uncontrollable; and pain is a permanent condition (Adams et al., 2015). ● Hypervigilance is an attentional bias for pain that might lead to increased fear-avoidance behavior. ● Perceived control versus helplessness —when individuals be- lieve they can influence the duration, frequency, intensity, or unpleasantness of symptoms, they are often more motivated to pursue solutions to managing these symptoms. By contrast, persons with low perceived control report worse outcomes, including greater pain intensity and poorer physical and psy- chological adjustment to illness. As expected, patients with higher perceived control function better (Adams et al., 2015). ● Self-efficacy refers to the extent to which a person believes they can successfully complete the tasks necessary to achieve the desired outcome in each situation. Patients with higher self-efficacy have better outcomes with pain (Adams et al., 2015). ● Psychological inflexibility refers to an inability to act in ac- cordance with one’s own values in the midst of interfering thoughts, feelings, or bodily sensations. High levels of psy- chological inflexibility (i.e., low levels of psychological flex- ibility) are associated with avoidant coping methods such as denial, behavioral disengagement, and self-blame (Adams et al., 2015). ● Social learning provides a framework for how a patient’s symptom behaviors develop and are maintained. Ideas about symptoms are learned from parents, culture, and environ - ment. For example, people whose pain behavior is reinforced are more likely to continue to display those behaviors. ● Social stigma and skepticism —individuals with central sensi - tization often report that the stigma arising from other people’s response to their illness is a relevant issue for them. According to Adams et al. (2015), social stigma has negative implications for psychological well-being, quality of life, and health main- tenance, with the potential to result in decreased self- esteem and higher rates of depression. This can result in lower rates of engagement with the healthcare system. Chronic pain pa- tients often feel stigmatized by healthcare professionals (Ad- ams et al., 2015). ● Social support —there is very strong evidence to support the idea that social ties and feeling cared for by others is positively associated with mental health, physical health, and life span (Adams et al., 2015). Patients with chronic headaches have been shown to exhibit cen- tral sensitization as detected by various methods (Filatova et al., 2008). The biopsychological model of pain and the concept of central sensitization make evaluation of the patient with chronic headache much more complex for the physical therapist. Train- ing in pain neuroscience, which encompasses the biopsychosocial model of pain and the concept of central sensitization, is an im- portant part of effective evaluation and treatment of patients with headaches. It is the perspective of the author that clinicians with the highest level of education in neuroscience, the highest levels of compassion for their patients, and the highest levels of under- standing regarding each patient’s personhood and past are best able to use their skills and knowledge to effectively help clients with headaches and symptoms of central sensitization. Assessing central sensitization The Central Sensitization Inventory has been developed for the purpose of assessing the dimensions of central sensitization and quantifying the degree of central sensitization symptoms. The test consists of two parts. Part A consists of 25 items and is an inven - tory of presenting symptoms. Some of the items include: ● I am unrefreshed when I wake up in the morning. ● I get tired very easily when I am physically active. ● I feel pain all over my body. ● I have low energy. ● I have muscle tension in my neck and shoulders. The second part of the inventory is a list of diagnoses that the patient has been given by a medical provider. These include rest-
perspective considers the psychological, social, and contextual factors that combine with biological influences to contribute to the experience, maintenance, and exacerbation of pain symp- toms (Adams et al., 2015). This model is an advancement on the previous one, which is often how our patients understand their pain, believing that the experience of pain is in direct propor- tion to the degree of tissue strain/stress and that alleviation of symptoms should center on addressing that tissue damage. Psy- chological factors that have been shown to influence the expe- rience of pain include depression, anxiety, posttraumatic stress disorder, and substance misuse and dependence (Adams et al., 2015). Cognitive and affective features that have been shown to contribute to the experience of pain include anger, the patient’s interpretation of their situation (“This pain means something is terribly wrong”), catastrophic thinking and fear avoidance, hyper- vigilance, perceived helplessness, self-efficacy, and psychological inflexibility. Social factors associated with the experience of pain include social learning, social stigma and skepticism, and social support (Adams et al., 2015). A critical part of the biopsychosocial pain model and of pain neu- roscience education is the concept of central sensitization. Cen- tral sensitization involves changes in the central nervous system that lead to pain hypersensitivity and the potentiation of chronic pain (Latremoliere et al., 2009). Central sensitization enhances the sensory response to normal inputs, including those sensations that would usually not cause pain (Latremoliere et al., 2009). Sev- eral explanations have been offered for the development of cen- tral sensitization. These include dysregulation in both ascending and descending central nervous system pathways due to physi- cal trauma and sustained pain impulses, and the chronic release of pro-inflammatory cytokines by the immune system as a result of physical trauma or viral infection (Mayer et al., 2012). Another possible explanation is dysfunction of the stress system, including the hypothalamic–pituitary–adrenal axis (Mayer et al., 2012). Biopsychosocial factors associated with headaches ● Depression —the prevalence of chronic pain is higher among those with a diagnosis of depression. Conversely, the preva- lence of depression among individuals with chronic pain is also higher (Adams et al., 2015). According to Adams et al. (2015), depression seems to exacerbate the experience of pain and is a strong determinant of pain-related disability. ● Anxiety —individuals with chronic pain often report being anx- ious and worried about their pain. In addition, there is strong evidence to support the influence of anxiety on pain percep- tion. ● Posttraumatic stress disorder (PTSD) —when a formal diag- nosis of posttraumatic stress disorder is present, the preva - lence of chronic pain is 50%. The diagnosis of PTSD means a person has been exposed to a traumatic event that can in and of itself can cause pain. PTSD can also prolong the pain expe- rience, with one study finding that PTSD symptoms were the only baseline factor that predicted persistent pain three years after involvement in serious accidents (Adams et al., 2015). ● Substance misuse and dependence —the relationship be- tween substance misuse and chronic pain is seen often in clini- cal practice (Adams et al., 2015). ● Anger —people with central sensitization often report feelings of frustration and anger related to their situation, the intensity of their symptoms, the lack of a cause or cure, and challenges within the healthcare system. One possible explanation for the relationship between pain and anger is the finding that people who have high levels of anger expression may have deficits in their endogenous opioid function, resulting in increased pain sensitivity (Adams et al., 2015). ● Symptom appraisal and symptom belief —how a person looks at and interprets a situation can have a profound in- fluence on their experience. The following specific beliefs have been identified as particularly maladaptive in managing chronic pain: pain is a signal of damage; activity should be avoided when pain is present; pain leads to disability; pain is
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