Why Chronic Pain Needs a Different Approach: Understanding the 3 Types of Pain

As a Doctor of Physical Therapy and certified chronic pain specialist, most of the patients I see have already tried traditional physical therapy and other interventions, and it hasn’t fully resolved their pain.

The reason for this is that there are three different types of pain, each requiring different diagnostics and treatments, but conventional medicine treats all pain the same way. To break the chronic pain cycle, we have to stop treating all three types of pain like an acute injury by addressing the root causes within the nervous system.

The Three Types of Pain

There are three types of pain: nociceptive pain, neurogenic pain (also called neuropathic pain), and neuroplastic pain (also called nociplastic pain or central sensitization).

Nociceptive Pain

Nociceptive pain is the kind of pain you have when you have an acute injury. It is associated with tissue change or damage. If you break a bone, cut your finger, or sprain your ankle, you will have nociceptive pain.

Pain is a nervous system reaction to potential danger. 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.

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.

Once the injured tissues heal, physical therapy is typically effective for regaining strength and mobility.

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.

Neurogenic Pain (also called Neuropathic Pain)

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, and diagnoses such as

• 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)

Nerves are highly sensitive, and recovering from neurogenic pain can take time and practice. Nerve injuries tend to heal at a rate of one inch or less per month.

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. If we return to the analogy of pain being like a fire alarm, neurogenic pain is like a fire alarm with faulty wiring.

Symptoms of Neurogenic 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 Neurogenic Pain

Neurogenic 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 supplys 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.

Neurogenic 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.

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, spinal cord or nerve stimulation, nerve blocks, or nerve ablations can be helpful for symptom management, but to heal the root causes of neuropathic or neurogenic pain, it is important to determine why the nerves are sensitive and to reduce that sensitivity.

Neuroplastic Pain (also called Nociplastic Pain or Central Sensitization)

Neuroplastic pain is pain that occurs because the nervous system has become sensitive and is interpreting safe sensory stimuli as threatening, activating a pain response. 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 lasts longer than typical tissue healing time after an injury.

It is often called Central Sensitization because it causes widespread sensitivity throughout a region of the body, or in some cases, such as with conditions like fibromyalgia, throughout the whole body. Neuroplastic pain also used to be called complex regional pain syndrome, causalgia, or reflex sympathetic dystrophy.

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, nondangerous 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.

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. Read this article to learn more about the global symptoms of central sensitization and the common conditions that are associated with a sensitive nervous system.

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.

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, 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.

Do you think your pain is due to nervous system sensitivity?

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 neurogenic pain or neuroplastic pain, you need to treat your nervous system.

I offer CranioSacral Therapy to help the nervous system relax and unwind, and to support the body’s natural ability to heal.

I also help people who have neurogenic/neuropathic pain, or who have neuroplastic pain or central sensitization rewire their nervous system through Integrative Physical Therapy and Pain Coaching. This includes Pain Neuroscience Education, vagus nerve exercises, and mind-body training to reduce nervous system sensitivity, improve sensory discrimination, and reduce pain associated with nervous system sensitivity.

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.