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Understanding Nociplastic Chronic Pain: A Comprehensive Guide in 2024

Key Takeaways

  • Nociplastic Pain is pain that arises from altered nociception, with no evidence of tissue damage.
  • Also called Chronic Primary Pain, was previously called ‘central pain’ or ‘central sensitisation’
  • Associated with anxiety and depression.

What is Nociplastic chronic pain?

Nociplastic chronic pain is a relatively new category of chronic pain in addition to nociceptive chronic pain and neuropathic chronic pain.

The term ‘nociplastic pain’ was first introduced in 2017 by the International Association for the Study of Pain (IASP), signifying a pivotal moment in understanding the complexities of chronic pain conditions.

nociplastic chronic pain
Image source: https://www.scielo.br/j/clin/a/xzknPbfpVVDSQMJjCXRYsFR/

Definition of Nociplastic chronic pain

The formal definition, from the IASP, of nociplastic pain is “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.” But what does that actually mean?

Nociplastic chronic pain might sound like a complex medical term, but let’s break it down. In essence, it refers to a type of chronic pain that does not fit neatly into the categories of ‘nociceptive’ or ‘neuropathic‘. Instead, nociplastic chronic pain arises when the nervous system itself misinterprets or overreacts to signals, turning ordinary, harmless stimuli into perceived pain. Imagine your brain’s pain interpretation mechanism acting like an overzealous security guard, sounding alarms when there’s no actual threat. That’s nociplastic chronic pain.

Symptoms

Nociplastic pain, is a complex and often misunderstood type of chronic pain. It occurs when the nervous system processes non-painful stimuli as harmful and triggers a pain response. This can result in a variety of symptoms and challenges that greatly affect a person’s quality of life.
Living with nociplastic chronic pain is a unique journey, with symptoms varying greatly from person to person. Nevertheless, there are common experiences and symptoms we can talk about. Here are some symptoms that those with nociplastic chronic pain often report:

  1. Unexplained pain: Perhaps one of the most difficult aspects of nociplastic chronic pain is it does not have an identifiable source. There’s nothing to point to on a scan, no injury or tissue damage, to explain it. This can often leave people feeling frustrated and confused, on an endless quest for a diagnosis or ‘reason for the pain’.

    Obviously, it feels very challenging to manage or treat something when you can’t pinpoint the root cause. But remember, while the cause might be elusive, your pain is real and valid, and very treatable.
  2. Inabilty to pinpoint the location of the pain: Nociplastic pain can be vague and/or widespread, changeable from day to day, sometimes making it difficult to pinpoint the source. This can make it difficult to describe the pain to friends and family, or a health care professional and can be hard for others to understand it. This often leaves people who live with nociplastic pain feeling disbelieved and unsupported.
  3. Pain that moves around: Unlike specific pain caused by an injury or inflammation, nociplastic pain can be unpredictable and move around the body. One day it might be your lumbar spine that’s hurting…the next it might be your left shoulder.  This can lead to confusion and frustration for both the person experiencing the pain and those trying to understand.  It can even make some health care professionals suspect the person in pain is a hypochondriac or making up or exaggerating their pain, which is never the case. 
  1. Pain that persists beyond normal tissue healing time and is disproportionate to any observable injury or disease. For example, you may have sprained your ankle six months ago, the tissues have most certainly healed, but you still feel pain in the ankle.  Or, you have a mild injury, but the pain feels excruciating, and far more severe than you would expect. These are signs of nociplastic pain.
  2. Hyperalgesia: Hyperalgesia, in simple terms, refers to an increased sensitivity to pain and a lowered pain tolerance. Meaning, pain hurts more. For example, two people stub their toes.  The first person yelps in pain, but the pain quickly subsides, and they carry on. But the second person, who has hyperalgesia, experiences excruciating pain that does not quickly subside. Their oversensitive nervous system amplifies the pain signals so they feel much more pain.
  1. Allodynia: Allodynia is a condition where non-painful stimuli can cause pain. For example, a light touch or pressure on the skin may be perceived as painful for someone with allodynia. This happens because the nervous system processes these non-painful stimuli as harmful and triggers a pain response.
  2. Fatigue: Dealing with nociplastic pain can be draining both physically and emotionally, resulting in fatigue and exhaustion that impacts daily life. This can also contribute to a vicious cycle of pain, as fatigue can increase pain sensitivity and make it harder to cope. Increased pain in turn causes more fatigue, and the cycle continues.
  3. Increased sensitivity: Nociplastic pain can make you more sensitive to physical touch, temperature changes, light, sound and even emotional triggers. Your brain becomes hyper-vigilant, constantly on the lookout for potential pain signals. This can be exhausting and overwhelming, often leading to heightened anxiety or depression.
  4. Poor sleep: One of the most challenging aspects of dealing with nociplastic pain is disrupted sleep or insomnia. The intensity of pain can make it difficult to fall asleep or maintain restful sleep throughout the night. This lack of sleep, in turn, amplifies the pain sensitivity, creating a cycle that is tough to break. The more intense the pain, the harder it is to find restful sleep.  The less sleep one gets, the worse the pain seems to feel.
  5. Anxiety and depression: Living with nociplastic chronic pain can take a toll on one’s mental health. The unpredictability and/or constant presence of nociplastic pain can make it harder to manage day-to-day life, engage with friends and family and life a functional life. Nociplastic pain can lead to isolation and feelings of loneliness and abandonment, as nociplastic pain is most often invisible, and hard for others to understand.  It’s essential to seek support and find healthy coping mechanisms to manage the emotional toll of nociplastic pain.
  6. Ineffectiveness of Pain Medication: A particularly challenging aspect of managing nociplastic pain is the fact that it often does not respond to traditional pain medications. Powerful analgesics, including opioids, that are typically used to manage other types of pain, often prove ineffective at alleviating nociplastic pain. A holistic approach, or multidisciplinary care, is the best way to treat nociplastic pain. A combination of physical therapy, psychological therapies, education and medications are first line treatments, but it can take a lot of time, and trial and error, to figure out which therapies and treatments, work for a particular person.  This can be a frustrating process.  It is a very individual process and no two people with have the same ‘recipe’ of therapies that help alleviate their pain.

