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Masterclass: A pragmatic approach to pain sensitivity in people with musculoskeletal

disorders and implications for clinical management for musculoskeletal clinicians

Darren Beales, Tim Mitchell, Niamh Moloney, Martin Rabey, Wendy Ng, Trudy
Rebbeck

PII: S2468-7812(20)30423-9
DOI: https://doi.org/10.1016/j.msksp.2020.102221
Reference: MSKSP 102221

To appear in: Musculoskeletal Science and Practice

Received Date: 9 June 2020

Revised Date: 29 June 2020
Accepted Date: 4 July 2020

Please cite this article as: Beales, D., Mitchell, T., Moloney, N., Rabey, M., Ng, W., Rebbeck, T.,
Masterclass: A pragmatic approach to pain sensitivity in people with musculoskeletal disorders and
implications for clinical management for musculoskeletal clinicians, Musculoskeletal Science and
Practice (2020), doi: https://doi.org/10.1016/j.msksp.2020.102221.

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Masterclass: A pragmatic approach to pain sensitivity in people with
musculoskeletal disorders and implications for clinical management
for musculoskeletal clinicians

Darren Beales a,b

Tim Mitchell a,b

Niamh Moloney c,d

Martin Rabey a,d

Wendy Ng a

Trudy Rebbeck e

a
School of Physiotherapy and Exercise Science, Curtin University. GPO Box U1987, Perth,

Western Australia, Australia, 6845

b
Pain Options, 7 Hardy Street, South Perth, Western Australia, Australia, 6151
c
Faculty of Medicine, Health and Human Sciences, Macquarie University, 75 Talavera Road,

NSW 2113, Australia.

d
Thrive Physiotherapy, 66 Grande Rue, St. Martin, Guernsey, GY4 6LQ
e
, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney,

C43A Cumberland Campus, New South Wales 2006, Australia

1
Corresponding Author

Dr Darren Beales. School of Physiotherapy and Exercise Science, Curtin University. GPO Box
U1987, Perth, Western Australia, Australia, 6845. Tel.: +61 89266 4644 E-mail address:
D.Beales@curtin.edu.au

Declaration of Interest

DB, TM, NM, MR and TR all run professional development courses on musculoskeletal pain and
pain sensitivity.

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Author background and experience in the topic area

Darren Beales
As a Specialist Musculoskeletal Physiotherapist, Darren spends a lot of time with people with
persistent pain. He interacts extensively with their management team to try and facilitate a
consistent understanding and approach to management. As a Senior Research Fellow at Curtin
University, Darren’s interest is clinical pain. His research in this area is broad, covering
mechanistic understanding of clinical pain through to efforts to enhance the management of
persistent pain and implementation of knowledge into practice. Darren has multiple
publications related to pain sensitivity. With his co-authors he has presented the conceptual
framework described in this Masterclass at multiple national conferences in Australia and in
workshops for physiotherapist and non-physiotherapist in multiple jurisdictions.

Tim Mitchell
Tim is a Specialist Musculoskeletal Physiotherapist who works clinically both managing and
providing second opinions on people with more complicated and persistent musculoskeletal
pain problems. He has taught extensively on post-graduate musculoskeletal physiotherapy
programs and is also involved in reviewing physiotherapy curricula in Australia. Tim’s key area
of research and teaching interest is in translating musculoskeletal pain knowledge into logical
clinical practice. He is the lead author on the eBook; ‘Musculoskeletal Clinical Translation
Framework: From Knowing to Doing’.

Niamh Moloney
Niamh is a Specialist Musculoskeletal Physiotherapist (SMISCP) who specializes in persistent
pain. Her PhD and subsequent research has focused on assessment of pain and sensory profiles
in a number of musculoskeletal conditions, how this correlates with pain and disability and
whether it influences physiotherapy treatment. Niamh has numerous publications in this field,
including an invited book chapter and invited editorial and has presented this research at

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national and international conferences. She currently splits her time between private practice,
teaching pain-related clinical education across Europe and conducting pain-related research.

Martin Rabey
Martin is a Specialist Musculoskeletal Physiotherapist and Fellow of the Australian College of
Physiotherapists. Having completed his PhD at Curtin University examining multidimensional
sub-grouping in persistent back pain he undertook a short post-doctoral role at Neuroscience
Research Australia, before heading home to Guernsey. There he splits his time between private
practice, providing pain-related clinical education across Europe and ongoing pain research
examining the assessment and management of multidimensional factors (movement, lifestyle,
psychological, general health etc.) that influence persistent pain.

Wendy Ng
Wendy is a musculoskeletal physiotherapist who currently works in private practice in
Singapore and is a current PhD candidate at Curtin University. The primary area of her research
is improving the translation of evidence for the management of pain into clinical practice. Her
research focuses on driving the clinical behaviors of physiotherapists towards adopting a
biopsychosocial approach in musculoskeletal pain care.

Trudy Rebbeck
Trudy is a Specialist Musculoskeletal Physiotherapist (FACP) with an area of clinical expertise in
the management of upper cervical spine disorders. In addition, Trudy is an Associate Professor
and NHMRC Research Fellow at the University of Sydney. She leads a programme of research in
implementing clinical pathways for musculoskeletal conditions and in investigating headache
and pain mechanisms. Of 50 peer reviewed publications, many are focused on the clinical
assessment of pain sensitivity and the ability to translate this into clinical practice. She has been
an invited speaker at many national and international conferences and workshops in this area.

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Abstract

INTRODUCTION

Research on musculoskeletal disorders indicates that pain sensitivity can be an important

consideration for musculoskeletal clinicians in the holistic view of a patient presentation.
However, diversity in research findings in this field can make this a difficult concept for
clinicians to navigate. Limited integration of the concept of pain sensitivity into clinical practice
for musculoskeletal clinicians has been noted.

PURPOSE

The purpose of this masterclass is to provide a framework for the consideration of pain
sensitivity as a contributing factor in the presentation of people with musculoskeletal pain. It
provides pragmatic synthesis of the literature related to pain sensitivity through a lens of how
this information can inform clinical practice for musculoskeletal clinicians. Guidance is provided
in a ‘how to’ format for integration of this knowledge into the clinical encounter to facilitate
personalised care.

IMPLICATIONS

The relationship of pain sensitivity with pain and disability is not clear or linear. The real
importance of pain sensitivity in a clinical presentation may be: (1) the potential for pain
sensitivity to modify the effect of common treatments utilised by musculoskeletal clinicians, or
(2) the effect of pain sensitivity on the prognosis/course of a disorder. Screening tools and
subjective features have been highlighted to indicate when physical assessment of pain
sensitivity should be prioritised in the physical examination. A pragmatic blueprint for specific
assessment related to pain sensitivity has been outlined. A framework for integrating
assessment findings into clinical reasoning to formulate management plans for the pain
sensitive patient is provided.

1
Key Words

musculoskeletal; pain; sensitivity; clinical practice

Funding

This research did not receive any specific grant from funding agencies in the public, commercial,
or not-for-profit sectors.
TR is funded by an NHMRC Career Development Fellowship.

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Introduction

This masterclass provides a framework for consideration of pain sensitivity as a contributing

factor in presentations of people with musculoskeletal (MSK) pain. It is presented in a ‘how to’
format to assist integration of pain sensitivity knowledge into clinical practice to facilitate
personalised care. Pain sensitivity in the clinical context can be considered as a term used to
encompass the phenomena that some peoples’ experience and perception of pain is enhanced
beyond that of others (Table 1).

