Why Chronic Pain Needs a Different Approach: Understanding the 3 Types of Pain
Have you ever wondered why you are still in pain, or why treatments that work for others don’t work for you? That’s because not all pain is the same.
There are three main types of pain:
Pain due to injury (nociceptive pain)
Nerve pain (neurogenic pain or neuropathic pain)
Chronic pain (neuroplastic pain or central sensitization).
Each type of pain has a different root cause and requires a different treatment approach.
Conventional pain tends to treat all pain as a structural problem, which often leads to inaccurate diagnosis and ineffective treatment of nerve pain and chronic pain.
In this post, we’ll break down the differences between the three pain types, including symptoms, diagnosis, and the most effective treatment approaches.
If you’ve been stuck in the chronic pain cycle, understanding your pain type is the first step toward lasting relief.
THE THREE TYPES OF PAIN
Did you know that there are three types of pain and they all require a different approach to diagnosis and treatment because they each have a different root cause?
Nociceptive pain occurs when injury causes tissue damage. Nociceptive pain is the type of pain you probably think of when you think about pain. The modern medical system is well-equipped to diagnose and treat nociceptive pain because it has a clear cause that can be seen on diagnostic images. Nociceptive pain typically responds well to orthopedic treatments, such as immobilization or splinting to help the tissue heal, and physical therapy to restore mobility and strength.
Neuropathic pain (also called neurogenic pain) is caused by nerve injury or irritation. Because the nerves transmit sensory information to the brain, when they are injured or irritated, the can become hypersensitive to movement, temperature, stress, and other activating factors. Sometimes nerve injury can be deduced through diagnostic imaging if the space around a nerve appears compressed, but diagnostic imaging cannot “see” nerve sensitivity. The root cause of neuropathic pain is often not the structure, but the electrical wiring of the nervous system. This means that a traditional orthopedic approach to treatment is often insufficient. Healing from neuropathic pain requires treating the nervous system and reducing the sensitivity of the nerves.
Neuroplastic pain (also called nociplastic pain or central sensitization) occurs when the central nervous system becomes hypersensitive. Often central sensitization occurs without any injury or tissue damage, but it can also occur when an injury causes stress to the nervous system, causing the pain to persist long after the tissue has healed. Central sensitization is like having a sensitive alarm system that is easily activated.
Continue reading to learn more about the root causes, symptoms, diagnosis, and treatment of each of the three types of pain.
NOCICEPTIVE PAIN (Pain due to injury)
Nociceptive pain can be caused by acute injury, such as a broken bone, sprained ankle, cut, or bruise. It is associated with tissue change or damage.
Pain is like a fire alarm. Sometimes the alarm is activated by faulty wiring, dust, humidity, or the steam from the shower or the stove. Nociceptive pain is the equivalent of a fire alarm ringing because there is an actual fire in the building.
Nociceptive pain is a positive evolutionary adaptation because its presence prompts you to take care of an injury to prevent additional damage and to enable you to heal.
That said, it is possible to have tissue damage and not have any pain. Have you ever noticed a cut or a bruise after the fact and been unsure where it came from? If so, you’ve likely experienced tissue damage that wasn’t painful because your nervous system didn’t perceive any damage.
Pain is a nervous system reaction to potential danger.
It is important to keep this in mind because it is possible to have structural changes in your body, such as osteoarthritis or a meniscus tear, and not have any pain or loss of function if the nervous system is resilient and does not interpret the structural changes as threatening. This is why incorporating the nervous system into orthopedic treatment for acute injuries is an important chronic pain prevention tool.
Common Causes of Nociceptive Pain
Broken bones
Sprains or strains
Surgery
Muscle pull or tear
Symptoms of Nociceptive pain
There is a clear mechanism of injury.
The amount of pain is proportional to the injury.
There are known aggravating and easing factors.
The pain is intermittently sharp and dull, and throbs at rest.
There isn’t any burning, shooting, or electric shock pain.
The pain is relieved with rest, and there is little to no night pain.
Diagnosis and Treatment of Nociceptive Pain
Conventional medicine excels at diagnosing and treating acute injuries via orthopedic assessments, palpation, visual inspection, and diagnostic imaging.
