Opinion Nociplastic pain: controversy of the concept

[Joan Crawford]

Korean J Pain 2025; 38(1): 4-13

Published online January 1, 2025 https://doi.org/10.3344/kjp.24257

Copyright © The Korean Pain Society.

Nociplastic pain: controversy of the concept

Valdas Macionis

Independent Researcher, Vilnius, Lithuania

Correspondence to:Valdas Macionis
Independent Researcher, Fabijoniskiu 11, Vilnius 07122, Lithuania
Tel: +370 65674900, E-mail: valdas.macionis.md@gmail.com

Handling Editor: Francis S. Nahm

Received: August 5, 2024; Revised: October 22, 2024; Accepted: November 4, 2024

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Classically, pain can be of a nociceptive or neuropathic nature, which refers to non-neural or neural tissue lesions, respectively. Chronic pain in conditions such as migraine, fibromyalgia, and complex regional pain syndrome (CRPS), is thought to perpetuate without a noxious input. Pain in such patients can be assigned neither to the nociceptive nor neuropathic category. Therefore, a third pain descriptor, named “nociplastic pain”, has been adopted by the International Association for the Study of Pain. The current controversy-focused narrative review updates littledebated aspects of the new pain concept. The most disputable feature of nociplastic pain is its autonomous persistence, i.e., existence without causative tissue damage, presumably because of a malfunction of pain pathways and processing. This contradicts the fact that nociplastic pain is accompanied by persistent central sensitization that has been shown to require a continuing noxious input, e.g ., nerve injury. Even if sensitization occurs without a lesion, e.g ., in psychogenic and emotional pain, peripheral stimulus is necessary to produce pain. A logical weakness of the concept is that the word “plastic” in biology refers to adaptation rather than to maladaptation. The pathophysiologic mechanism of nociplastic pain may, in fact, be associated with background conditions that elude diagnosis because of the limitations of current diagnostic means. Misapplication of the nociplastic pain category may weaken diagnostic alertness toward occult causes of pain. Possible diagnostic errors could be avoided by understanding that nociplastic pain is a mechanism of pain rather than a diagnosis. Clinical use of this pain descriptor deserves a wider critical discussion.

Keywords: Central Nervous System Sensitization, Chronic Pain, Complex Regional Pain Syndromes, Diagnosis, Fibromyalgia, Hypersensitivity, Neuralgia, Nociception

Full article:

Nociplastic pain: controversy of the concept

Valdas Macionis. Korean J Pain 2025;38:4-13. https://doi.org/10.3344/kjp.24257

www.epain.org

 

[Creekside]

Blind men describing an elephant? It may be a long time before we can map out precisely which neurons are responsible for the perception of pain.

 

[Utsikt]

These seems like fairly basic questions to ask of any scientific theory, but based on my conversations with supporters of this theory I can’t say I’m surprised that they have not been addressed by them previously.

There’s some talk about trigger points in FM, which I’ve understood might not actually be a thing after all?

The discussion on psyche-driven pain misses the point about the psyche being a result of physical processes, so even if the psyche caused the pain it wouldn’t be pain without a cause.

 

[rvallee]

The pathophysiologic mechanism of nociplastic pain may, in fact, be associated with background conditions that elude diagnosis because of the limitations of current diagnostic means

It's truly amazing how "there might be things we don't understand yet" is both the least controversial statement of fact in the profession, and the most, at the same time. It is generically accepted as a truism, but never in any specific case. A thing that is always true yet also must always be false every time it is evaluated. A groundbreaking statement that is usually never given a second of thought, let alone any of its implications.

The whole thing basically works like a law enforcement system that could not accept unresolved crime, and so simply accuses the victims of their own crimes when they fail to do so, noting positively how it has the potential to massively reduce incidence of crime reporting, without ever thinking though the implications of that. Zero thoughts in those heads going on about any of this.

Because simply thinking this is such an oddity, that a Lithuanian researcher is publishing it in a Korean journal. Has not even the Catholic papacy renounced its past claims of infallibility? The medical profession is very far from being able to even think about it. Even though it constantly applies the same reasoning when it doesn't matter. What a truly odd bunch.

 

[Joan Crawford]

It does all seem a lot of chatter that would be better off instead of inventing/creating labels like nociplastic, just simply state - dunno. Not hard really. To be fair that is in the paper.

If "Chronic pain in conditions such as migraine, fibromyalgia, and complex regional pain syndrome (CRPS), is thought to perpetuate without a noxious input." Perhaps looking for the noxious input would be worth a punt. Maybe 'they' are 'on with it' but I don't get that sense.

My chronic pain has largely resolved with antimicrobials long term. My chronic daily migraines have been tamed with monoclonal antibody treatment (Ajovy). Migraine treatments seem much further developed than fibromyalgia/chronic pain.