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.

 

[Snow Leopard]

The word "mechanism" is mentioned a lot given there is no known mechanism.

A number of studies have shown that persistence of central sensitization, a mechanism of nociplastic pain, is unlikely without supportive noxious stimuli.

I'd argue further that central sensitization is in fact a normal part of healthy nociception - they'd have to demonstrate abnormality of that mechanism as well.

 

[Sean]

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.

If ever.

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.

Must be nice to be able to deal yourself the perfect get-out-of-jail-free card whenever reality gets a little too close for comfort.

 

[shak8]

The author Valdus Macionis is a plastic surgeon in Vilnius, Lithuania

His Google Scholar publications include several articles that underpin his feelings against the idea of nociceptive pain. His surgeries involve nerves and nerve grafts.

Whether or not there is nerve compression that causes and perpetuates "nociceptive" chronic pain conditions---I would think that this would have already been uncovered by now.

One or two likely causes (of many) of FM (nociceptive) pain to me is: an initial insult to muscle tissue (surgery, repetitive muscle strain). After the post-op period, chronic pain can begin. There is no more lesion, no more peripheral nerve injury. In repetive muscle strain, the overuse stops. But the chronic pain persists and spreads to other regions.

So, the idea of a focal cause of pain-generating sensory neurons (a huge amount of transmission) after the lesion or damage has ended---well, this has been disproved, and thus the warranted concept of nociceptive pain was generated, I believe.

Here is another article from his Google Scholar list of publications:


Chronic pain and local pain in usually painless conditions including neuroma may be due to compressive proximal neural lesion
Authors
Valdas Macionis
Publication date
2023/2/20
Journal
Frontiers in Pain Research

Description
It has been unexplained why chronic pain does not invariably accompany chronic pain-prone disorders. This question-driven, hypothesis-based article suggests that the reason may be varying occurrence of concomitant peripheral compressive proximal neural lesion (cPNL), e.g., radiculopathy and entrapment plexopathies. Transition of acute to chronic pain may involve development or aggravation of cPNL. Nociceptive hypersensitivity induced and/or maintained by cPNL may be responsible for all types of general chronic pain as well as for pain in isolated tissue conditions that are usually painless, e.g., neuroma, scar, and Dupuytren's fibromatosis. Compressive PNL induces focal neuroinflammation, which can maintain dorsal root ganglion neuron (DRGn) hyperexcitability (i.e., peripheral sensitization) and thus fuel central sensitization (i.e., hyperexcitability of central nociceptive pathways) and a vicious cycle of chronic pain. DRGn hyperexcitability and cPNL may reciprocally maintain each other, because cPNL can result from reflexive myospasm-induced myofascial tension, muscle weakness, and consequent muscle imbalance- and/or pain-provoked compensatory overuse. Because of pain and motor fiber damage, cPNL can worsen the causative musculoskeletal dysfunction, which further accounts for the reciprocity between the latter two factors. Sensitization increases nerve vulnerability and thus catalyzes this cycle. Because of these mechanisms and relatively greater number of neurons involved, cPNL is more likely to maintain DRGn hyperexcitability in comparison to distal neural and non-neural lesions. Compressive PNL is associated …
Total citations
Cited by 4

 

[rvallee]

The word "mechanism" is mentioned a lot given there is no known mechanism.




I'd argue further that central sensitization is in fact a normal part of healthy nociception - they'd have to demonstrate abnormality of that mechanism as well.

This reads to me exactly like "a perpetual motion machine is possible as long as you give it just a little push at the right time".

That's because it is. But of course in the belief systems where "central sensitization" is a thing, or it could be "fear avoidance", or "abundance of farts" for all that it matters, the push is magical, thoughts and beliefs are enough to keep the perpetual motion going, you just have to believe in it.

Because if you don't believe in it, it just looks like a bunch of fraudulent bullshit. Because it is.

 

[MrMagoo]

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.

Schrödinger’s illness. There’s an illness in the human somewhere, but if we look into it we might find out the cause.