The treatment typically involves immobilization and rest to give the injured tissue time to heal. This may include a cast or brace in the case of a fracture or sprain, or modifications to exercise and functional tasks to reduce strain on the injured area.
Rest, ice, heat, or anti-inflammatory medications may help reduce pain.
Once the injured tissues heal, physical therapy is typically effective for regaining strength and mobility and helping you gradually restore your function.
The good news is that most injuries will heal within 6 - 12 weeks, and the pain should decrease proportionally.
If you have an acute injury and your pain lasts for more than three months, that isn't a sign that your injury needs to heal, its a sign that your pain is no longer nociceptive and your nervous system has become sensitive.
Keep reading to learn about nervous system sensitivity and the role the nervous system plays in pain.
2. NEUROPATHIC PAIN (Nerve Pain)
Neuropathic pain (sometimes called neurogenic pain) arises from the nervous system and is associated with an injury to a nerve or nerve plexus. This includes compression or traction injuries.
Common Causes of Neuropathic Pain
Radiculopathy (often associated with a herniated disc)
Plexopathy (associated with trauma, compression, inflammation, or traction of a nerve plexus)
Neuropathy
Carpal Tunnel Syndrome
Cubital Tunnel Syndrome
Sciatica
Trigeminal Neuralgia
Spinal Cord Injury
Central Neuropathic Pain Syndrome resulting from a lesion in the Central Nervous System (often following stroke, spinal cord injury, multiple sclerosis, or damage to the somatosensory pathways from the CNS to the body)
Shingles
Post-Surgical Nerve Damage
Nerves need space, blood flow, oxygen, and movement, and they don't like to be compressed or pulled. If a nerve is irritated, it can lead to altered sensations, such as numbness, tingling, burning, or shooting pains. Because peripheral nerves contain sensory and motor branches, nerve irritation can also lead to muscle weakness, deep muscle spasms or cramps, or muscle twitches.
If we return to the analogy of pain being like a fire alarm, neuropathic pain is like a fire alarm with faulty wiring.
Symptoms of Neuropathic Pain
Numbness
Burning
Tingling
Shooting pains
Electric shock-type pain
Symptoms follow the path of a nerve and might spread from the original site.
Pain is often worse after activity, but there can be a delayed reaction. You might not feel pain during the activity, but later in the day you might experience a flare in your symptoms.
Pain is often worse at night and interrupts sleep.
Diagnosis and Treatment of Neuropathic Pain
Neuropathic pain is diagnosed by evaluating the peripheral nervous system.
Nerves are designed to communicate sensory information from the body to the central nervous system and to send motor commands from the central nervous system to the muscles. If a nerve is irritated or injured, it can cause altered sensation and/or decreased muscle strength.
Each nerve root contains a sensory branch that supplies sensation to a specific region of skin and a motor branch that innervates specific muscles. We can evaluate the sensory system to determine if there is a region that is hypersensitive or desensitized. We can also test the strength of the muscles supplied by each specific nerve to determine if they are receiving proper neurological communication.
Neuropathic pain can also be assessed by the patient’s description of their symptoms, and by moving the affected body part into a position that places tension on the nerve to assess whether or not symptoms are activated.
In some cases, your medical doctor might refer you for an electromyography (EMG) or nerve conduction study to measure the electrical signals in your nerves and assess for nerve damage.
In an EMG, the provider will place a small needle with an electrode into your muscle and record the electrical activity when you are at rest and when you contract the muscle.
In a nerve conduction study, the provider will insert electrodes into your skin that will deliver small electrical pulses to record your muscles’ response to electrical stimulation.
These tests measure electrical activity only at the insertion site of the electrode, so they are not always the most conclusive tests and may not be necessary if you are receiving treatment from someone educated in pain neuroscience and skilled in treating the nervous system.
Nerves are highly sensitive, and recovering from neuropathic pain can take time and patience. Nerve injuries tend to heal at a rate of one inch or less per month.
Nerves need space, movement, and blood flow. The goal of treatment is to enable nerves to glide through the surrounding tissues without impingement or compression through a combination of manual therapy and specific exercises.
