Chronic Pain .

Central Sensitization & Peripheral Sensitization.

Dr.Debanjan Mondal(PT), Mphil, MPT,BPT,CMT,CE.www.korecphysiocare.com
We all know about pain, its an unpleasant physical or emotional experience. International Association for the
Study of Pain (IASP) Defined pain is An unpleasant sensory & emotional experience associated with actual or
potential tissue damage or described in terms of such damage. We cant measure, we cant touch, and we cant
feel it. So each and every person has their own pain & there is no way to alternatively objectified. Each of
everyone has their own pain score in same stimulus.

TYPES OF PAIN:-Acute Pain & Chronic Pain.

Acute Pain:-Its a short term pain, it can be intense. It can be happened or indicate a injury & it
disappear after a period of time when the injury heals.
Chronic Pain:-This stay for prolonged period of time.
There is different type of clinical pain:1) Nociceptive Pain:-Its an unpleasant emotional aspect of pain with some tissue injury that means it is
associated with Inflammation. So there should be redness, tenderness, worm, swelling & Loss of
function. Nociceptive pain is also two type Somatic (Sprain) & Visceral(LBP).
Example:-Arthritis, Low Back Pain (LBP), Headache, Aches & Sprains, Cancer pain.
2) Allodynia:- Pain produce by normally non producing stimuli, because the nervous system is in a
persistent state of heightened reactivity, the sensation is registered in the brain as painful or
uncomfortable even in light touch.
3) Hyperalgesia:-hyperalgesia occur when a actual painful stimuli is perceived as a more painful that it
actually is.
(From F. Cervero study)
4) Neuropathic Pain:-Injury or damage to the nerve due to some viral attack, or injury. It comes from
within the nervous system only. Like:-Reflex Sympathetic Dystrophy or RSD, Post Herpetic
Neuralgia, Cancer Pain, Cancer Pain, Diabetic Neuropathy, Phantom Limb Pain, post stroke, spinal
cord injury are the example of it.
ANATOMY OF PAIN
Any stimulus gows through primary afferent neurone to dorsal root ganglion -To the posterior horn
of the spinal cord through second order neurons then cross to the opposite side dorsal horn (sensory),
then to ventral horn (motor) to the brain stem and thalamus. But if we look about a peripheral nerve,
it consists of small and large diameter primary afferent fibers, its all different size of nerve fibers.
1) Large Myelinated- A Fibers.
2) Small Myelinated -A Fibers
3) Unmyelinated- C Fibers.

Peripheral Sensitization:Largest one conducts very quickly, response to light touch. Small fibers are responding to painful
type of stimuli. But the small fibers can set its tissue after an injury the small diameter fibers may
respond to innocuous(Non-Painful) stimulation, so that there is an injury -they change their property,
so non painful stimulus can heart, its happen in periphery so its called Peripheral sensitization. If
there is some injury which may cause a lot of tissue damage-resulting synthesis of Arachidonic

Acid .Formation of Arachidonic Acid get tacked by a enzyme called Cyclo-oxigenase, when cyclooxigenase act with Arachidonic Acid produce Prostaglandins which act right on the nerve fiber (C
fiber) then it lowers its threshold ,now patient got Allodynia. So that nerve fiber got pain in a light
touch, it produces a lot of pain.

The problem with this type of pain is -if you take cox-2 inhibitor or any other pain killer, the question
is how this drugs know where they have to go, we took the painkiller/NSAID/Analgesic (whatever) it
gows to the digestive system then through blood it reaches all over the body, and if you have some
problem with stomach, intestine or you have ulcer, this drugs make the situation worse.

Central Sensitization:So what is the role of the large diameter fibers?

The Large diameter, myelinated afferents do not respond to noxious stimulation but, activity of large
diameter fibers can reduce the pain that results from activity in small diameter fibers.
What is Chronic Pain or persistent pain?
Chronic pain is not a prolonged acute pain, its not merely a symptom of some other chronic disease,
and chronic pain is itself a disease, a disease of the nervous system.
Key to a disease of chronic pain is Central Sensitization or pain memories .its an altered nervous system,
neurological problem, understanding it is very critical. Maladaptive memorise that create nervous system to
setting of an injury when you wind up with this memorise you got chronic pain. central sensitization is a
process when a tissue got some injury or nerve injury, it send information to the brain, after a period of time
nerve fiber changed and those memories last for long time and gets regulated in a persistent state of high
reactivity. This reactivity remained unchanged even after the injury healed. Allodynia & Hyperalggesis is a
part of central sensitivity syndromeAllodynia:- Pain produce by normally non producing stimuli, because the nervous system is in a
persistent state of heightened reactivity, the sensation is registered in the brain as painful or
uncomfortable even in light touch.
Hyperalgesia:-hyperalgesia occur when a actual painful stimuli is perceived as a more painful that it
actually is.(from-institute of chronic pain)