MSK clinicians will understand some patients are more pain sensitive than others, even patients
with the same diagnosis. Quantitative sensory testing (QST) has been utilised in pain research
to investigate potential underlying pain mechanisms via a range of somatosensory stimuli.
There is growing interest in using this assessment for people with MSK pain clinically, which is
termed clinical sensory testing (CST) (Zhu et al. , 2019). What follows is a pragmatic approach to
clinical application of contemporary knowledge of pain sensitivity for MSK clinicians. It
emphasizes ‘knowing and doing’ to supplement clinical reasoning. This paper should be viewed
within the broader context of triage (red flags), assessment, clinical reasoning and management
for MSK disorders (Mitchell et al. , 2017;Rabey et al. , 2017a;Tousignant-Laflamme et al. ,
2017;Walton and Elliott, 2018). For MSK clinicians, CST assessment should be considered one
element of the overall clinical consideration of pain sensitivity (see Online Supplementary Case
Study).

Use of terminology around pain sensitivity is highly divergent adding to confusion in clinical
implementation (Zusman, 2012). Conflicting language also creates confusion for individuals
with MSK pain. Table 1 provides a glossary of terminology as applied in this paper. It is
recommended the reader be familiar with this at the outset. Full explanation of the concepts in
the glossary is beyond the scope of this paper. The reader is referred to contemporary pain
literature for review of these concepts (eg (Beales et al. , 2016;Brodal, 2017;Chimenti et al. ,

3
2018;International Association for the Study of Pain, 2020;Kuner and Flor, 2017;Nijs et al. ,
2015)). Further, the historical roots of pain sensitivity are acknowledged in the concept
‘irritability’ (Maitland, 1977;Zusman, 1998).

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Why should MSK clinicians consider pain sensitivity?

While acknowledging diversity in the research literature, there are reasons to consider pain
sensitivity in MSK pain presentations.

1. Assessing likely response to treatment: Perhaps most importantly for MSK clinicians, pain
sensitivity may alter a patients’ response to interventions (be a treatment effect modifier). For
example, pain sensitivity has a negative effect on outcomes of lumbar surgery (Kim et al. ,
2015a), knee surgery (Kim et al. , 2015c;Petersen et al. , 2015), guideline-based physiotherapy
management for knee osteoarthritis (O'Leary et al. , 2018) and chronic whiplash (Jull et al. ,
2007). However, in a systematic review, there was insufficient evidence to support an
independent relationship between pain sensitivity and treatment outcome (O'Leary et al. ,
2017). While further research is warranted, it is our assertion that people with higher levels of
pain sensitivity very likely respond differently to interventions commonly used by MSK clinicians
(See Online Supplementary Case Study).

2. Helping patients with increased pain sensitivity understand their condition: The utility of
understanding pain sensitivity as a contributing factor may be to help explain to patients why
they are in pain beyond expected tissue healing times (if there was an injury in the first place),
why they are in pain in the absence of any clear injury or overuse mechanism, or why their pain
persists, even following unsuccessful treatments (surgery, injections, medication, manual
therapy, exercise) directed at pathology (see Online Supplementary Case Study).

3. Providing insight into prognosis: Another reason for considering pain sensitivity could be to
explore prognosis (Georgopoulos et al. , 2019;Treede, 2019). This has been demonstrated in
acute whiplash disorders, where heightened sensitivity to cold stimulus has been associated
with delayed/poorer recovery (Goldsmith et al. , 2012). However, it must be recognised that
this is not necessarily the same for all acute injuries (Marcuzzi et al. , 2015), and prognostic

5
modeling of MSK pain in general highlights that prognostic factors are biopsychosocial in
nature. It is not clear that QST findings are prognostic for chronic MSK complaints in the same
way they might be for acute presentations (Moloney et al. , 2018;Rabey et al. , 2015b).

CLINICAL IMPLICATION: The potential treatment modifying, educative and predictive effects of
pain sensitivity related to MSK therapy are likely to be relevant for some people with MSK pain.
This provides reason for MSK clinicians to consider pain sensitivity in their clients. How this
might influence assessment and treatment decision-making is discussed below (also see Online
Supplementary Case Study).

4. Sub-grouping based on pain sensitivity profiling to facilitate recognition of pain sensitivity

at an individual level: Sub-grouping people with pain based on their QST profiles has been
demonstrated (eg (Arendt-Nielsen et al. , 2018;Lluch et al. , 2017;Nijs et al. , 2014;Rabey, Slater,
2015b;Smart et al. , 2012;Vaegter and Graven-Nielsen, 2016;Zusman, 2012), though this can be
performed in pain-free individuals as well (Hastie et al. , 2005). The clinical utility of sub-groups
has not been fully explored and requires further investigation. Sub-grouping can be performed,
but what does this lead to? We contend that awareness of these sub-grouping systems can
facilitate recognition of the spectrum of pain sensitivity presentations seen clinically, and
facilitate consideration of the impact of pain sensitivity at an individual level. Akin to sub-
grouping, pain sensitivity findings are integral to determining pain types
(nociceptive/neuropathic/nociplastic; see Table 1) which may facilitate targeted management,
however, criteria for delineating nociceptive and nociplastic pain types are currently lacking.

CLINICAL IMPLICATION: There is acknowledged complexity in the understanding of pain

sensitivity profiles of people with pain (Moloney et al. , 2016). Table 2 presents caveats that are
important for understanding the concept of pain sensitivity for MSK clinicians.

6
Questionnaire based screening for pain sensitivity.

Questionnaires have been developed to assist identification of pain sensitivity (eg Central
Sensitisation Inventory (Mayer et al. , 2012), Pain Sensitivity Questionnaire (Ruscheweyh et al. ,
2009)) (Table 3). These tools have reasonable psychometric properties for the conditions they
were validated in. Additionally, questionnaires exist for the identification of neuropathic pain
(eg Pain Detect (Freynhagen et al. , 2006), DN4 Neuropathic Pain Diagnostic Questionnaire
(Bouhassira et al. , 2005), Leeds Assessment of Neuropathic Symptoms and Signs (LANSS)
(Bennett, 2001). A person with high pain sensitivity but not true neuropathic pain (Table 1)
might also score highly on these neuropathic pain questionnaires. From a pragmatic
perspective, this is not a reason not to use them. Rather, it is a reminder that the results of the
questionnaires are best interpreted in relation to the entire assessment. These are readily
available online.

CLINICAL IMPLICATION: Use of these questionnaires may help prioritise elements of the
assessment, or assist clinical reasoning processes to decide the presence and contribution of
pain sensitivity in a person’s presentation. The questionnaires may be useful to communicate
and justify pain sensitivity to other healthcare practitioners (or others who may not have a
medical background such as insurance claims managers). For example, providing a Central
Sensitisation Inventory score, along with its interpretation in relation to cut-off values (Table 3),
may hold more weight than simply stating a person has pain sensitivity. These questionnaires
can also serve as an educational tool for patients to provide validation for ‘strange’ sensations
they have been experiencing, acknowledging such sensations are recognised and experienced
by others, and are important to consider (see Online Supplementary Case Study).

The patient interview and history through a pain sensitivity lens

7
The content of Table 4 aims to deconstruct the patient interview so MSK clinicians can make a
clinical decision on the likelihood that pain sensitivity should be LESS or MORE of a priority in
the physical examination (and overall presentation). While there are two columns in Table 4
attempting to address specific elements of the patient interview and history, it would be a
superficial, overly reductionist view to think that responses can be dichotomised.

CLINICAL IMPLICATION: It is important to let the person with MSK pain tell their story (Larivaara
et al. , 2001;Smith and Hoppe, 1991) in a non-judgmental fashion. More specific/direct
questioning can follow to further clarify if features of the presentation align to the presence of
pain sensitivity (Table 4). In general, this might include hints of disproportionate responses to
activities, the presence of allodynia and or hyperalgesia, and feelings that pain is unpredictable
in nature (see Online Supplementary Case Study).

CLINICAL IMPLICATION: Some people may have been through unhelpful interactions with
biomedically oriented healthcare professionals who do not have a contemporary understanding
of pain science. As a result, they may feel threatened or have difficulty forging trust. Listening in
the first instance helps break down potential barriers.

