Did you know that there are 3 types of pain?
In 2018, the International Association for the Study of Pain, or IASP, released a new
pain classification.
The three types are: Nociceptive pain
Neuropathic pain Nociplastic pain
In this video, I’ll explain: - What they mean
- How do we diagnose them in clinical practice - How we treat each one of them
So, let’s talk about the Three types of Pain today
To understand these three types of pain, let me tell you what pain is.
Pain is the alarm system of our body.
It is good to have an alarm system, some people are born without the ability to feel pain,
and they die at an early age.
As an alarm system of a house, you install sensors for smoke, break-ins, water leak,
carbon monoxide all over your house.
Our body has various sensors distributed everywhere.
The skin is where most of the sensors are, but we also have some sensors in the internal
organs.
The skin has sensors to detect high temperatures, low temperatures, too much pressure, chemicals,
and many others.
All of these sensors send electrical signals to the spinal cord.
The spinal cord is similar to the box on the wall where all the wires of the house alarm
convey.
Here in the box, you can activate the alarm, de-activate it, turn the volume up or down,
give different passwords to various people in your household, and many other adjustments.
This box will communicate with the central office via telephone.
The main office will analyze the information coming from your house and decide to send
the ambulance, firetruck or the police to your home.
In the human body, the brain decides what to do with the information of pain.
Let’s study Nociceptive Pain Nociceptive pain is pain caused by an injury
or a disease activating the pain receptors.
That is exactly what the pain system is designed to do.
To alert the brain that something is causing damage to the body.
Examples are bruises, sprains, burns, bone fractures, appendicitis, menstrual cramps,
heart attack, kidney stones, surgery, a medical procedure, and many other acute events to
the body.
In the analogy of the alarm of the house: There is a fire in the house, and the central
office has to send the firetruck.
There is a burglar, and the central office has to send the police
There is a medical emergency, and the central office has to send the ambulance.
This type of pain is what we call “Acute pain.”
It is short-lived, lasts a few hours or days.
The body heals, and the pain stops.
We treat nociceptive pain with ice packs, transcutaneous electrical nerve stimulation
(TENS), acetaminophen, anti-inflammatories, and in some cases opioids.
The second type is Neuropathic Pain.
This type of pain is a consequence of an injury or disease of the nervous system.
The nervous system communicates with and controls the whole body, sending orders and receiving
information.
The nervous system comprises the central, peripheral and autonomous nervous systems.
The central nervous system contains the brain and the spinal cord.
They are surrounded by special membranes and they are kind of isolated from the rest of
the body, and protected inside very think bones: the skull and the vertebraes.
The peripheral nervous system is composed of all the nerves that exit the spinal cord.
The autonomous nerve system has some parts inside the central nervous system and parts
outside the central nervous system.
It is divided into two parts: the sympathetic and the parasympathetic autonomous nervous
system.
If there is an injury or damage to the nervous system, this will generate a sensation that
will be interpreted by the brain as pain.
It is not actually pain from nociceptor stimulation.
In the analogy of the alarm system, it is like if someone cuts a wire.
The central alarm office will receive a signal that someone cut the wire of your house.
That doesn’t seem good.
Maybe someone will try to invade and disconnect the alarm from your house.
So, the central office will have to do something about that.
You can’t just go on with the alarm wires cut off.
When a nerve is injured by a cut, a pressure or a disease, it generates neuropathic pain.
The brain will detect that the wires have been cut and the way to alert you is by creating
pain.
So, it is a different kind of pain from nociceptive pain, because here, the injury is in the alarm
system itself.
These injuries to the pain system can happen in the periphery, the central or the autonomous
nerve system.
Examples of conditions that cause neuropathic pain are peripheral neuropathies, nerve compressions,
radiculopathy, spinal cord injury, stroke, and multiple sclerosis.
Neuropathic pain can be acute, if the injury starts abruptly, or can be slowly progressive
in case of nerve compressions or neuropathies.
The treatment for neuropathic pain is different from nociceptive pain.
Neuropathic pain is treated with agents that reduce the activity of nerves and neurons.
These are usually antidepressants and anticonvulsants.
Opioids are sometimes combined with these drugs to increase the pain analgesia effect.
But acetaminophen and anti-inflammatories rarely have some effects on neuropathic pain.
It seems that cannabinoids, lidocaine and ketamine have some benefits to neuropathic
pain.
Before I continue, let me remind you that this video is not intended to replace medical
advice.
It is for educational purposes only.
You should contact your doctor for a proper diagnosis and treatment plan for you.
In case of emergency, go to the nearest emergency department or call an ambulance.
Now, let’s talk about the third type of pain: Nociplastic pain.
This pain is caused by neuroplasticity, or changes in the pain system that occur as consequence
of a nociceptive or neuropathic pain.
