Parts 2 and 3 of this series focused on the assessment of pain sensitivity. Once the assessment is complete, we need to consider the findings.

Here we discuss the whole-person perspective, followed by making sense of pain features.

We then present a simple method for prioritising pain sensitivity in treatment planning.

The whole-person perspective

We hear the term biopsychosocial so often in relation to contemporary management of pain that it can become white noise.

However, as a clinician with a patient with increased pain sensitivity in front of you, understanding the biopsychosocial nature of that individual’s presentation is often the key to helping them make sense of their pain—and the path to increased clinical satisfaction for yourself.

There may be additional factors influencing their pain sensitivity.

Consider the following potential scenarios in relation to a person you have assessed as having increased pain sensitivity: creates a high level of helpful sensitisation to protect injured tissues.

•    they are not sleeping more than four hours per night
•    they have a habitual movement pattern that is loading the sensitive tissues in the region of their pain and they do this movement frequently
•    they have anxiety associated with a family issue
•    there are no supports at home so although their symptoms are easily aggravated by heavier housework, they continue to do it
•    they have a scan that identifies local pathology that at least partly explains their symptoms
•    they have a scan that identifies no local pathology to explain their symptoms but they strongly believe there is something wrong that has not been identified
•    they are employed in a physically demanding job for 12-hour shifts, tasked with duties beyond their certified work capacity and
with an unsupportive direct supervisor.

If you have assessed that underlying tissue pathology is not strongly contributing to a patient’s ongoing pain, then as a clinician you need to make logical sense (for yourself, the patient and their significant others) of how different biopsychosocial elements of a person’s presentation might interact to produce their pain experience and pain sensitivity.

However, this does not mean making up a story that you hope the patient will ‘buy’—it means making sense of their own story based on the clinical presentation and evidence-informed practice.

Darren Beales.

It is worth stating here that many people with persistent pain (or acute pain) want their condition considered in a holistic manner and appreciate healthcare practitioners and services that allow this to occur.

We are part of a team who wrote Musculoskeletal Clinical Translation Framework: From Knowing to Doing (click here), which is designed to assist clinicians in the application of the biopsychosocial model in clinical practice.

While it was written for musculoskeletal pain, we believe that the premise of the framework is suitable for all health disorders where pain is a feature of the presentation and certainly for those disorders managed with physiotherapy.

While it was written for musculoskeletal pain, we believe that the premise of the framework is suitable for all health disorders where pain is a feature of the presentation and certainly for those disorders managed with physiotherapy.

Pain features

Sensitivity is one element among the pain features of an individual’s presentation (see Figure 1 here). 

All pain types—nociceptive, neuropathic and nociplastic—can and do result in increased sensitisation.

In terms of pain characteristics, with a mechanical presentation the patient’s pain responses may seem proportional to any stimulus and pain levels are linked to clear aggravating and easing factors.

With non-mechanical presentations, the pain is decoupled from the stimulus and the response to stimuli is disproportionate.

There may be constant symptoms with a lack of easing factors. Widespread sensitisation might be commonly associated with non-mechanical pain presentations, but the relationship between sensitisation and non-mechanical presentation is not exclusive.

Consider an acutely sprained ankle, where the ‘chemical soup’ of the acute inflammatory response to injury creates a high level of helpful sensitisation to protect injured tissues.

Weight-bearing on the ankle is very problematic; non-weight-bearing is not so bad.

A mechanical presentation with a high level of sensitisation might be present.

Focusing on pain type might be important for the pharmacological management of pain and understanding sensitisation might be very important for informing management choices across the spectrum of physiotherapy interventions.

Reasoning specifically related to pain sensitivity

After a patient assessment, we have some idea of the level of pain sensitivity present. Table 1 here provides a framework for considering the assessment findings.

The big picture

Pain sensitivity might be expected in acute presentations where there has been tissue injury (as in the ankle sprain example).

With the right management and time, the acute inflammatory response should subside and with it the local sensitivity.

In this case, initial heightened pain sensitivity might be helpful as it is an indication that an appropriate inflammatory response is in situ.

It may ‘remind’ the injured person to take some level of care during the initial healing phase (minimising the potential for additional injury).

Perhaps we could say that pain sensitivity provides a biological advantage in this situation.

How would you consider increased pain sensitivity immediately after surgery in this light?

Tim Mitchell.

Can you think of an example where, in the acute phase of symptoms, increased pain sensitivity is unhelpful or a biological disadvantage?

In the majority of persistent pain states, when heightened pain sensitivity is encountered, is it perhaps less helpful?

Let us go to the extreme—complex regional pain syndrome, a disorder characterised by an extreme level of pain sensitivity.

It is difficult to imagine a biological advantage for the pain sensitivity associated with this disorder.

Can you think of different presentations where, for example, the presence of increased pain sensitivity in the shoulder of a person post-stroke could be either helpful or unhelpful?

Can you think of a common localised persistent pain presentation where pain sensitivity is unhelpful?

Categorisation of the sensitivity

Once the big picture has been considered, categorising the sensitivity can be a helpful process when planning management.

Management may range from patient education in protective and minor contribution categories to a focus on factors driving the sensitivity in the significant contribution category or a multimodal approach if sensitivity is felt to be the main barrier.

Examples are provided in Table 2 here. Links to case studies are provided in the Resources section below.

We find it helpful to consider the concept of pain sensitivity across a range of case examples and then reflect on its relevance to some of our own patients.

Why not make it a discussion topic among your colleagues?

Next time: In the next article in this series, we’ll discuss managing the person with a significant contribution of pain sensitivity.

Resources

Like to hear Tim and Darren casually chat about the interpretation of pain sensitivity findings? Click here.

Want to read about the biological advantage of acute pain sensitivity in squid? Click here for Price, T.J. and Dussor, G. ‘Evolution: The Advantage of “Maladaptive” Pain Plasticity.’ Current Biology, vol. 24, issue 10, 2014. 

Want to read about complex regional pain syndrome? Click here.

Looking for case studies that consider pain sensitivity? Click here for Beales et al. ‘Masterclass: A pragmatic approach to pain sensitivity in people with musculoskeletal disorders and implications for clinical management for musculoskeletal clinicians.’ Musculoskeletal Science and Practice, 2021.

Click here for Rabey, M. et al. ‘Multidimensional pain profiles in four cases of chronic non-specific axial low back pain: An examination of
the limitations of contemporary classification systems.’ Manual Therapy, vol. 20, issue 1, 2015.

Click here for the Musculoskeletal Clinical Translation Framework, 2023.

Want to know more about pain features? Click here. 

Like something short and fun? (Yes, it’s Tim and Darren again.) Click here. 

>> Darren Beales FACP is a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2008) and a director at Pain Options in Perth, WA. As a senior research fellow at Curtin University, Darren is undertaking broad research into clinical pain, from the mechanistic understanding of clinical pain to efforts to enhance the management of persistent pain and implementation of knowledge into practice.

>> Tim Mitchell FACP is a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2007) and a director of Pain Options. Tim has completed a PhD in the area of low back pain and has a special interest in the translation of logical reasoning into clinical practice. He holds positions with the Australian Physiotherapy Council and the Australian College of Physiotherapists.