Stephen’s post on Central Sensitization got a lot of attention, and it is well deserved. Part of getting results in this population is explaining how the nervous system works. The following metaphor is a nice way to get the idea across.
The CNS Wind-UP:
So, we’ve all seen little kiddos get upset. They fall down, bump their knee and start crying. This situation parallels your patient’s injury. The first reaction is appropriate and normal due to the circumstance. Let’s add some things to the equation: the kiddo is tired and hungry (biopsychosocial factors!)… now the crying is louder and lasts longer. Perhaps the kiddo sees the parent get upset too, or has found some benefit to being hurt or has a temperament that predisposes a longer cry… this will lead to a cry “wind-up” (for those that have kids, this will be familiar).
Once wound-up, the crying can turn into a tantrum that the child can have difficulty controlling, they are just upset and sensitive. Now you can ask this wound-up child if they would like a hotdog, for example, and that may just worsen the tantrum: “NO!!! I do NOT want a HOTDOG!” (read: allodynia).
Now here is the part where most adults don’t know what to do, they may just walk away of think that the kiddo is poorly parented, crazy, making it up for attention, etc. But the smart parent (read: clinician!) will know to find a way to calm the child down. This could be from rubbing their back or a hug (the power of touch!) not giving into the crying and squirming, could be just to sit next to the child and wait it out in a calm confident manner, etc.
The tantrum/wind-up is the CNS wind-up. It was based on something, often nociception mixed with biopsychosocial factors and environmental factors, that have spun out of control and the patient unable to manage it.
Think about this the next time your 10/10 patient comes into the clinic… they could just be all wound-up. (thanks to all the neuroscience out there we now understand more about WHY sometimes kiddos don’t cry after a fall, the reduced threat perception, context, etc) Using the explain pain model is still very difficult to implement, but spend some time on it during treatment, it just might lend some understanding…