensitization. For acute injuries, the goal is preventing chronicity by limiting ongoing nociceptive input and addressing pain beliefs early. For chronic widespread pain, therapists must work below the pain threshold to avoid triggering more sensitization. This means gentler techniques, patient education about pain neurophysiology, and carefully graded exercise programs.
Importantly, therapists who ignore these principles may actually worsen chronic pain by sustaining central sensitization processes.
Key Findings
| Finding | Detail | Impact |
|---|---|---|
| Central sensitization involves hyperexcitability of spinal cord neurons and brain dysfunction | Process includes NMDA receptor hyperexcitability, malfunctioning descending pain inhibition, and altered sensory processing | High |
| Manual therapy techniques that increase pain can worsen central sensitization | Aggressive trigger point treatments and exercise above pain threshold can sustain chronic pain | High |
| Pain neurophysiology education can improve outcomes | Education reduces catastrophizing and improves movement performance even without physical activity | High |
| Three-month timeline is critical for preventing chronicity | Tissue healing and pain recovery should occur within 3 months to prevent chronic widespread pain | Medium |
| Stress system dysfunction contributes to central sensitization | HPA axis and sympathetic nervous system deregulation found in fibromyalgia patients | Medium |
Process includes NMDA receptor hyperexcitability, malfunctioning descending pain inhibition, and altered sensory processing
Aggressive trigger point treatments and exercise above pain threshold can sustain chronic pain
Education reduces catastrophizing and improves movement performance even without physical activity
Tissue healing and pain recovery should occur within 3 months to prevent chronic widespread pain
HPA axis and sympathetic nervous system deregulation found in fibromyalgia patients
Strengths
- Comprehensive integration of pain science into clinical practice
- Clear practical guidelines for manual therapy modifications
- Addresses both prevention and treatment of chronic pain
- Incorporates biopsychosocial model of pain
Limitations
- Theoretical framework not tested in clinical trials
- Limited direct evidence for proposed manual therapy approaches
- Recommendations based on extrapolation from research
- No specific outcome measures or treatment protocols provided
Key Takeaways for Patients
What This Means for You
- 01If you have fibromyalgia or chronic widespread pain, your nervous system has become oversensitive to normal stimuli
- 02Manual therapy and exercise need to be gentler than normal - treatments that increase your pain may actually be harmful
- 03Learning about how chronic pain works in your body (pain education) can help reduce pain and improve function
- 04Early, appropriate treatment of acute injuries may help prevent them from becoming chronic pain conditions
- 05Stress management and addressing fear about movement are important parts of recovery