CLINICAL IMPLICATION: Some people may not provide full details on their symptomatology if it
has been previously dealt with in a dismissive way, or if their experience seems strange to
them, they may not share it for fear of a dismissive listener. Or they may not yet be aware that
prior events, symptoms or past medical history has relevance to their current pain
presentation. Inquisitive questioning, providing validation and being empathic can facilitate
disclosure and assist people with musculoskeletal pain to achieve an understanding of their
condition. This is not necessary for all people, but should be utilized for those with more
complicated stories that emerge during the patient interview and history.

8
Of note, the information provided in Table 4 aligns to a previous consensus statement
(formulated using consensus building methodology) from 103 pain consultants and MSK
physiotherapists (Smart et al. , 2010). However, that consensus statement was formed around
the constructs of nociceptive pain mechanisms, peripheral neuropathic pain mechanisms and
central pain mechanisms, not the broader topic of pain sensitivity considered here (Table 1).

9
Focusing on pain sensitivity in the physical examination

The focus here is on CST related to pain sensitivity, however, it must be considered within the
broader physical examination during which features of pain sensitivity may be noted. For
example, allodynia or disproportionate responses may be observed during palpation, specific
orthopaedic tests/pain provocation tests or movement assessment.

Where does CST fit?

MSK clinicians may not be sure where CST fits within the physical examination. In a time-limited
clinical encounter there is a need to prioritise elements of the physical examination, and
knowing where to start is challenging. The old adage of “it depends on the patient” is
applicable, but the following may offer guidance.
1) If there is subjective indication of specific neurological compromise (eg radiculopathy), then
triage of neurological conduction is a reasonable place to start the physical examination.
Focusing on CST should not be the initial priority.
2) If the subjective examination suggests a mechanical presentation but the source of the
symptoms is unclear, a pertinent place to start may be with structurally-orientated pain
provocation testing to identify (as much as possible) the source of symptoms (or perhaps the
symptomatic level(s) in spinal pain). Focusing on CST should not be the initial priority.
3) If the subjective examination suggests a mechanical presentation and the source of the
symptoms is clear and/or not a priority, then functional testing can be a useful place to start.
Focusing on CST should not be the initial priority.
4) If the subjective assessment suggests a situation where pain sensitivity is MORE of a feature
as a potential contributing factor (Table 3) and/or there is a dominantly non-mechanical
presentation, focusing on CST at the outset of the physical examination is a useful strategy (see
Online Supplementary Case Study).

CLINICAL IMPLICATION: Pain sensitivity has significant potential to influence interpretation of

other elements of the physical examination. For example, if a person with knee pain is highly

10
sensitised with allodynia/hyperalgesia, interpretation of orthopaedic tests in relation to specific
tissues may not be possible (all tests appear positive due to the allodynia/hyperalgesia, not
necessarily due to pathology). Thus, in these situations, understanding the level of sensitivity
before performing other elements of the physical examination is useful (see Online
Supplementary Case Study).

General considerations in CST

RESPONSE TYPES: Sensory testing has long been a standard element of MSK examination,
specifically related to identification of peripheral nerve conduction disturbance. This generally
focuses on identifying areas of reduced sensitivity (sensory loss). MSK clinicians would be
familiar with this.

With CST, the focus is on changes in somatosensory perception, but more frequently
heightened responses (sensory gain) are observed. Allodynia, hyperalgesia and temporal
summation might be recognised as markers of heightened pain sensitivity, and are an obvious
outcome of this assessment when present. However, sensory loss could occur as a result of
altered sensory processing (Baron et al. , 2012) (not just with peripheral conduction loss) and
might be equally important to consider as sensory gain. Further complicating matters, it must
be acknowledged that a person may exhibit mixed sensory gain and loss to different stimuli
(Moloney et al. , 2015;Tampin et al. , 2012), or the same stimuli in different test regions. We
retain the focus on heightened responses to CST here, as this is arguably a more common
occurrence (see Online Supplementary Case Study).

RESPONSE LOCATION: Testing may reveal localised areas of altered response. For example, this
video (Online Supplementary Web Links- https://www.youtube.com/watch?v=MEGdtmMRwaI)
shows a person with a normal response to light touch with a 4g Von Frey fibre on one side of
their lower back, and a significant muscle response on the other (with report of allodynia). Or,
testing may result in a finding of more widespread sensory changes. Another response to
observe for is spread of symptoms away from the area where the stimulus is applied. An

11
example may be the provocation of symptoms in the lower extremity with cold applied to the
lower back.

Application of CST

What follows is a pragmatic approach to CST related to pain sensitivity for MSK clinicians. It is
not an exhaustive protocol. The Standardized Evaluation of Pain protocol fills that niche (Scholz
et al. , 2009) but is more time consuming. What follows can be included in the physical
examination in a time-efficient manner, with minimal adjunct equipment, and is within the skill-
set and competency of MSK clinicians. Further work is emerging in the literature comparing CST
with QST (Maxwell and Sterling, 2013;Rebbeck et al. , 2015;Zhu, Bottger, 2019), where
information related to the criterion validity of CST can be found.

Table 5 provides direction on four tests related to pain sensitivity that can be readily integrated
into clinical practice and provide MSK clinicians with a good understanding of pain sensitivity.
(See Online Supplementary Web Links for video links to all tests.)
1) Light touch sensitivity assessed with a nylon monofilament (2-4g)/tissue/brush (for
allodynia).
2) Sharp sensitivity assessed with a toothpick/pin (for sharp hyperalgesia).
3) Deep pressure sensitivity assessed with digital pressure applied by the clinician in a light to
moderate to firm manner. Fair correlation between this assessment and use of a pressure
algometer has been established (Rebbeck, Moloney, 2015) (for deep pressure hyperalgesia, but
allodynia may also occur).
4) Cold sensitivity assessed with an ice cube. Fair to moderate correlations have been
established between this assessment and use of a thermal sensory testing unit (Maxwell and
Sterling, 2013;Rebbeck, Moloney, 2015).
NOTE: Temporal summation can be assessed with the above tests. For example, an escalating
pain response may be revealed with repeated tapping with a monofilament or a toothpick.

12
It is the authors’ experience that these tests can provide MSK clinicians with an understanding
of a person’s sensory profile and pain sensitivity. It is not exhaustive. Other tests may be
dictated by a person’s subjective complaint. For example, if a person reports heat hyperalgesia,
testing the response to heat application may be useful. Or if the focus is on understanding
response to exercise from a pain sensitivity perspective, then exercise induced hypoalgesia
(Rice et al. , 2019) testing can be performed.

Test order should minimise symptom escalation; the outlined recommended order minimises
this. Testing typically starts in a remote body region, moving to the unaffected side, and then
the affected side. For spinal problems where side-to-side comparison may not be relevant, a
remote area could be used for comparison. When interpreting the results of CST, MSK clinicians
should consider obvious side to side differences and/or responses clearly outside of the normal
(eg disproportionate). Subtle changes are likely to be less relevant (see Online Supplementary
Case Study).

CST as a patient education tool

While education is a critical management strategy (see below), it is worth noting that thorough
CST assessment can be a highly educative process for the person with pain sensitivity. It offers a
chance to highlight the disconnect between stimulus and pain. This experience can quickly
become ‘personally meaningful’ to the individual with pain sensitivity. It provides an excellent
opportunity for reflective questioning (Resnicow and McMaster, 2012); upon eliciting allodynia
one might ask “What do you think this response means?”. Understanding this early, can be
used to influence the person’s responses to/feelings about other elements of the physical
examination.

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Interpretation of Assessment Findings

Armed with findings from all elements of the assessment, the MSK clinician needs to make
decisions on the overall influence of pain sensitivity on a person’s presentation. This should fit
within a holistic view of this person (Mitchell, Beales, 2017;Rabey et al. , 2015a). The following
questions may assist MSK clinicians in doing so.
1) If there is pain sensitivity, is it helpful or unhelpful? Pain sensitivity in acute pain may be a
necessary and useful system response.
2) If there is pain sensitivity, does it matter? Is the pain sensitivity contributing to the person’s
presentation in a negative manner?
3) What is the relationship between pain sensitivity and other dimensions within a
biopsychosocial view? Are other factors (e.g. psychological affect, poor sleep) driving pain
sensitivity? Will addressing other factors be likely to alter pain sensitivity, or does pain
sensitivity need to be a primary consideration of management?

