What is nociplastic pain and why is it a challenge for medical diagnosis?

is it possible to feel muscle contractures, fatigue or insomnia and that the medical studies do not reflect injuries or one organic disease that explains these symptoms? The answer is yes and it is related to the nociplastic pain. But to be more specific, it is well worth reviewing why, in these cases, the diagnosis it becomes a real challenge.

Headaches, stiffness, irritable bowel syndrome, bruxism, interstitial cystitis, general chronic pain, tiredness and even depression or anxiety are some of the signs that people report in the medical consultation, showing very affected his quality of life. However, traditional diagnostic studies, including magnetic resonancedo not yield conclusive results.

It is considered that, in many of these pictures, the origin of the ailments is the so-called nociplastic pain, a relatively recent concept that was introduced by the International Association for the Study of Pain (IASP). According to the entity, this kind of annoyance arises from a incorrect processing of stimuli They are normally painless and occur in the absence of infection or injury. Generally, it manifests with symptoms in various areas of the body but without a organic disease evident.

The reasons behind nociplastic pain range from organic factors associates up psychological components significant, often related to personal stories or even with background of violent relationships or of abuses.

Until accepted by the IASP, the pain mechanisms considered were two: on the one hand the pain nociceptivewhat is pain protective, which occurs when there is a wound, injury or fracture, and which warns us not to act on that part of the body that is injured because it can get worse. Then there was the pain neuropathicwhich is generated when the connections of the nervous system are damagedand for which there are neurological diagnostic criteria that accredit it.

Now, in nociplastic pain, what happens is the persistence of chronic and disabling pain over time, without any identifiable damage. It’s like a house alarm being miscalibrated and going off by mistake for nothing.

According to recent research, the perpetuation of nociplastic pain is related to psychosocial factors that contribute to plastic changes in neurons. In this sense, Dr. Nicolás Renna, cardiologist and president of the Argentine Society of Arterial Hypertension (SAHA), explained: “The heart contains an intrinsic nervous system that exhibits both short- and long-term memory functions.”

“The intrinsic nervous system of the heart consists of approximately 40,000 neurons called sensory neurites, which transmit information to the brain. Previous studies have linked negative emotions, such as depression, anxiety, and anger, with an increased risk of heart disease. Because these emotions tend to overlap and co-exist, it has been difficult to assign relative importance to any of them,” he continued.

“There is an entity called ‘broken heart syndrome’ -Renna continued- in which a very terrible emotion, such as the death of a loved one, a move or job loss, can release an exaggerated amount of chemically of catecholamines, a hormone linked to stress, such as adrenaline, and produce cardiomyopathy, which can manifest itself in exactly the same way as heart failure or a heart attack. This speaks of the connection between the heart and the brain beyond the receptors. On the other hand, chronic pain linked to stress, frustrations and emotions can cause chest pain, without there being heart disease”.

Some patients with nociplastic pain often fear the possibility of a serious disease, such as a tumor. These are people who have been suffering from discomfort for years and, in this context, may come to the idea that they have a terminal illness even though they do not have any evidence of it. What is produced, then, is a maladaptive thinking that causes suffering and fear.

For Renna, “there is a kind of vicious circle, because patients with nociplastic pain think or manifest certain symptoms that affect their daily lives and they abandon many healthy habits such as going for a walk, exercising, eating healthy or integrating socially; they even give up medication or over-medicate irresponsibly, giving rise to the development of a conventional cardiovascular pathology, there with a real possibility of a heart attack”.

Dr. Santiago Guaycochea, president of the Argentine Association for the Study of Pain (AAED), explained: “Generally, nociplastic pain is diagnosed in patients whose studies are good, but still feel pain. Some doctors find it difficult to recognize it because it is a very new medical entity, so there is still a high level of underreporting; it is diagnosed with the clinic, more than with studies”.

It is for this reason that an exhaustive clinical evaluation is essential, because it serves to rule out physical alterations that could cause this condition. A noise or even a caress can cause pain. Likewise, the therapeutic approach for this type of pain includes: physical therapy, psychotherapy and also pharmacological treatment. On the whole, It is intended that the patient does not abandon their socio-affective, educational or work activities.

He physical treatment consists of the practice of some activity in a smooth and gradual wayas aqua gym, stretching or postural rehabilitation. Meanwhile, for the psychological treatment therapy is widely used cognitive behavioral. Among the existing pharmacological resources that inhibit neuronal hyperexcitability, there is pregabalin and certain drugs intended to increase serotonin and norepinephrine in the brain, such as antidepressants.

“The treatment must be interdisciplinary to achieve better results. The long-term consequences of this chronic pain must be prevented, such as ‘mental fog’, mental disorders or failures at work”, warned Guaycochea, who will be a speaker at the Hybrid Pain Summit, which will be held in Buenos Aires on the 19th. May, convened by Upjohn division of Pfizerwithin the framework of the Week of Pain, which is commemorated from May 5 to 12.

And he added: “As red alert flags that would allow us to suspect the presence of nociplastic pain, the following can be identified: situations in which the pain is not always in the same place, absence of fever (which could mean an infection or rheumatological disease) and exacerbation of it in conflictive emotional situations. Today we know that it is difficult to diagnose because there is no ‘dolorimeter’, because pain is very individual and subjective”.

It is important to explain to patients what it is about, so that they are patient with their symptoms and with their treatment. Generally, it reassures them to hear that what is happening to them is that they have a misperception of stimuli. Before it was said, in an almost pejorative way, that what they felt was psychiatricnow we know that It is nociplastic pain.

Finally, Dr. Renna, who will be a speaker at the Regional Summit on Cardiovascular Risk Management -also organized by the Upjohn division of Pfizer- that will take place in the city of Medellín, in Colombia, indicated: “The most important thing is that, Just as we learned about this new classification of pain mechanisms, we have to understand that there must be an interaction between medical specialties, because -clearly- as we advance in the profession we realize the importance of integration”.

And he concluded: “Thus, for example, in a pathology that was purely cardiac, today it is known that there are other components such as diabetes, nutritional or psychological issues, among others; then, the way to approach it must have a new interdisciplinary perspectivenot only include several specialists, but that we work interrelated for the benefit of patients”.

* Professor and doctor Roberto Rey is head of Neurology at the Finochietto Sanatorium in Buenos Aires and director of the diploma course in electromyography at the University of Buenos Aires (UBA).

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