Nociplastic pain is the semantic term proposed by the international pain research community to describe a third category of pain that is mechanistically distinct from nociceptive pain, which is caused by persistent inflammation and tissue damage, and neuropathic pain, which is caused by nerve damage.
The mechanisms underlying this type of pain are not yet fully understood, but it is assumed that increased pain and sensation processing in the CNS and altered pain modulation play an important role.
Symptoms may include: multifocal pain that is more widespread or more intense, or both, than would be expected given the extent of identifiable tissue or nerve damage, as well as other CNS-related symptoms such as fatigue, sleep, memory and mood problems.
This type of pain can occur in isolation, as is often the case in conditions such as fibromyalgia or tension-type headaches, or as part of a mixed pain condition in combination with persistent nociceptive or neuropathic pain, as can occur in chronic low back pain.
It is important to recognize this type of pain as it responds to different therapies than nociceptive pain, as it responds less well to peripheral therapies such as anti-inflammatory drugs and opioids, surgery or injections.
Overarching principles for the treatment of nociplastic pain
- Trusting doctor-patient relationship
- Psychoeducation (explanations using terms such as “overstimulated”, “sensitized” or “excited” nervous system, explanation of treatment strategies and development of realistic expectations)
- Promotion of self-management and self-regulation
- Promotion of good lifestyle habits (health-related physical activity, nutrition and weight management, sleep hygiene, stress reduction)
- Psychological approaches (cognitive-behavioral therapy, acceptance-based therapies, hypnotherapy or psychodynamic therapies)Psychiatric-psychotherapeutic treatment of psychological comorbidities Physical therapies, osteopathy (insertion of Liem), chiropractic, acupuncture, massage or naturopathy
- Pharmacological treatments as a second step (e.g. zentally acting drugs (pain modulators), tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, gabapentinoids and other membrane stabilizers)Simple analgesics and non-steroidal anti-inflammatory drugs have little effectopioids should be avoided
- Neuromodulation
- Interdisciplinary support
Fitzcharles MA, Cohen SP, Clauw DJ, Littlejohn G, Usui C, Häuser W. Nociplastic pain: towards an understanding of prevalent pain conditions.
Lancet.
2021 May 29;397(10289):2098-2110.