CLINICAL IMPLICATION: The MSK clinician may decide pain sensitivity fits one of the following
categories.
1) ADAPTIVE/PROTECTIVE: Presence is reasonable in relation to the stage of the disorder and
may be a potential indicator of recovery aligned to expected timeframes.
2) INCIDENTAL: Though present, pain sensitivity can essentially be ignored as it is not a driving
factor. It may be part of the person’s normal sensory profile, or might be expected to resolve as
the disorder improves.
3) MINOR CONTRIBUTION: Potentially needs to be monitored, but on its own will not influence
management.
4) SIGNIFICANT CONTRIBUTION: Understanding and addressing pain sensitivity will form part of
management planning.
5) MAIN BARRIER: Understanding and addressing pain sensitivity will form an integral and
major part of management planning.

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Case study examples considering pain sensitivity in clinical reasoning are available in the Online
Supplementary Case Study and elsewhere (Mitchell, Beales, 2017;Rabey, Beales, 2015a;Reid et
al. , 2018). Further, as part of clinical reasoning, it is important to consider the influence of pain
sensitivity on prognosis, which may help set realistic expectations and goals, and provide a
‘balance-check’ for implementation.

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Implications of pain sensitivity for managing MSK pain

Do you want to manage the person with significant pain sensitivity?

Recognising pain sensitivity is one matter, managing it is another. Some clinicians may not wish
to manage people who have a significant pain sensitivity component to their presentation.
Others may realise they do not yet have the skills to do so, or require assistance. We strongly
recommend the utilisation of more experienced clinicians in such cases. The MSK clinician
should not consider just inter-professional referral, but also intra-professional referral. Intra-
professional referral is lacking in MSK therapy, but new models of utilising within-profession
expertise including shared-care are emerging (Bandong et al. , 2018;Rebbeck et al. , 2016).
Concurrently, if significant pain sensitivity is identified, then the MSK clinician should consider
ceasing low-value treatments (see Online Supplementary Case Study).

CLINICAL IMPLICATION: A consistent message from multiple practitioners can have a powerful,
positive effect to help a person with MSK pain understand their problem.

Considerations in the management of people with pain sensitivity?

Contemporary MSK practice provides a broad range of approaches for managing MSK pain,
including education/advice, application of manual therapy techniques and exercise. There is
extensive literature investigating the efficacy of these approaches, and they form the basis of
guideline-based management for MSK pain (Lin et al. , 2019). These approaches may directly
influence sensitivity, for example hands-on manual therapy techniques (Aspinall et al. ,
2019;Bond et al. , 2020;Coronado et al. , 2015) or exercise (Coronado, Bialosky, 2015;Henriksen
et al. , 2014;Polaski et al. , 2019) can have hypoalgesic effects. However, hypoalgesic
mechanisms may be ‘broken’ in people with pain sensitivity. Exactly how this might lead to
treatment effect modification (see above in Why should MSK clinicians consider pain

16
sensitivity?) is not clearly understood. While some research is emerging (e.g. those with poorer
pain modulation are more likely to demonstrate poorer exercise-induced hypoalgesia (Fingleton
et al. , 2017)), more is needed. Herein lies the difficulty for clinicians, where there is a lack of
consensus about how to manage pain sensitivity (Mitchell et al. , 2015). Thus, a pragmatic
approach is required to management in the same way it is need for assessment. This is
provided in Table 6.

Pain sensitivity is a spectrum. Classification as high or low does not convey the reality of pain
sensitivity in clinical practice, but Table 6 represents the higher end of the spectrum. This might
be recognizable to most MSK clinicians and provides a reasonable basis from which to consider
implementation of the pain sensitivity concept into management.

CLINICAL IMPLICATION: Generally, when pain sensitivity is a significant and potentially

dominant contributor to a person’s presentation, the following should be considered:
1) Management strategies that inadvertently continue to facilitate pain sensitivity and increase
the sensory threat of the pain experience are unlikely to be helpful. Facilitating pain sensitivity
begets continued pain sensitivity.
2) Management needs to carefully balance the known benefits of movement, i.e. the need to
encourage activity, coupled with the need to minimise continued facilitation of pain sensitivity.
Balancing ‘too little’ and ‘too much’ activity in people with significant pain sensitivity can be a
challenge for clinicians and patients.
3) Conversely, passive management and avoidance of activity are unlikely to be helpful.
4) Patient understanding and active engagement is critical. If the patient does not understand
or ‘buy-in” to pain sensitivity, then it is the authors’ experience that engagement with
recommended management and therefore recovery is poor.
5) Tailoring a management plan to make it ‘personally meaningful’ for the person with pain
sensitivity is critical (collaborative goal setting).
6) A consistent, team-based approach in the delivery of care is vital.

17
7) Consideration of pain sensitivity needs to be integrated into the broader holistic
management requirements of an individual from a biopsychosocial perspective (Mitchell,
Beales, 2017).
8) The model of care and care setting in which the MSK clinician is operating, must facilitate the
specific needs of managing people with significant pain sensitivity (see Online Supplementary
Case Study).

There is some emerging evidence that improvements in QST/CST measures might improve with
management (Vaegter et al. , 2020). Further research into this phenomenon is required.

18
Conclusion

MSK clinicians have long aligned their practice to pain science. Both laboratory-based and
clinical pain science knowledge is rapidly expanding. So rapidly, that it can be difficult for MSK
clinicians to evolve their practice to accommodate these advances. Additionally, new
knowledge indoctrinated in research protocols may not be readily or practically transferred into
clinical practice. We have provided a pragmatic guide for MSK clinicians to enhance their clinical
reasoning, and ultimately their practice, for the management of people where pain sensitivity
might be a significant part of their presentation. We hope this manuscript might contribute to
future discussion and debate, and stimulate further translation into practice in the field of pain
sensitivity in MSK disorders.

19
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31
Table 1: Glossary of pain terms for MSK clinicians (as used in this manuscript).
Term Definition
Pain “An unpleasant sensory and
emotional experience
associated with actual or
potential tissue damage, or
described in terms of such
damage.” (International
Association for the Study of
Pain, 2020)
- Pain may be a primary
complaint, or secondary to
underlying disease (Treede et
al. , 2019).
Pain Sensitivity Clinical term, used to
encompass the phenomena
that some peoples’
experience and perception of
pain is enhanced beyond that
of others.
- While this is somewhat
vague, and not specifically
defined by the International
Association for the Study of
Pain (International
Association for the Study of
Pain, 2020), this is a very
common term used in pain
science literature.
- In this manuscript, it is used
as an umbrella term, that
encompasses many concepts
including, but not limited to,
pain types, sensitisation, pain
characteristics, and specific
stimulus responses such as
allodynia, hyperalgesia and
temporal summation.
Considerations for MSK
Clinicians
- There is still a
considerable emphasis on a
direct stimulus-response
understanding of pain in
many areas of MSK
practice. This is unhelpful
and a significant barrier to
the application of
contemporary pain
management.
- Patients are likely to have
a direct stimulus-response
understanding of pain.
- This term can be well
understood and
comprehended by people
with pain when supported
with simple physical
examination and practical
explanations.
- This term is well
comprehended by people
involved in managing
people with pain who do
not have a medical
background (eg insurance
workers).
- Typically thought of as a
heightened response
(sensory gain).
- Should be considered as a
spectrum, rather than
discrete categories/levels
of sensitivity.
32
Quantitative Sensory Tests performed with - Static tests include
Testing standardised somatosensory immediate responses to
stimuli in an attempt to light touch, blunt pressure,
quantify pain responses (for thermal (hot, cold) and
example pain thresholds or sharp stimuli.
pain tolerances). - Dynamic tests assess
exercise induced-
- These are considered hypoalgesia (Rice, Nijs,
‘psychophysical’ tests in that a 2019), temporal
physical stimulus is applied summation (McPhee and
but the test result relies on Graven-Nielsen, 2019) or
the individual’s response conditioned pain
(Hansson et al. , 2007). modulation (Fernandes et
- In this manuscript, we lean al. , 2019).
to referring to quantitative
sensory testing as
standardised laboratory-
based procedures often
needing specialised
equipment (see Clinical
Sensory Testing below as a
contrast). However, we
acknowledge there is overlap
between laboratory and
clinical somatosensory
testing.

