Not all Pain is the Same

Different people can have different kinds of pain. That sounds odd, but it’s true. We both could have back pain, but why we feel pain can be different. The hope of this article is to help describe the

Different people can have different kinds of pain. That sounds odd, but it’s true. We both could have back pain, but why we feel pain can be different. The hope of this article is to help describe the various types of pain.

Nociceptive

This is the pain type that makes the most sense for people. The phrase often used is ”the issue is in the tissue“. This is the sort of pain usually associated with physical tissue damage. But how does this pain actually work?

You have nerves in your skin, and these nerves act as sensors. These nerves respond to temperature (hot, cold), mechanical stimulus (pressure, sharp, vibration), and chemical stimulus (inflammation). When these sensors get too much input they will send a strong signal to your brain. The brain will produce pain as a response to try and get you to stop doing whatever is causing the stimulus. It’s important to note that it sends the signal when your body perceives that you might get damage. You touch a hot stove you remove your hand before damage has been done. So pain can be a response to actual or perceived damage.

Pain is an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage - IASP

The threshold is the amount of sensory input that triggers your nerves to send a message to your brain. Lots of different things can change this threshold. Different co-morbidities can decrease your threshold; diabetes, hypertension, trigger points, lots of inflammation. This means that you might have the feeling of pain faster than someone else. But pain is also an emotional experience. Therefore how much pain you feel can be highly related to your cultural upbringing, societal influences, and personal history.

What does Nociceptive pain end up looking like?

• Localized to area of injury (you can put a finger on it)

• Recent onset of pain (acute time frame)

• Clear anatomical nature to aggravating and irritating factors (it makes sense. I move this and it hurts every time)

• Usually intermittent and sharp in nature, but could be a dull throb at rest

• Has inflammation that decreases over time (swelling, redness)

• Responds well to NSAIDs (nonsteroidal anti-inflammatory drug)

• Usually you also move funny. You have an antalgic posture or movement pattern as you are trying to avoid irritating the acute injury

What should not be present?

• Abnormal sensations

• Pain that is described as burning, shooting, sharp, electric

What do we do about it?

Neurogenic / Neuropathic

Think of the nerves in our skin that are sensors as neighborhood streets. If you are on a local street and want to get downtown you will most likely jump on an interstate or major highway. You are going to get on a 12 lane major road. These interstates and massive streets are your peripheral nerves. They are large bundles of nerves that run between your spinal coord and the local nerves in specific areas of the body. These peripheral nerves all have specific areas of the body they are in charge of.

Most people have heard of nerve roots (C5, C6, L4), or they have heard of the sciatic nerve. These names allow medical providers to understand where something might be effected, but they also let us know what areas of their body might now be weak or have decreased sensation/feeling.

But nerves being irritated or painful don’t always mean you are going to have a loss of sensation or muscle strength. Sometimes nerves can just be a cause of pain.

There are lots of reasons why nerves might get irritated. These are usually the symptoms:

• Pain in a dermatomal or cutaneous distribution (nerves have distinct areas they provide sensation to)

• History of nerve injury, pathology, or mechanical compression

• Pain or paresthesias with mechanical movement testing that stress neural tissue (when you move in a way that stretches the nerve it hurts)

The important thing to also note is that tingling does not always mean nerve. Muscles for instance can cause something called Myofascial Pain Syndrome. Muscles themselves can cause some weird patterns of pain.

Pain patterns from specific Nerve Roots

Pain pattern of Myofascial Pain Syndrome of the Scalenes

What do you do for Neuropathic pain?

Give it space, give it blood, give it stress. - Adriaan Louw

Nerves need room. Your body in some positions give certain nerves space. In other positions they might compress that nerve. Massage therapy is a way for instance to relax muscles and tissues around a nerve to try and let it breath a bit better. Joint distractions in the spine can relieve pressure on certain nerves. There are lots of ways to allow for space.

Giving it blood is really making sure that you are moving the tissue around it. By pumping the muscles in the area they will bring in fresh blood, and flush out old staleness. This is important for the nutrition of the nerves.

Give it stress. All things get stronger when they have a stress applied to them. You want bigger muscles? You pick up heavy stuff. Same is true for nerves. There are ways to put tension on nerves, and they respond to this by being more resilient. The amount of stress can’t be so much that it continues to irritate the nerve though. Its like Goldilocks. You want some stress but not too much.

Nociplastic

When we talk about Nociplastic pain we are referring to a processing issue that is occurring in the spine or the brain. We are no longer referring to tissues sending signals to the brain. Now you are having alterations in how you perceive stimulus. Your nervous system has altered slightly. Let’s first start with some of the symptoms that can occur with Nociplastic pain.

Symptoms:

• Pain that occurs with light touch, or soft touch. Pain that occurs without specific mechanic, thermal, or chemical stimulii.

  • This pain in essence doesn’t make sense. Its more or disproportionate to the nature and extent of the injury someone may or might not of had. Its disproportionate to the activity that causes pain. (someone who says the sheet or shirt touching their skin causes pain)

• Pain that is more widespread, lacking a specific location. (can't point to the exact pain spot).

• Pain that starts to occur on both sides. Knee hurt originally and then the other knee starts to hurt.

• Start to have referred pain into different places. Pain is going down the knee and spreading.

• General fatigue, and lack of cognitive focus.

• Sleep dysfunction.

• Sensitivity to cold.

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. - IASP

There are multiple reasons why someone can develop nociplastic pain. The most important things to understand are:

1. This can be treated or managed

2. This is not all in your head, your pain is real.

This is a real phenomenon that occurs because of your nervous system being extra sensitive, or sensitized. Some physical therapists are well trained in managing these conditions. It takes a combination of exercise, pain education, and ways to calm down the nervous system. Examples of things that can “calm down the nervous system” are diaphragmatic breathing, yoga, meditation, journaling, biofeedback, aquatic therapy, humor, etc.

Some researches think that Fibromyalgia, Irritable Bowl Syndrome, Adrenal Fatigue, Non-celiac Gluten Sensitivity, Chronic Lyme Disease, Chronic Fatigue Syndrome are all forms of Nociplastic changes.

Association with Maladaptive Cognitions

Something that Physical Therapists will (hopefully) always screen for are maladaptive cognitions. These are poor mental states that people will often have when they have pain. Some of these are perfectly understandable, but they shouldn't get in the way of movement. Fear, kinesiophobia, helplessness, rumination, magnification of symptoms, or even perseverance. These are mental states that can get in the way of someone being able to do the things they need to in order to reduce their pain. Often these mental states are perpetuating their pain!

This is where the pain education is so important. Besides the education and doing things to calm your nervous system you need to understand that your body can heal, why its feeling what its feeling, and hope to cope with those symptoms.

Conclusion

Hopefully that gives a quick overview of the concepts of Nociceptive, Neurogenic and Nociplastic pain. The intent of this article was an introduction to pain, and to let you know that pain can occur because of different reasons. This means that different people need different treatments.

In addition, you might have all 3 pain types simultaneously. However, only 1 of the pain types is usually the dominant pain type needing management. If that is treated the rest can fall into place. So find an expert to help you with your condition.