Remember, this isn’t an exhaustive list, and everyone’s experience is unique. You likely won’t have all of these symptoms. However, if you’re recognizing these signs and symptoms in your own life, then your chronic pain could be nociplastic in nature.

How is nociplastic pain diagnosed?

Since nociplastic pain doesn’t stem from a visible injury or detectable disease, it can be a challenge to diagnose. It’s important to remember that you cannot diagnose nociplastic pain unless ALL other physical/structural/pathological sources of chronic pain have been ruled out.

It is not a matter of, if the cause of the pain is not immediately apparent, diagnose nociplastic pain.

It is the opposite!

Diagnosing nociplastic pain requires a comprehensive evaluation that incorporates a patient’s medical history, physical examination, scans and other test results. Clinicians typically use pain questionnaires to help assess the nature of the patient’s pain, the severity and quality of the pain, and their quality of life and functional ability.

Diagnostic criteria from organizations such as the International Association for the Study of Pain can also be instrumental.

There are several questionnaires and assessment tools that physicians may utilize to help diagnose nociplastic pain.

The Brief Pain Inventory (BPI) is a widely-used tool that measures the severity of pain and the impact of pain on daily functions.

The McGill Pain Questionnaire, another common tool, offers a multidimensional approach to assessing pain, capturing information about the sensory, affective, and evaluative aspects of a patient’s pain experience.

The Pain Catastrophizing Scale (PCS) evaluates an individual’s tendency to magnify the threat value of pain stimuli and to feel helpless in the presence of pain. These tools, among others, offer invaluable insights into a patient’s pain experience, aiding clinicians in their diagnostic process.

Treatment

Nociplastic pain treatment often relies on a multidisciplinary approach, combining various therapeutic strategies to manage pain and improve patients’ quality of life.

Non-pharmacological therapies

Non-pharmacological therapies play a crucial role in nociplastic pain management, as they help to alleviate pain, improve functionality, and enhance patient well-being without the side effects associated with medication.