Clinical Sensory Testing Branch of quantitative - This should only be

sensory testing where the test
procedures are tailored to the
clinical setting, with the goal
of understanding specific
responses to somatosensory
stimuli that help inform the
presence of pain sensitivity.
considered one element of
the overall clinical
consideration of pain
sensitivity in a person’s
presentation.

- Stimuli are applied in as

standardised a manner as
possible; however, not all
stimuli are quantifiable.

Sensitisation “Increased responsiveness of - This should be considered

nociceptive neurons to their a normal physiological

33
 normal input, and/or
recruitment of a response to
normally subthreshold inputs”
(International Association for
the Study of Pain, 2020).
Peripheral Sensitisation:
“Increased responsiveness
and reduced threshold of
nociceptive neurons in the
periphery to the stimulation
of their receptive
fields.”(International
Association for the Study of
Pain, 2020).
Central Sensitisation:
“Increased responsiveness of
nociceptive neurons in the
central nervous system to
their normal or subthreshold
afferent input”. (International
Association for the Study of
Pain, 2020;Woolf, 2014).
Neuropathic pain “Pain caused by a lesion or
disease of the somatosensory
nervous system”
(International Association for
the Study of Pain, 2020).
- Specific guidance is available
for classification of
neuropathic pain (Haanpaa et
al. , 2011).
Nociceptive pain “Pain that arises from actual
or threatened damage to non-
neural tissue and is due to the
activation of nociceptors”, in a
“normally functioning
somatosensory nervous
system”(International
response in an acute injury,
but can become persistent
and unhelpful.
- Therefore, use of this
term as a diagnostic label
for an abnormal pain state
may not be accurate.
- We acknowledge however
that there is broad use of
this term as a diagnostic
label.
- When persistent
sensitisation is present, or
in some acute
presentations where it is
considered unhelpful,
implications for manual
therapy and other MSK
interventions may be
affected.
- Care must be taken using
this term in practice. This
term is often erroneously
used in the absence of
evidence of a lesion or
disease of the nervous
system.
- Some clinical symptoms
and signs of sensitisation
may mimic those of true
neuropathic pain.
- Nociceptive pain is not
mutually exclusive from
other types of pain
(neuropathic or
nociplastic). It should not
be considered an
alternative to neuropathic
34
 Association for the Study of
Pain, 2020;Kosek et al. , 2016)
Nociplastic pain “Pain that arises from altered
nociception despite no clear
evidence of actual or
threatened tissue damage
causing the activation of
peripheral nociceptors or
evidence for disease or lesion
of the somatosensory system
causing the pain”
(International Association for
the Study of Pain, 2020;Kosek,
Cohen, 2016).
Disproportionate When the response to a
stimulus is beyond what
might usually be expected (for
example when a mismatch
exists between the magnitude
of the response to an
innocuous stimulus) (Nijs,
Torres-Cueco, 2014).
Allodynia “Pain due to a stimulus that
does not normally provoke
pain” (International
Association for the Study of
Pain, 2020).
“Increased pain from a
Hyperalgesia stimulus that normally
pain (Kosek, Cohen, 2016).
- Inflammatory pain is also
included under this pain
type.
- This definition is built on
the understanding that
altered nociceptive
function can constitute a
condition in itself (Kosek,
Cohen, 2016).
- While by definition
classification of nociplastic
pain requires that pain is
not predominantly
nociceptive or neuropathic,
it is recognised that mixed
pain types exist.
- This is a new term and
replaces terms like ‘central
sensitisation pain’ for
reasons outlined above.
- Specific criteria for its
classification are pending
but will likely include pain
sensitivity testing.
- While there is inherent
subjectivity in determining
if a response is
‘disproportionate’, it is
reasonable to accept this as
a clinical judgement.
- These responses should
be considered a normal
physiological response in
most acute injuries, but can
become persistent and
unhelpful.
- Allodynia and/or
hyperalgesia may be
35
 provokes pain” (International
Association for the Study of
Pain, 2020).
- These might be considered
classic disproportionate
responses.
Mechanical Pain Used in this context as a
Characteristics Clinical term, denoting a
proportionate and coupled
stimulus-response
relationship.
- Typically the response to
mechanical stimuli (physical
test/movement/activity etc) is
predictable and proportionate
(Mitchell, Beales, 2017).
- Less affected by non-
mechanical stimuli.
Non-Mechanical Pain Used in this context as a
Characteristics Clinical term, denoting a
disproportionate and
decoupled stimulus-response
relationship.
- Response to mechanical
stimuli (physical
test/movement/activity etc) is - Some red flag conditions
disproportionate and can be
seemingly random (Mitchell,
Beales, 2017) , particularly to systemic
the person with non-
mechanical pain.
observed with clinical
sensory testing.
- Allodynia and/or
hyperalgesia may be
observed with other
elements of the
examination including
movement testing and
specific orthopaedic tests.
- When unhelpful allodynia
and/or hyperalgesia are
present, responses to
manual therapy and other
MSK interventions may be
affected.
- Symptom behaviour
(more intermittent pain),
with clear mechanical
aggravating factors and
easing factors, help inform
this, along with clinical
examination.
- Symptom behaviour
(constant pain,
spontaneous pain), with
report of ‘everything being
aggravating’ and ‘no
effective easing factors’
help inform this, along with
clinical examination.
may have non-mechanical
presentations, eg tumours,
diseases/conditions.
36
 - May see disproportionate
response to other stimuli (eg
cold, stress or reduced sleep).

MSK=musculoskeletal

37
Table 2: Caveats essential to understand sensory testing and pain sensitivity in MSK disorders

Caveats to Understanding Pain Sensitivity For MSK Clinicians

1. QST was not primarily designed for all MSK pain

- QST protocols, a basis of pain sensitivity assessment, were developed for sensory profiling
in people with neuropathic pain (Rolke et al. , 2006). It cannot be surmised that biological
processes in neuropathic pain states are akin to all MSK pain presentations.
- Care must be taken in extrapolating results from QST studies investigating neuropathic
pain to broader MSK pain presentations.
- There is growing QST literature in MSK pain presentations (such as knee pain, neck pain
and whiplash, and back pain) and CST research supporting such testing in clinical practice
(Maxwell and Sterling, 2013;Rebbeck, Moloney, 2015;Zhu, Bottger, 2019).

CLINICAL IMPLICATION:
- Care is needed when applying QST research findings across conditions.

2. Sensory testing is unable to delineate specific pain pathways

- One basis for QST has been to uncover specific receptors and pathways from stimulus to
pain perception, that could lead to targeted interventions. This especially applies to
attempts to better target medications at underlying pain processes (Yarnitsky, 2015).
- However, the assumption that specific stimuli can provide information on specific pain
pathways in MSK disorders cannot be supported (Cruz-Almeida and Fillingim, 2014).
- The concept of specific stimuli travelling in a linear fashion through specific pain pathways
to evoke a specific response can be refuted because the whole premise of pain sensitivity is
that these pathways are interconnected, complex and plastic.

