Pain Rehab Program Linked to Reduced Central Sensitization

Pauline Anderson

March 30, 2017

ORLANDO — Patients completing an outpatient interdisciplinary chronic pain rehabilitation program (iCPRP) at the Cleveland Clinic have significantly reduced self-reported central sensitization (CS) scores, preliminary research suggests.

The retrospective analysis assessed CS by using the recently developed central sensitization inventory (CSI).

"Essentially, we wanted to see what impact iCPRP care has on central sensitization syndromes because, to my knowledge, this has not been tested before," said Xavier Jimenez, MD, a psychiatrist at the Center for Behavioral Health, Cleveland Clinic, Ohio.

Dr Jimenez presented their research during the American Academy of Pain Medicine (AAPM) 2017 Annual Meeting.

CS is common among pain patients. It involves abnormal and intense enhancement of pain signaling in the central nervous system. It can result in pain hypersensitivity and allodynia and is believed to be involved in a multitude of conditions, including irritable bowel syndrome, fibromyalgia, temporomandibular joint disorder, migraines, and chronic low back pain.

The Cleveland iCPRP "is one of the oldest and most well-established" programs of its kind, Dr Jimenez told meeting delegates.

Patients come to the Cleveland program with a variety of comorbid conditions, including, for example, depression, anxiety, insomnia, addiction, family strife, and post-traumatic stress disorder. They are in the outpatient program for 3 to 4 weeks.

Biopsychosocial Focus

The program uses a functional restoration model that has a biopsychosocial focus. Services include medical management, detoxification from opioids and benzodiazepines, psychiatric and psychological assessments, physical therapy (for example, yoga and t'ai chi), occupational therapy, biofeedback, counseling, and family and group therapy, he noted, "so it's quite comprehensive."

Outcomes for 231 patients who went through the program were "pretty positive," according to a 2015 analysis, said Dr Jimenez. "At discharge, 93% of folks had dramatic improvement in pain disability and that was sustained at 6 months, for the most part."

Patients also had decreases in anxiety, depression, and opioid use.

The recently developed and validated self-reported CSI "captures this phenomenon of central sensitization as experienced by the patient," said Dr Jimenez. He added that higher severity on the CSI has been correlated with certain pain diagnoses and outcomes.

Part B of the CSI, which is not scored, asks patients if they have previously been diagnosed with one or more specific disorders, including seven separate CS syndromes.

But the current analysis focused on Part A of the CSI, in which patients are asked how often (never, rarely, sometimes, often, or always) they experience 25 health-related symptoms (for example, feeling tired and unrefreshed when awakening, having stiff and achy muscles, anxiety attack, grinding or clenching teeth, and problems with diarrhea and/or constipation), with total scores ranging from 0 to 100.

"I am sure as clinicians you have heard these complaints over and over," said Dr Jimenez.

The new analysis included 49 patients, with a mean age of 48.3 years. Most were female (77.1%), married (61.4%), and white (87.1%).

Their pre-iCPRP pain score was about 54.7 and their post-iCPRP score fell to 40.5 (difference of 14.2; P < .05).

Dr Jimenez explained that the score fell from about that which a patient with fibromyalgia might report to what a patient with low back pain might experience.

"That may not mean much," but even healthy persons have symptoms that manifest in elevated CSI scores, said Dr Jimenez. "The CSI captures lots of things we all experience, especially on a bad day."

Dr Jimenez stressed that "these are preliminary findings" and that patients going through the program have a lot of comorbidities. "Most often, it's the sickest of the sick who come to our clinic," he said. "This may be as good as it gets, and it seems like a good positive first finding."

It's unclear what is contributing to the change in CS, said Dr Jimenez.

"Is it that we improved their depression? Is it that they are less hypervigilant of their symptoms? Is it that something else was the active ingredient? I would argue that it's probably a mix of all of those. But the point is that we can't necessarily definitively say which component is leading to this change."

He and his colleagues aim to increase their sample size and to corroborate self-reported measures of pain, such as CSI, with objective measures through quantitative somatosensory testing. The team has already started pain threshold testing of patients in the pain rehab program, said Dr Jimenez.

After his presentation, Andrea Rubinstein, MD, Permanente Medical Group, Santa Rosa, California, wanted to know more about the program's somatosensory testing. Her own center also has a multidisciplinary pain program.

"Somatosensory testing provides objective hard data that you could use to show other than just self-reports that your program is actually changing something neurologically," she said.

Cleveland patients are identified as "good candidates" for this testing as soon as they come into the program, have their first assessment within about 48 hours, and are assessed again at discharge, said Dr Jimenez.

The assessment takes 2 to 3 hours, he added. "It's a big undertaking so you need to carve out that time."

Jordan L. Newmark, MD, pain medicine associate program director and clinical assistant professor, Division of Pain Medicine, Stanford University, California, wondered about data showing whether the benefits of the program are maintained through the months following discharge.

"It would be great to demonstrate a persistently low score as justification for insurance," he said.

Although this has not yet been documented, "we do see some sustained benefit in some areas," said Dr Jimenez. "The next step would be to see what the CSI looks like."

Dr Jimenez has disclosed no relevant financial relationship.

American Academy of Pain Medicine (AAPM) 2017 Annual Meeting. Poster 224. Presented March 17, 2017.

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