  1. Exercise and Physical Therapy: Engaging in a regular exercise regimen and undergoing supervised physical therapy can result in significant improvement in a patient’s physical functioning and a reduction in pain levels.
  2. Psychological Interventions: The utilization of psychological therapies, such as cognitive-behavioural therapy (CBT) and mindfulness-based stress reduction, can prove to be highly impactful in handling the emotional and psychological dimensions associated with nociplastic chronic pain.
  3. Patient Education and Self-Management: Empowering patients through education about their condition and equipping them with self-management techniques is a critical component of comprehensive pain management.
  4. Complementary Therapies: The use of alternative complementary therapies such as acupuncture and massage can potentially offer relief. However, the level of effectiveness from these therapies can vary from individual to individual.

Pharmacological therapies

Though medications aren’t always effective for nociplastic pain, pharmacological therapies still serve as an important role in a comprehensive pain management plan. Pain medications may work symbiotically with non-pharmacological methods to enhance their efficacy. Each person is individual, and the use of pain medications is very much trial and error.

  • Antidepressants: Certain classes of antidepressants such as Tricyclic Antidepressants (TCAs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) may be efficactive in soothing pain sensations.
  • Anticonvulsants: Specifically, medications like Pregabalin and Gabapentin, traditionally used to manage epilepsy, have been shown to reduce nociplastic pain symptoms.
  • Non-Steroidal Anti-inflammatory Drugs (NSAIDs): These agents might provide a degree of relief. However, they tend to be more effective for nociceptive pain than nociplastic pain.  They are worth trailing, however..
  • Opioids: Opioids come with risks, as all medications do, but as with NSAIDS they do seem to be less effective for nociplastic pain.  However, they are worth trialling, but only after other medications have failed. Opioids are never a first line treatment. 

Lifestyle changes

In addition to pharmacological and non-pharmacological interventions, embracing healthy lifestyle habits can play a pivotal role in managing nociplastic pain.

  • Staying Physically Active: Engaging in regular exercise not only fortifies your body but also serves as a natural painkiller by releasing endorphins, also known as ‘feel-good’ hormones. The type of exercise can be tailored to individual abilities, ranging from light stretching to more vigorous routines.
  • Eating Wisely: A nutritious and balanced diet rich in anti-inflammatory foods can contribute to overall health and potentially alleviate pain symptoms. Consuming a variety of colourful fruits and vegetables, lean proteins, whole grains, and healthy fats can bolster your body’s natural defences and promote recovery.
  • Prioritizing Sleep: Good sleep hygiene is crucial in pain management. Establishing a regular sleep schedule, creating a serene sleep environment, and minimizing screen time before bed can enhance sleep quality, which in turn can positively impact pain.

Lifestyle changes can play a significant role in managing nociplastic pain, they should be viewed as part of a holistic treatment plan.

It’s very important to remember that each patient’s treatment plan is highly individualized, tailored according to their unique symptoms, pain experience, and overall health status. No two people’s pain is the same, and no two people’s treatment plan should be the same.

Diseases associated with nociplastic pain

Nociplastic pain is associated with a variety of conditions. Here are some of the prototypical diseases linked with this type of pain:

  • Fibromyalgia: This is a common and complex chronic pain condition that causes widespread pain and tenderness to touch. It’s characterized by profound fatigue, sleep abnormalities, and often psychological distress.
  • Irritable Bowel Syndrome (IBS): This is a common disorder that affects the large intestine. Symptoms include cramping, abdominal pain, bloating, gas, and diarrhea or constipation, or both. The exact cause of IBS isn’t known, but nociplastic pain can play a significant role in the discomfort experienced by patients.
  • Chronic Fatigue Syndrome (CFS): Also known as Myalgic Encephalomyelitis, CFS is a profound, prolonged, and medically unexplained fatigue that substantially reduces activity levels. Pain is a common symptom and can present in various forms such as muscle pain, joint pain, and headaches.
  • Temporomandibular Disorders (TMD): These are a group of conditions that cause pain and dysfunction in the jaw joint and the muscles that control jaw movement. The pain experienced is often nociplastic in nature, as there is no clear injury or damage to the jaw.
  • Non-specific lower back pain. Non-specific lower back pain (NSLBP) is a term used to describe lower back pain that lacks a clear, identifiable cause, such as a specific underlying condition or injury.

Each of these conditions is unique, and so is the experience of each patient. A deep understanding of these diseases and their association with nociplastic pain can aid in developing personalized and effective treatment strategies.