CLINICAL IMPLICATION:
- While heightened responses to sensory stimuli can be measured, where this modulation
occurs cannot be discretely ascertained from QST/CST.
- We can identify pain sensitivity, but not the exact neurophysiological process(es) causing it
(eg. peripheral sensitisation, central sensitisation, specific nociplastic mechanisms)

3. In the general population there is a wide range of responses to sensitivity tests

- Even in pain-free people there are broad responses to sensory stimuli (Hastie, Riley,
2005;Rolke, Baron, 2006;Waller et al. , 2016).
- That some people without pain can be sensitive to certain stimuli needs to be considered
when interpreting the QST/CST in clinical populations.
- There are a limited number of body sites with reference data available, and for limited

38
stimuli.

CLINICAL IMPLICATION:
- Within-person variation may be as important as comparison to known reference data (and
more practical in clinic).
- Small side-to-side differences, common in the general population (Rolke, Baron, 2006),
may not be relevant in the clinical profile of a person with a MSK disorder.

4. Sensory testing is not clearly related to pain and disability in MSK pain presentations

- Meta-analysis has demonstrated that QST measures in MSK spinal pain are not clearly
related to pain or disability (Hubscher et al. , 2013).
- Further, sub-grouping people with low back pain on QST changes still does not present a
clear relationship between pain sensitivity and pain or disability (Rabey, Slater, 2015b).
- While pain sensitivity might indicate altered pain processing, pain and disability might be
more directly affected by other contributing factors, such as movement behaviours and
psychological factors (Moloney, Beales, 2018;Rabey et al. , 2016;2017b).
- However, there may be some individuals for whom QST measures are related to their
presenting pain and disability (O'Sullivan et al. , 2014).

CLINICAL IMPLICATION:
- Clinicians should be aware that QST/CST findings are not a reliable indicator or measure of
a person’s report of overall pain and disability.

5. Sensory testing should not be considered in isolation to understand the overall

person’s presentation

- Clinical sensory testing forms one element of the overall approach a MSK clinician should
use to understand pain sensitivity and MSK pain presentations (Mitchell, Beales,
2017;Rabey, Beales, 2015a;Rabey, Hall, 2017a;Tousignant-Laflamme, Martel, 2017;Walton
and Elliott, 2018).
- Failure to recognise this can result in ineffective and inappropriate management. There
are multiple factors variably associated with QST profiles in the literature. These include
genetics, age, sex, ethnicity, adiposity, sleep, physical activity/inactivity, mental health
status, smoking, MSK pain, non-MSK pain, pregnancy and medications.

CLINICAL IMPLICATION:
- A holistic, person-centred approach requires integration of QST/CST findings into a
broader, comprehensive understanding of all (multidimensional) factors contributing to
their presentation (Mitchell, Beales, 2017).

6. Pain sensitivity might be helpful

- An acute tissue injury is associated with (both peripheral and central) sensitisation (and

39
resultant pain sensitivity) (Chimenti, Frey-Law, 2018).
- This can be considered a normal protective response and necessary to help prevent
further tissue damage and stimulate healing.

CLINICAL IMPLICATION:
- Pain sensitivity must be considered within the context of the stage (acute, recurrent,
persistent) of the disorder.

MSK=musculoskeletal, QST=quantitative sensory testing, CST=clinical sensory testing

40
Table 3: Questionnaires to assist with the assessment of pain sensitivity.

Questionnaire Designed For Qualities Interpretation of Scores

Central Sensitization Sensitisation Subjective Score of 40-100 indicates “central

Inventory (Mayer, Neblett, sensitivity” as defined by the authors
2012;Neblett et al. , 2017)
0-29: Sub-clinical
30-39: Mild severity
40-49: Moderate severity
50-59: Severe severity
60-100: Extreme

Pain Sensitivity Sensitisation Subjective Scores greater than 5.2 (Azimi and
Questionnaire (Azimi and Benzel, 2016) or 6.6 (Kim, Park, 2015b)
Benzel, 2016;Kim et al. , predict poorer outcome from lumbar
2015b;Ruscheweyh, surgery.
Marziniak, 2009)

Pain Detect (Freynhagen, Neuropathic Subjective 0-12: Neuropathic pain unlikely

Baron, 2006) 13-18: Ambiguous
19-38: High likelihood of neuropathic
pain

DN4 Neuropathic Pain Neuropathic Subjective Score equal to or greater than 4/10 is
Diagnostic Questionnaire and considered diagnostic for neuropathic
(Bouhassira, Attal, 2005) Objective pain

The Leeds Assessment of Neuropathic Subjective 0-11: Neuropathic pain mechanisms are
Neuropathic Symptoms and unlikely
and Signs (LANSS) Objective 12-24: Neuropathic pain mechanisms
(Bennett, 2001) are likely.
- Subjective
only version
available.

41
Table 4: Interpretation of the patient interview and history in the consideration of the degree
sensitivity influencing a person’s presentation.

Elements of the Pain Sensitivity Is Pain Sensitivity Is Additional

Patient Interview LESS likely to be MORE likely to be a Considerations
and History a significant significant
contributing contributing factor
factor
Area of Pain - Likely to be - Can be localised - More widespread pain
- From body chart localised. - Can be has been associated
- May include widespread with higher levels of
somatic referral. - Spread of pain in sensitivity (Gerhardt et
unexpected ways al. , 2016).
(non-dermatomal - Multiple pain areas
pain referral) may add to sensitivity
in a more than additive
manner. This could
occur in the presence of
multiple specific
pathologies/isolated
symptom regions.

Consistency of Pain - Pain more likely - Pain frequently - Some people say they
- “Are you ever to be described as have constant pain, but
without pain?” intermittent. constant. on further questioning
it is only constant with
particular activities,
meaning it is actually
intermittent.

Pain Intensity - Larger range - Frequently high-

- “What level of pain from worst to level pain reported
do you experience at best. (8+/10 at best).
worst, best and - Lower average - Worst, best and
average?” pain (say <5/10). average pain less
variable.

Spontaneous Pain - Less common. - More frequent. - Spontaneous pain has

- “Do you ever been described as a
experience sudden hallmark symptom in
bursts of pain at neuropathic pain
rest?” presentations.
- “How frequently - Some people do

42
does this occur?” confuse spontaneous
pain with movement
related pain (eg getting
up from sitting rather
than just sitting). This
may need
exploration/clarification
with the client.
- Higher frequency of
spontaneous pain may
be more relevant than
infrequent occurrences.

Neurological Type - Less common. - More frequent. - Needs to be

Symptoms - Occur in non- considered within the
- “Do you experience dermatomal context of potential for
pins and needles or distribution. radiculopathy/specific
numbness?” neuropathy (see
Haanpaa et al.
(Haanpaa, Attal, 2011)
for classification
guidelines on
neuropathic pain).
- Consider presence of
neurological symptoms
in area not related to
primary complaint, eg
pins and needles in the
hands with low back
pain.
- May report whole
limb numbness/pins
and needles.

Sensitivity to Hot or - Less common. - More frequent. - Giving examples may

Cold be helpful if the patient
- “Do you experience doesn’t fully
sensitivity to hot or understand the
cold?” question.
- “Does hot or cold - Not to be confused
increase your pain?” with report of changes
in pain with changes in
the weather.

43
Sensitivity to Touch - Less common. - More frequent. - People may allude to
- “Do you get pain if this during standard
someone lightly questioning.
touches you, or from - Giving examples may
light pressure on be helpful if the patient
your skin like clothes doesn’t fully
or bed sheets?” understand the
question.

Sensitivity to Light, - Less common. - More frequent. - Giving examples may

Sound and Smell be helpful if the patient
“Are you sensitive to doesn’t fully
other things like understand the
light, certain smells, question.
or noise?”
“Do these things
affect your
pain/symptoms?”

Aggravating - Discrete - ‘Everything’

Activities/Postures aggravating aggravates
- Standard activities and symptoms.
aggravating activity postures. - Wind-up of
questioning. symptoms appears
‘disproportionate’
(Nijs, Torres-Cueco,
2014) to the
characteristics of
the activity.

Easing - Discrete easing - Nil, or very

Activities/Postures activities and ineffective.
- Standard easing postures.
questioning.