Nerves are sensitive by nature, so it is important to return to full movement and functional activity gradually while decreasing the sensitivity of the nerves. Pain Neuroscience Education, combined with sensory integration techniques, and mindfulness practices can help return to full activity without reactivating symptoms.
In some cases, medications targeting the nerves (e.g. Gabapentin, Neurontin, Lyrica), spinal cord or nerve stimulation, nerve blocks, or nerve ablations can be helpful for symptom management, but to heal the root causes of neuropathic pain, it is important to determine why the nerves are sensitive and to reduce that sensitivity by calming the nervous system.
3. CENTRAL SENSITIZATION (Chronic Pain from a Sensitive Nervous System)
Central Sensitization occurs because the central nervous system has become sensitive and is interpreting safe sensory stimuli as threatening, activating a pain response.
Central sensitization is sometimes called nociplastic or neuroplastic pain because of the brain’s malleability. You may have heard the phrase “neurons that fire together wire together.” When the nervous system creates pain pathways, the pain alarm can become easily sensitized or activated.
Neuroplastic pain is not caused by an injury to the body’s tissues. In contrast to nociceptive pain, neuroplastic pain either occurs in the absence of injury, or begins with an injury but the pain persists after the injury heals.
Central Sensitization is a protective response that causes widespread sensitivity throughout a region of the body, or in some cases, such as with conditions like fibromyalgia, throughout the whole body.
Remember, pain is the nervous system’s reaction to potential danger. Neuroplastic pain is similar to an extra sensitive fire alarm that is activated by benign, non-dangerous things like cooking dinner. To heal this type of pain, we have to help the nervous system feel safe in order to reduce the intensity and sensitivity of the alarm.
Common Causes of Central Sensitization
Chronic stress or trauma
Chronic depletion and overload
Autoimmune conditions
Rewiring of the nervous system to create pain pathways
Unresolved pain that lasts for a long time
High levels of fear and pain avoidance
Symptoms of Central Sensitization
Pain without a clear cause.
Global sensitivity.
Disproportionate pain.
Symptoms that are easily activated and not easily relieved.
Diffuse tenderness to palpation.
Pain that has spread from the original site.
Pain that keeps coming back.
Pain that migrates throughout the body.
Pain that impacts other areas of life, including sleep, digestion, memory, concentration, mood, and cognition.
Central Sensitization can impact all systems of the body and affect quality of life. Many common diagnoses, such as IBS, fibromyalgia, and Chronic Lyme Disease, involve central sensitization pathways.
Diagnosis and Treatment of Central Sensitization
We cannot see pain on an MRI or X-ray, so those types of diagnostic tools are not helpful in diagnosing central sensitization. Because conventional medicine tends to assume that all pain is the result of an injury, many people with Central Sensitization are sent for multiple MRIs or other scans, but they do not lead to a conclusive diagnosis because the cause of the pain is not tissue damage.
Diagnosis is made by the cluster of symptoms. The Central Sensitization Inventory can be used to identify the symptoms of nervous system hypersensitivity.
The physical exam includes sensory testing to determine if the nervous system is hypersensitive and to assess the accuracy of sensory perception.
Because nerves are designed to detect sensory stimulation, if the nervous system is sensitive, it can interpret safe sensations, such as light touch or cold temperature, as painful.
Treatment includes reducing sensitivity and re-educating the nervous system to improve the ability to accurately detect and interpret sensory information. This involves Pain Neuroscience Education, sensory discrimination training, sensory integration practices, graded motor imagery, and graded exposure to sensory system activators.
Because neuroplastic pain is a form of nervous system dysregulation or dysautonomia, it is important to restore safety to the nervous system so the alarm is not so easily activated.
WHY UNDERSTANDING YOUR PAIN TYPE MATTERS
When you are in pain, you want to understand why you hurt and have a clear and effective plan to address it.
The conventional approach to pain is to look for a structural cause and to offer biomechanical, orthopedic solutions.
Nerve pain and chronic pain are more complex conditions, and misdiagnosis or lack of diagnosis leads to frustration, confusion, and prolonged pain and suffering.
