Recognitionofcentralsensitizationinpatientswithmusculoskeletalpain:Applicationofpainneurophysiologyinmanualtherapypractice

Chronic musculoskeletal pain affects millions of people worldwide, yet many patients do not respond to conventional treatments targeting local tissue pathology. One major reason is that their pain may be driven by central sensitization — a state where the central nervous system becomes hyperresponsive to various stimuli. Central sensitization is known to occur in conditions such as fibromyalgia, chronic whiplash-associated disorders, chronic low back pain, and temporomandibular disorders. However, many manual therapists lack clear guidance on how to recognize this phenomenon in everyday clinical practice.

Without recognition, patients may receive inappropriate treatments that could worsen their condition. This paper addresses the critical need for practical, mechanism-based clinical guidelines to help manual therapists identify central sensitization in patients with musculoskeletal pain.

The authors, experts in pain neurophysiology and manual therapy, developed clinical guidelines for recognizing central sensitization based on existing scientific literature. They synthesized evidence from original research studies examining signs and symptoms associated with established measures of central sensitization in various musculoskeletal pain conditions. The guidelines are organized around four main sources of clinical information: (1) the medical diagnosis, (2) patient history, (3) physical examination, and (4) analysis of treatment response. For the medical diagnosis, they compiled a table of conditions where central sensitization is either characteristic or present in a subgroup.

For history taking, they identified symptoms suggestive of generalized hypersensitivity, including sensitivity to bright light, sound, touch, temperature, and mechanical pressure. For clinical examination, they described tests to distinguish primary hyperalgesia (local tissue sensitivity) from secondary hyperalgesia and generalized central sensitization, including pressure pain threshold testing at remote sites, sensitivity to touch, vibration, heat, and cold, as well as exercise-induced pain threshold changes. They also included the brachial plexus provocation test and assessment of joint end feel. Finally, they discussed how treatment response — including symptom aggravation, expansion of symptoms to remote sites, post-exertional malaise, and decreased pain thresholds during hands-on treatment — can indicate central sensitization.

The authors found that central sensitization is frequently present in various chronic musculoskeletal pain disorders, though it is not universally present in all cases of any given diagnosis. They identified that a pressure pain threshold below 4 kg/cm² can indicate increased sensitivity to pressure. They noted that in healthy individuals, pain thresholds increase during and for up to 30 minutes after exercise due to endogenous opioid release and activation of anti-nociceptive pathways, but in certain chronic pain populations, these mechanisms fail to respond appropriately. Specifically, they cited that a bilateral loss of elbow extension ≥30° during brachial plexus provocation testing, combined with moderate pain reports, might indicate central hyperexcitability in post-whiplash patients.

They found that patients with both widespread cold and mechanical hyperalgesia showed least improvement in physical rehabilitation for chronic whiplash. They also identified that 20–35% of patients with rheumatoid arthritis fulfill diagnostic criteria for fibromyalgia. The authors emphasized that no single sign or symptom is diagnostic of central sensitization; rather, clinicians should look for consistent patterns across multiple domains.

These guidelines provide manual therapists with a practical framework for recognizing central sensitization in clinical practice. This has important implications for treatment selection and intensity. When central sensitization is present, aggressive manual therapy techniques such as high-velocity joint manipulation or forceful myofascial treatment like ischemic compression may worsen symptoms. Instead, therapists should consider more gentle approaches and focus on gradually increasing the patient's load tolerance without overwhelming their nervous system.

The recognition of central sensitization can help explain why some patients fail to respond to conventional treatments and may reduce the risk of iatrogenic harm from overly aggressive interventions. For patients, this means their pain is being taken seriously as a real nervous system phenomenon rather than dismissed as purely psychological or imaginary. However, the authors note that these guidelines require large-scale testing in clinical populations to develop clear diagnostic decision trees. The framework represents an important step toward integrating pain neuroscience into everyday manual therapy practice, potentially improving outcomes for a substantial subgroup of patients with chronic musculoskeletal pain.