I’ve never heard of the concept of nociplastic pain or a treatment modality called pain reprocessing therapy (PRT), until my colleague, Dr. Ariel Portera, a primary care and integrative medicine doctor (based at UCSD), brought it to my attention. Learning about it led to a seismic shift in how I approach my patients who have chronic pain and how I talk to them about pain.
A good introduction to the concepts behind nociplastic pain can be found in a 2021 Lancet article, “Nociplastic Pain: Towards an Understanding of Prevalent Pain Conditions.” The article does a thorough job of describing what nociplastic pain encompasses. Nociplastic pain is described as a mechanism of altered processing and heightened sensitivity of the nervous system, rather than the traditional concepts of direct tissue injury (nociceptive pain) and nerve injury (neuropathic pain). The article goes over the most common nociplastic pain syndromes, which includes chronic widespread pain, fibromyalgia, chronic low back pain of unknown causes, chronic temporomandibular pain disorders, IBS, chronic primary bladder pain syndrome, chronic primary pelvic pain syndrome in men, and chronic primary pelvic pain syndrome in women.
In my clinical practice as a rheumatologist, the most common of the nociplastic pain conditions I come across is fibromyalgia, which can occur more frequently in patients with rheumatological conditions than in the general population. In rheumatoid arthritis, one of our most common rheumatological conditions, fibromyalgia was estimated to be prevalent in up to 18% to 24% of rheumatoid arthritis patients. I have found that patients who have concomitant fibromyalgia are often the most challenging to treat and manage. It can be difficult for both the clinician and patient to parse out how much of their ongoing pain is rheumatological versus fibromyalgia in origin. It can be difficult to decide whether to direct treatment toward the rheumatological condition or direct treatment toward factors like fibromyalgia and nociplastic pain.
Treatments that have been used for nociplastic pain are similar to how we approach fibromyalgia. Priority should be given to nonpharmacological treatment such as a strong doctor-patient relationship, patient education, stress reduction, sleep hygiene, physical activity, and psychological therapies (i.e., cognitive behavioral therapy). Pharmacological therapies are available but are primarily ones approved for fibromyalgia (i.e., serotonin–norepinephrine reuptake inhibitors, gabapentin, pregabalin). In practice, I have found both nonpharmacological and pharmacological can oftentimes be limited in effectiveness for treatment of fibromyalgia and nociplastic pain. Studies have shown that commonly used medications may not actually help fibromyalgia and the ones that do may only help up to 1 out of 10 patients with fibromyalgia. Additionally, pharmacological therapies can frequently cause side effects.
There have only been a few studies published on PRT for nociplastic pain, primarily done for chronic back pain. The first study of PRT was published in JAMA Psychiatry in 2021. The PRT modality created was described by the authors as a combination of cognitive, somatic, and exposure-based techniques, with the aim of helping patients reframe their pain. The results showed that 66% participants were pain free or nearly pain free after four weeks of treatment versus 20% of participants in the placebo group and 10% of participants in the usual care group. The benefits were reported to be sustainable through the one-year follow-up.
I think it’s important for physicians to become aware of the concept of nociplastic pain and how it can direct conversations with patients with chronic pain. It can help bridge the concept of mind and body in chronic pain and help remove some of the stigma that it’s “all in their heads” or psychosomatic, for some of our patients. And though there are very limited published studies on PRT, if the results in the limited trials could be reproduced in larger trials, and for the other common nociplastic pain conditions, especially fibromyalgia, the benefits could be seismic.
How do you approach patients whose pain doesn’t match their labs or imaging? Share in the comments.
Dr. Richard Lau is a practicing rheumatologist in the Sacramento community. He is interested in exploring integrative approaches that combine conventional medicine with complementary therapies to support patient well-being.
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