The World Health Organization (WHO) in its 11th revision of the International Classification
of Diseases (ICD-11) includes chronic pain as a diagnosis in its own right, it can be
chronic primary pain and chronic secondary pain.
Chronic primary pain refers to pain that exists despite complete tissue healing, or pain that
has no identifiable cause.
This is noticplastic pain.
Chronic secondary pain occurs in association with underlying diseases, they can be nociceptive,
neuropathic or mixed.
So what exactly is nociplastic pain?
In the analogy of the pain system, it is like this.
There was a fire in a house; it burned the whole kitchen.
It was bad.
The house appeared on the local radio and TV news, the owners were super scared, their
kids were screaming in the street, but nobody got seriously injured or died.
The insurance company fixed the kitchen, and they got new appliances and all new furniture
for the kitchen.
It looks much better than the old kitchen.
However, the owners are still frightened by what happened.
they are so afraid of this happening again that they are not using the new kitchen.
In addition, the alarm office was terribly affected by this whole situation.
When the alarm was triggered, the lady who received the call at the central office was
distracted, she didn’t send the firetrucks right away and this delay contributed to the
whole kitchen being destroyed.
She feels guilty, even years after the fire has happened, she still is afraid of making
that mistake again.
The co-workers are having regular staff meetings to solve this situation and help her.
She keeps getting panic attacks every time that ther is incoming call from a house fire.
So, this is nociplastic pain.
The injury has healed, the body has been restored, but the person still has fears and memories
of the pain.
The person is afraid of using that body part, cannot sleep at night, is constant fatigued
during the day, cannot concentrate on simple tasks, cannot work, and their life starts
spiraling down.
The person is afraid of making a mistake, and fear is paralyzing.
Now, even the autonomous sympathetic nerve system is alert all the time.
Instead of enjoying their life and accomplishing what they would like to do, they are stuck
in the memory of pain.
So, like the family in the house, instead of enjoying the new kitchen, they are paralyzed
by fear.
And like the central alarm office, instead of forgiving a mistake and retraining the
staff to avoid this from happening again, they are stuck in guilt, shame and perfectionism.
The treatment of nociplastic pain involves brain retraining, mind-body therapies.
I have another video that I explain various evidence-based mind-body therapies that work
for chronic pain.
It is very simple to retrain the brain, the person first needs to understand that the
pain is coming from malfunctioning of their pain system, that the pain is real, but it
is coming from the fear of pain.
Once the person sees that, it is easy to erase the memory of pain.
It makes me sad when I see a patient with nociplastic pain for years and nobody ever
told them this, and worse, they are prescribed multiple medications that are good for nociceptive
or neuropathic pain, but they do nothing to nociplastic pain.
Well, in case of opioids, it can make nociplastic pain worse, we call this opioid induced hyperalgesia.
I have another video that explains that.
So, how do we diagnose these three types of pain?
This is done by taking a good history of the pain, their other symptoms, how it happened,
what makes it worse or better.
I have another video that I teach how you can explain your pain to your doctor, and
there is a worksheet to download for you to get all the essential details of the pain
before you meet with your doctor.
We also do a mental health screening to see if there are psychological symptoms, as these
are important to differentiate nociplastic pain from other pains.
We do a physical exam to look at the body parts that are affected by pain, which includes
a sensory examination of the pain nociceptors in the skin, an examination of the parts that
hurt and a neurological exam.
And finally, we may need to order some labs and tests to find out where the pain is coming
from, for example, if we suspect there is a kidney stone causing pain, we might need
to order an ultrasound to see where the stone is and to confirm the diagnosis.
In chronic pain clinics, it is common to see patients who have these different types of
pain simultaneously.
Sometimes, the person may have purely an ongoing nociceptive pain, inflammation for example,
this is common in arthritis.
But some people will develop an exaggerated fear of pain and that fear will paralyze them.
And there are cases of purely nociplastic pain, an example is fibromyalgia.
I have another video that I explain in more details what fibromyalgia is, and another
video that explains what are risk factors that predispose a person to develop fibromyalgia,
or in other words, risk factors that put a person at higher risk of developing nociplastic
pain.
The good news about nociplastic pain is that it is treatable, and the results are incredibly
satisfying.
The brain is plastic which means that the brain can heal itself.
We can teach the brain to think differently, to not be afraid of pain, and let go of guilt,
shame and perfectionism.
I have seen patients who overcame their nociplatic pain with very simple and quick mind-body
therapies.
Many people are pain-free today.
Others still have residual nociceptive or neuropathic pain, but they tell me that these
pains are easier to manage, and they are not debilitated by them.
What was very debilitating was the fear they had from pain, which is now gone.
They don’t fear pain anymore, they stopped pain medications, they practice self-compassion,
they meditate, they exercise regularly and they are able to enjoy their lives and fulfill
their dreams.
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Good bye!