Negative - Less likely to be - More likely to be a - Negative psychological

Psychological Affect a significant significant affect influences pain
- Full assessment additional additional sensitivity and vice
required (beyond contributing contributing factor. versa.
the scope of this factor.
paper).
- A proficient, non-
threatening strategy
is to ask about the

44
effect of mood on
symptoms as part of
the aggravating
activity assessment
(eg “We have spoken
about how your pain
is related to different
physical activities.
Some people also
report a relationship
between their
symptoms and their
mood. Have you
been experiencing
anything like this?”
- “Is there a
relationship
between your mood
and your pain?”
- “You mentioned
you often feel
stressed or anxious.
Do you notice when
you feel this way
that your pain is
different?”

Beliefs - Biomedically - Biomedically - It is common for

- “What do you orientated beliefs orientated beliefs people with more pain
understand is may be may be at odds sensitivity to have been
causing your pain?” reasonable in the with the given multiple and
- “What have you context of the presentation, frequently conflicting
been told is causing presentation. contributing to opinions (perceived as
your pain?” confusion. conflicting or actually
- Often, these conflicting) as in regard
people do not know to the nature of their
what is causing problem.
their problems.

Comorbidity of - Less common. - Greater - Presence of multiple

Other (Pain) probability of co- comorbidities are
Sensitivity Disorders morbid disorders known to add to
- Medical history linked to sensitivity in a more
screening. sensitisation than additive manner.

45
 - Examples may
include migraines,
fibromyalgia,
irritable bowel
syndrome or other
unexplained
stomach
complaints,
menstrual pain and
restless leg
syndrome.

Sleep Disturbance - Less common. - More frequent. - Sleep

- “How are you disturbance/non-
sleeping?” restorative sleep is
- “Do you feel rested significantly related to
in the morning/at pain sensitivity in a
any time?” bidirectional manner
“How does your (Finan et al. , 2013).
pain/symptoms
behave when your
sleep is poor?

Fatigue and - Less common. - More frequent. - While these can

Cognitive frequently be related to
Dysfunction side effects of
- “Are you medication, they can be
experiencing related to primary
fatigue?” central changes related
- “Are you having to pain.
any issues with your
mental alertness or
concentration”

Body Perception - Less common. - More frequent. - This might need

Changes further explanation to
- Full assessment help the patient
required (beyond understand the
scope here). questions.
- This can be quite - The Fremantle Back
abstract for patients Awareness
so a non-threatening Questionnaire (Wand et
way to ask about this al. , 2014) can assist in
can be: “Other subjectively

46
people sometimes documenting altered
describe unusual body perception.
body sensations, like
the area feels bigger
or it’s harder to
sense or connect
with the area. Do
you ever experience
sensations like
that?”

Medication - Positive response - Being aware of use of

- Standard to centrally acting centrally acting
questioning of medication. medication may be
medication use. - important to assist with
- If the patient is understanding the
using centrally acting findings in the physical
medication targeting examination. Pain
pain sensitivity, is sensitivity may be less
this helpful? apparent with these
medications.
- In contrast pain
sensitivity can increase
secondary to long-term
opioid use.
- Unwanted side-effects
to medication targeting
pain sensitivity can be a
significant issue.

47
Table 5: Example assessment scripts for clinical examination pain sensitivity.

GENERAL INSTRUCTIONS
The stimulus should be first applied in areas remote to symptoms for a baseline indication
of sensitivity, before moving to the painful areas. Ideally show the patient on a remote
body area that they can see. If it is a limb, then test the unaffected limb first. If it is the
spine, test an unaffected area of the spine first. Some people find it easier if they close
their eyes.

SIDE TO SIDE DIFFERENCES

The key is to identify significant differences side to side (or to other body areas in the case
of the spine). This difference is sensation might just be sensitivity, not pain. For some, it
might be pain.

ASSESSING TACTILE SENSITIVITY ASSESSING TACTILE SENSITIVITY

(LIGHT TOUCH) (SHARP)

HOW TO: HOW TO:

The stimulus is a thin nylon monofilament
(2-4g) or tissue or brush. Apply the
monofilament perpendicular to the skin in a
steady fashion 3-5 times to the point where
the filament bends (this standardises the
pressure) OR brush lightly with a tissue 2-3
times.
Sample instructions to patient:
“I am going to touch your skin lightly with
this filament/tissue. (Show patient). Let me
know what you feel when I do.”
Apply to unaffected area.
“Can you feel that?”
Apply to affected area.
“Can you feel that?”
“Does it feel any different from the other
area? How would you describe it?”
“Would you describe it as painful?”
Note any side-to-side differences
The stimulus is a toothpick or pin applied
perpendicular to the skin in a steady
fashion 2-3 times on each location.
Sample instructions to patient:
“I am going to apply this toothpick to your
skin. Let me know if the sharp feeling is
uncomfortable or reproduces any of your
symptoms.”
Apply to unaffected area.
“Can you feel that?”
Apply to affected area.
“Can you feel that?”
“Does it feel any different from the other
area? How would you describe it?”
“Would you describe it as painful?”
Note any side-to-side differences
Once you have finished: “Does the feeling
continue, or has it settled down again?”

Once you have finished: “Does the feeling Interpretation:

continue, or has it settled down again?” Those with increased sensitivity to sharp
stimuli or hyperalgesia (if it is unusually

48
Interpretation:
Those with increased sensitivity to light
touch (allodynia if it is painful) will report a
clear difference in the affected area (mild
differences are generally not considered
important). This may suggest pain
sensitivity is present, but not why or what
is causing it. Some may report the affected
area has reduced sensation.
ASSESSING TACTILE SENSITIVITY
(DEEP PRESSURE)
HOW TO:
The stimulus is blunt pressure with your
finger or thumb applied in a progressive
mild-moderate-firm sequence. There is
utility in doing multiple remote sites (eg.
for widespread pressure pain sensitivity
associated with disorders like fibromyalgia).
Sample instructions to patient:
“I am going to assess your sensitivity to
pressure. Let me know if it is uncomfortable
or reproduces any of your symptoms.”
Apply to unaffected area.
“Can you feel that?”
Apply to affected area.
“Can you feel that?”
“Does it feel any different from the other
area? How would you describe it?”
“Would you describe it as painful?”
Note any side-to-side differences
Once you have finished: “Does the feeling
continue, or has it settled down again?”
Interpretation:
Those with increased sensitivity to deep
pressure will report a clear difference in the continue, or has it settled down again?”
affected area (mild differences are
generally not considered important). This
painful) will report a clear difference in the
affected area (mild differences are
generally not considered important). This
may suggest pain sensitivity is present, but
not why or what is causing it. Some may
report the affected area has reduced
sensation.
ASSESSING THERMAL SENSITIVITY
(COLD)
HOW TO:
The stimulus is an ice cube applied directly
to the skin.
Sample instructions to patient:
“I am going to test your sensitivity to cold
by holding this ice cube on your skin. I will
hold it there for 5-10 seconds. At the end of
that time I need to know how
uncomfortable or painful the ice feels using
a scale of 0-10 (10 being extreme pain,
burning or freezing cold). If it gets too
painful during the test, let me know and I
will take it off immediately.”
Apply to unaffected area.
“Can you feel that?”
“What would you score that out of 10?”
Apply to affected area.
“Can you feel that?”
“What would you score that out of 10?”
“Does it feel any different from the other
area? How would you describe it?”
“Would you describe it as painful?”
Note any side-to-side differences
Once you have finished: “Does the feeling
Interpretation:
49
may suggest pain sensitivity is present, but
not why or what is causing it. Some may
report the affected area has reduced
sensation.
Those with increased sensitivity to cold (or
heat) will report a clear difference in the
affected area (score differences less than
2/10 are generally not considered
important). This may suggest pain
sensitivity is present, but not why or what
is causing it. Some may report the affected
area has reduced sensation.

