Central sensitization, chronic pain, and other symptoms: Better understanding, better management

Mary M. Volcheck; Stephanie M. Graham; Kevin C. Fleming; Arya B. Mohabbat; Connie A. Luedtke

doi:10.3949/ccjm.90a.22019

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Figure 1
The cycle of pain and fatigue in central sensitization, showing patient behaviors and emotions and family response.
From Mayo Clinic Patient Education. Managing your Fibromyalgia (MC2593-100). Rochester, MN: Mayo Clinic, 2017, pp. 7 & 32; used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.

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TABLE 1

Structural, functional, and neurochemical changes associated with central sensitization

Structural and functional changes in the thalamus, hypothalamus, and amygdala

Hyperexcitability of the cell membrane of central neurons, decreased action potential threshold, increased synaptic strength, decreased descending inhibitory transmission, reduced activation threshold, and enlarged receptive fields

Loss of gray matter volume in the anterior and posterior cingulate cortex and prefrontal cortex

Heightened functional activity within the somatosensory cortex (sensory processing), insula (emotional context of sensation, sensory appraisal), and amygdala (mood processing)

Increased temporal summation (leading to increasing ascending sensory amplification) and reduced conditioned pain modulation (reduction in descending inhibitory signals)

Maladaptive central and peripheral neuroplasticity

Hypothalamic-pituitary-adrenal axis changes

Hyperactive sympathetic nervous system and endogenous opioid system

Changes in neurotransmitter concentrations in the cerebrospinal fluid

Adapted from information in reference 1.

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TABLE 2

Central sensitization: Turning negatives into positives

Negative or distorted beliefs	Positive and rational beliefs
Because of my pain or symptoms, I am no longer the person I was. I no longer feel loved and appreciated.	I may have changed somewhat physically, but I am more than just a physical being. I am worthy of love and of being appreciated for all that I am.
People reject me because they can see I am disabled.	I am not disabled. I have goals and dreams and can accomplish many things.
I used to be able to do so many things—now I can’t do anything. I am no longer competent or adequate.	I can do a lot more than I thought. Almost everything I used to do, I can still do to some degree.
I can’t do anything because of my symptoms.	With moderation, I can be actively involved in life. I just need to pace myself and take breaks.
I have no control over my happiness. The pain or symptoms control me.	I can control my happiness. I can be happy and enjoy life even when I have pain or other symptoms.
People think I’m faking this.	People sometimes need help understanding medical issues. I can share what I know about chronic pain.
If my symptoms act up when I’m out with friends, I’ll be embarrassed and ruin things for everyone.	I can help my friends understand. I can take breaks and still enjoy myself when I’m with them.
Medical science can do so much. Surely there must be a cure for my symptoms.	Even if medical science can’t fix everything, I can choose my response and focus on self-care skills.
People at work are upset with me. I have restrictions and they think I am not doing my share.	I will do the best job I can. If people don’t understand, that’s their problem—I can’t please everyone.

From Mayo Clinic Patient Education. Managing your Fibromyalgia (MC2593-100). Rochester, MN: Mayo Clinic, 2017, pp. 7 & 32; used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.

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TABLE 3

Examples of graded exercise recommendations for self-management

Activity	Examples	Progression	Frequency
Flexibility	Head-to-toe stretches	Initially, may need to break up throughout the day (if too much to do in 1 session)	Once daily
Aerobic exercise	Walking, biking, swimming	Initial duration depends on the patient’s comfort level (eg, may be 5 minutes) Gradually increase time by 2–5 minutes every 2 weeks	30 minutes, 3 times a week^a
Strength training	Hand weights, resistance bands, water bottles	Start slowly Gradually increase resistance or weight	2 times a week^a

↵a Alternate aerobic exercise days and strength training days. For example, aerobic exercise could occur on Mondays, Wednesdays, and Fridays. Strength training could occur on Tuesdays and Thursdays.
From reference 44: Abril A, Bruce BK. Mayo Clinic Guide to Fibromyalgia: Strategies to Take Back Your Life. Rochester, MN: Mayo Foundation for Medical Education and Researech, 2019; used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.