Nerve pain and chronic pain must be treated at the nervous system level, not the structural level.
If you feel like you are chasing pain, getting repeated tests and seeing multiple providers without clear answers or lasting relief, you may be being treated for the wrong type of pain.
Breaking the pain cycle requires receiving accurate diagnosis and targeted treatment. When it comes to nerve pain and chronic pain, rewiring the nervous system is more effective than the
LEARN MORE ABOUT NERVOUS SYSTEM SENSITIVITY
Do I have Central Sensitization Pain?
References
Butler, DS. The Sensitive Nervous System. Adelaide: Noigroup; 2000.
Devor, M. The pathophysiology of damaged peripheral nerves. In: Wall, PD., Melzack, R., eds. Textbook of Pain. 3rd ed. Edinburgh: Churchill Livingstone; 1994.
Gifford, L. Pain, the tissues and the nervous system: A conceptual model. Physiotherapy, January 1998; 84:1: 27-36.
Moseley, GL. Reconceptualizing pain according to modern pain sciences. Physical Therapy Reviews. 2007; 12:169-178.
Smart, KM., Blake, C., Staines, A., Thacker, M., Doody, C. Mechanisms-based classifications of musculoskeletal pain: Part 1 of 3: Symptoms and signs of central sensitization in patients with low back (leg) pain. Manual Therapy. 2012; 17:336-344.
Smart, KM., Blake, C., Staines, A., Thacker, M., Doody, C. Mechanisms-based classifications of musculoskeletal pain: Part 2 of 3: Symptoms and signs of peripheral neuropathic pain in patients with low back (leg) pain. Manual Therapy. 2012; 17:345-351.
Smart, KM., Blake, C., Staines, A., Thacker, M., Doody, C. Mechanisms-based classifications of musculoskeletal pain: Part 3 of 3: Symptoms and signs of nociceptive pain in patients with low back (leg) pain. Manual Therapy. 2012; 17:352-357.
BREAKING THE PAIN CYCLE: WHERE TO START
Having lived with chronic pain, I know how it feels to try all of the conventional approaches to healing without seeing lasting results. Most medical interventions treat all pain as nociceptive pain, which simply doesn’t work when the pain is associated with the nervous system, and not with acute tissue damage.
If you have neuropathic pain or neuroplastic pain, you need to treat your nervous system.
My practice is focused on healing the nervous system to relieve the root causes of nerve pain and chronic pain.
In person Offerings
If you are local to the Chittenden County, VT region, my practice is based in Shelburne, VT and I’d love to work with you to support your nervous system.
CranioSacral Therapy in Shelburne, VT
I offer CranioSacral Therapy to help the nervous system relax and unwind, and to support the body’s natural ability to heal. CranioSacral Therapy is my favorite manual therapy for pain relief because it works directly with the nervous system to reduce fear and reactivity.
Integrative Physical Therapy in Shelburne, VT
I also help people who have neuropathic pain or central sensitization rewire their nervous system through Integrative Physical Therapy.
In contrast to orthopedic physical therapy, this is physical therapy for your nervous system. Whereas orthopedic physical therapy teaches you exercises for your physical body, when you work with me, you will learn exercises for your nervous system.
This approach includes Pain Neuroscience Education, vagus nerve reset exercises, and mind-body training to reduce nervous system sensitivity, improve sensory discrimination, and reduce pain associated with nervous system sensitivity.
Virtual Offerings
Break the Pain Cycle: Online Pain Neuroscience Course & Group Coaching Program
Pain neuroscience education is actually more effective than medication at reducing pain and improving function!
If you want to learn more about the science of pain so that you can finally break the pain cycle, join the waiting list for the next round of my Break the Pain Cycle Program. This course will introduce you to the fundamentals of pain neuroscience and teach you how to help your nervous system feel safe so that it is less sensitive and more resilient.
The Break the Pain Cycle Program is offered virtually so you can join from anywhere in the world.
READY TO BREAK FREE FROM PAIN?
If you would like to learn more about my approach and whether it would be a good fit for you, let’s connect. I’m happy to help you determine what type of pain you have and provide a recommendation for treatment.