ASSESSING TEMPORAL SUMMATION

(WIND-UP)

HOW TO:
Use a thin monofilament (2-4g), toothpick or thick monofilament (26g). Repeatedly tap at
a rate of approximately one tap per second for 20-60 seconds.

Sample instructions to patient:

“I am going to assess if the feeling when I am tapping on your skin changes or stays the
same with repeated tapping. Let me know if it is uncomfortable or reproduces any of your
symptoms.”

In each region:
“Can you feel that?”
As you continue tapping:
“Does the feeling change as I keep tapping?”
In the affected region:
“Does this feel any different from the other area?”
“How would you describe it?”

Interpretation:
Those with temporal summation (wind-up) will report a clear escalation in sensation to
the same stimulus (mild differences are generally not considered important). The
symptoms may continue to worsen after the tapping has ceased. This may suggest pain
sensitivity is present, but not why or what is causing it.

WARNING: In rare circumstances, CST can result in acute anxiety and/or feelings of being
overwhelmed. This has been noted in other areas of musculoskeletal practice (O'Sullivan
et al. , 2018). In such instances the musculoskeletal clinician should be empathetic,
maintain a calm demeanour, support the patient through the episode, and ultimately use
this as a reflective and learning exercise for the patient.

Footnote: See Online Supplementary Web Links for video links to all tests.

50
Table 6: Potential unhelpful and helpful considerations in the management where pain
sensitivity is a significant contributor or main barrier.

Unhelpful Strategies For MSK Clinician Based Strategies To Manage Altered Pain
Sensitivity

MANAGING THE PRESENTATION LIKE THERE IS LOW PAIN SENSITIVITY

Management of these presentations as if there was low pain sensitivity (or a primary
mechanical presentation) generally leads to facilitation of the pain sensitivity. People
often report that they feel worse initially after treatment, and are ‘better’ within 1-2 days.
However, ‘better’ often means they have returned to the pre-treatment level. They often
continue to seek out these types of treatments based on false beliefs that they will help in
the long run. Specific interventions that address specific physical impairments are less
likely to be helpful early on for these presentations.

LIMITED ROLE FOR PASSIVE/HANDS ON MANUAL THERAPY TREATMENT

Presence of pain sensitivity, for example allodynia, make the application of these types of
treatments very difficult. They may lead to facilitation of pain sensitivity. Thus, passive
treatments including manual therapy are often not indicated. In those with significant
pain sensitivity who also appear to have less helpful pain-related cognitions and poor
coping skills, care must be taken to avoid reliance on others (passive coping).

PACING TO PUSH THROUGH PAIN

Attempting to push through pain (‘no pain-no gain’ mentality) often spawns facilitation of
the pain sensitivity. As such, operant approaches (Nielson et al. , 2013) with pacing that
tend to progress regardless of pain (and fatigue) can be more problematic for these
people.

BLAMING PATHOLOGY (OR LACK THERE OF)

In cases of significant pain sensitivity, the contribution of pathology to the disorder can be
very difficult to know due to the complications of pain sensitivity on interpreting the
physical assessment. People with pain frequently expect a pathology-based explanation
for their pain. While pathology can be relevant in some cases, blaming pain sensitivity
fully on pathology can be a mistake. Likewise, MSK clinicians should be well aware that
the absence of pathology has little to do with the presence of pain, but this may be
difficult to rationalise to people with pain or with other stakeholders in their recovery.

Not addressing beliefs and expectations

The goal of many people with pain is to be pain free. But the goal for disorders with
significant (and particularly ongoing) pain sensitivity might be better aligned to
management of symptoms in the first instance at least. Not aligning patient expectations
to the reality of their presentation can be a mistake. Balancing realism while not being

51
pessimistic can be challenging.

Helpful Strategies For MSK Clinician Based Strategies To Manage Altered Pain Sensitivity

GIVING A DIAGNOSIS
Frequently these people don’t understand their diagnosis. They have often received
conflicting opinions. We contend that pain sensitivity should not be a diagnosis, but it can
help explain why a person is still experiencing pain in the absence of pathology, or when
treatment directed at pathology has not helped (Mitchell, Beales, 2017). Delivery of the
diagnosis and contributing factors needs to be reassuring but definitive.

EDUCATION
For the person with significant pain sensitivity, understanding the basis of their disorder is
highly important in itself, and then to align patient expectations and beliefs to what is
more likely to be a successful management pathway. Pain education in various formats
(eg (Moseley and Butler, 2015;Nijs et al. , 2011)) has been a long term competency of
MSK clinicians. While there is evidence for the use of pain neurophysiological education
for MSK pain (Louw et al. , 2016), we recommend that it used as part of an
comprehensive program (see Online Supplementary Case Study) and not in isolation
(Moseley et al. , 2004). Making the educative process ‘personally meaningful’ to the
person with pain sensitivity would seem to help. Reflective questioning during specific
testing of pain sensitivity can be highly useful in the educative process. Explaining one
construct at a time is also recommended. Simple messaging can be very effective (See
Online Supplementary Web Links for examples.)

CAREFUL PACING
Pacing approaches following conservation (stabilise symptoms) approaches (Nielson,
Jensen, 2013) are more likely to be tolerated and progressed rather than pacing to push
through pain in the first place. Frequently, the objective in the first instance may be to
just establish a more stable baseline, rather than advancement.

BREATHING AND RELAXING

These might be best approached as a pain management strategy, rather than an exercise.
It may be necessary to find comfortable positions for the person with significant pain
sensitivity to perform this and encourage use with a positive mind-set and environment.
Some people will benefit from focusing on pain during this, others will need to use it to
distract from pain, at least initially. Functional integration should be a goal, particularly
with normally provocative or avoided activities.

GENERAL EXERCISE
Evidence suggests regular exercise can reduce central facilitation of pain (Lima et al. ,
2017). Thus, it is not a matter of ‘if’ people with this significant pain sensitivity should
engage in general exercise, it is a matter of ‘what and how’. Goal setting around activity
enhancement rather than just pain levels is required. As a general rule, some pain

52
increase may be reasonable/expected, as long as it is no worse again after the subsequent
session. In some cases, there may need to be a focus on unaffected body regions first.
Starting at ‘preferred’ intensity (Booth et al. , 2017), increasing frequency before duration
or intensity (Polaski, Phelps, 2019), and avoiding fatigue (Lima, Abner, 2017) may mitigate
increasing pain sensitivity and instead, have positive effects.

FUNCTIONAL MOVEMENT THAT NORMALISE ABERRANT MOVEMENT BEHAVIOURS

The aim should be to normalise movement, initially with non-threatening movements and
situations (O'Sullivan, Caneiro, 2018). This includes managing unhelpful communicative
and protective behaviours (Sullivan et al. , 2006) like breath-holding, bracing, and
unnecessary verbalisations(Sullivan, Thibault, 2006). Lower repetitions performed across
the day may be more manageable.

GRADED MOTOR IMAGERY

It is beyond the scope of this paper to fully discuss potential graded motor imagery
practices that might help reduce overall pain sensitivity. The reader is recommended to
look elsewhere (Boesch et al. , 2016;Dickstein and Deutsch, 2007;Priganc and Stralka,
2011). Useful strategies might include body scanning, laterality training and visualisation
of movements.

Broader Helpful Strategies For Managing Pain Sensitivity

Complimentary considerations include:

• Multidisciplinary team management approaches.
• Medication specifically targeting pain sensitisation (Gangadhar et al. , 2014).
• Mood control and associated psychological assistance such as building resilience,
mindfulness and stress-inoculation (Roditi and Robinson, 2011).
• Sleep review, inclusive of sleep hygiene (Finan, Goodin, 2013).

MSK=musculoskeletal

53
Highlights

• Pain sensitivity encompass the phenomena an enhanced pain experience.

• Pain sensitivity may modify the effect of common musculoskeletal pain
treatments
• The patient interview can allude to pain sensitivity as a significant factor
• Specific clinical tests can provide an objective measure of pain sensitivity
• A framework to consider management of pain sensitivity is provided