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Am Fam Physician. 2023;107(1):92-96

Author disclosure: No relevant financial relationships.

Case Scenario

I have a busy morning during clinic, and I realize that a new patient has been added to my late afternoon schedule because of back pain, headache, abdominal pain, fatigue, and difficulty sleeping. A brief review of the medical record reveals that over the past years, this 32-year-old patient has been seen by primary care physicians, numerous specialists, and even in emergency medicine settings for various ongoing symptoms, including headache, neck pain, diffuse body aches, urinary frequency, dysuria, generalized fatigue, brain fog, and anxiety. Despite multiple investigations with negative results, the patient does not appear to have received any definitive diagnoses. Experiencing a moment of dread and anticipating a difficult patient encounter, I vent my frustration to my colleague, knowing that I will unlikely be able to offer any useful tests, explanations, or acceptable treatment recommendations. My colleague suggests that central sensitization could be a useful concept in understanding and explaining my new patient's various types of chronic pain.

Commentary

Patients and many physicians often think of chronic pain as a direct manifestation of ongoing tissue (nociceptive pain) or nerve (neuropathic pain) damage.1 In recent years, a third type of pain—centralized or nociplastic pain—has been recognized.1 Nociplastic pain is believed to be primarily generated by central sensitization, in which abnormal neural signaling causes the development and amplification of chronic pain as well as a variety of other symptoms that are often difficult to explain or to reconcile with traditional diagnostic tests. Central sensitization provides a robust conceptual and etiologic framework for chronic pain and many unexplained symptoms. The model facilitates patient engagement, builds trust, and may assist in acceptance of and adherence to a broader range of evidence-based therapies. Several chronic conditions (e.g., irritable bowel syndrome, functional dyspepsia, fibromyalgia, myalgic encephalomyelitis [formerly chronic fatigue syndrome], interstitial cystitis, chronic pelvic pain, chronic neck or back pain, chronic orofacial pain, headache, a variety of postinfectious syndromes) are believed to be attributable to ongoing nociplastic pain caused by central sensitization.16

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Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to afpjournal@aafp.org. Materials are edited to retain confidentiality.

This series is coordinated by Caroline Wellbery, MD, associate deputy editor.

A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside.

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