Prevalence of nociplastic pain

Nociplastic pain is increasingly recognized as a prevalent occurrence in society, affecting a significant proportion of the population. While precise estimates can be challenging due to its intricate nature and overlap with numerous conditions, studies suggest that conditions featuring nociplastic pain, such as fibromyalgia and irritable bowel syndrome, affect about 2-8% and 10-15% of the global population, respectively.

Chronic fatigue syndrome, another condition often associated with nociplastic pain, impacts an estimated 1 million people in the United States alone. Meanwhile, the prevalence of temporomandibular disorders, which often involve nociplastic pain, is reported to be between 5-12%. These figures reflect the significant presence of nociplastic pain, underscoring the need for further research and effective management strategies.

Conclusion

In conclusion, nociplastic chronic pain, a deeply complex and multifaceted phenomenon, is increasingly shaping our understanding of chronic pain syndromes. Its distinct characteristics and apparent prevalence highlight its significant role in conditions such as fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome, and temporomandibular disorders.

The figures reflect the global scale of the issue and underscore the urgency for further research into its mechanisms and the development of effective, individualized treatment strategies.

In closing, nociplastic pain embodies the challenges and opportunities inherent in the evolving landscape of pain management. It is a call to action for continued research, empathy, and innovation. By fostering a deeper understanding and developing effective treatments, we can unlock new horizons of hope for those navigating the complexities of this condition. Together, we can move towards a future where nociplastic pain is no longer a perplexing puzzle, but well understood and well differentiated from nociceptive and neuropathic chronic pain.  So that people living with each type of chronic pain receive the correct treatment.  

FAQs

  1. What is nociplastic pain?

Nociplastic pain refers to a type of 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. It is a relatively new term introduced to classify pains that do not fit the traditional categories of nociceptive or neuropathic pain.

  1. How prevalent is nociplastic pain?

Nociplastic pain is believed to be a common feature in many conditions, including fibromyalgia and irritable bowel syndrome, affecting 2-8% and 10-15% of the global population, respectively. It’s also often associated with chronic fatigue syndrome and temporomandibular disorders.

  1. What conditions are often associated with nociplastic pain?

Fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome, and temporomandibular disorders are some of the conditions often associated with nociplastic pain.

  1. Why is further research into nociplastic pain necessary?

Further research into nociplastic pain is necessary to understand its mechanisms, help develop effective, individualized treatment strategies, and inform our strides toward patient-centered care.

5. How is nociplastic pain diagnosed?
Diagnosing nociplastic pain involves a comprehensive evaluation that includes a patient’s medical history, physical examination, and sometimes diagnostic tests to rule out other causes of pain. It is diagnosed when pain cannot be attributed to other types of pain mechanisms and is often associated with conditions such as fibromyalgia, irritable bowel syndrome, and tension-type headaches.

6. What are the symptoms of nociplastic pain?
Symptoms can vary widely but often include persistent or chronic pain that may be described as aching, burning, or stabbing. Patients may also experience sensitivity to pain (hyperalgesia), pain from stimuli that do not usually provoke pain (allodynia), fatigue, sleep disturbances, and emotional distress.

7. Can nociplastic pain be treated?
While nociplastic pain can be challenging to treat, management strategies often include a combination of pharmacological treatments, such as pain relievers and antidepressants, and non-pharmacological approaches, including physical therapy, exercise, cognitive-behavioral therapy, and stress management techniques. Treatment plans are typically personalized to the patient’s specific symptoms and needs.

8. Is nociplastic pain a lifelong condition?
The course of nociplastic pain varies among individuals. Some people may experience periods of remission, while others may have persistent symptoms. Management and treatment can help improve quality of life, but it is often considered a chronic condition.

9. How does nociplastic pain affect daily life?
Nociplastic pain can significantly impact daily activities, work, and social interactions due to its chronic nature and the wide range of symptoms. It can lead to decreased mobility, difficulty in performing daily tasks, and challenges in maintaining social relationships. Emotional and psychological well-being can also be affected, with increased risks of anxiety and depression.

10. Where can I find support for nociplastic pain?
Support can be found through healthcare providers, pain management clinics, and support groups for chronic pain. Online resources and communities may also offer advice, share management strategies, and provide emotional support to individuals experiencing nociplastic pain.

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