Nociplastic Pain and the Sensitive Nervous System by Professor Leslie Russek

Nociplasitic pain is due to sensitive nerves that have changed to become better at processing pain. This pain needs to be managed quite differently than “Issues with the Tissues.”

A sensitive nervous system is in a constant state of alarm. Peripheral nerves are usually sensitized by inflammation so management of inflammation can calm the nerves. The central and autonomic nervous systems may be sensitive because of current stress and anxiety, poor sleep quality, a history of trauma, or inflammation.

You should suspect nociplastic pain if:

• Pain seems disproportionate to the amount of tissue damage or exists/occurs when there is no or no new tissue damage
• If the pain distribution doesn’t make sense anatomically
• Other senses are also over-sensitive, such as sensitivity to smell, sound, or light
• Pain increases when you are stressed or anxious
• You have a history of physical or emotional trauma, especially in childhood.

Management of nociplastic pain involves calming the nervous system to decrease the perception of danger.

You need to feel safe for the danger alarm to quiet down. It may help to put your body into a safe, supported position, such as lying down with appropriate pillows. It helps to avoid negative thinking patterns, such as panicking that you will always be disabled by your pain. Every time you think or worry about your pain, a little bit of neurotransmitter is released in your brain to increase pain.

Reframing how you think of pain can decrease this.

Thinking of pain as discomfort can make it less scary. Remind yourself that you have tools to manage your discomfort. Realize that not all discomfort indicates something is dangerous. This doesn’t mean ignoring discomfort because there may be “issues with your tissues” that you can address.

Reassure yourself that you have skills to calm your nervous system and that the alarm will quiet when you do so.

Coping skills like this are part of Cognitive Behavioral Therapy (CBT), which can effectively manage nociplastic pain. More strategies to calm the nervous system:

• Diaphragmatic breathing
• Slow breathing Meditation or visual imagery. Some meditations focus on really becoming aware of what you hear, smell, or touch to ground the nervous system
• Small range, slow, and gentle movements in the mid-range of the joints. This can decrease sensitization by showing the brain the feeling of movement can be safe
• Heart Rate Variability (HRV) is a measure of how active the parasympathetic (rest and digest) nervous system is. HRV biofeedback helps some calm their nervous systems.

The Zebra Club includes many of these strategies to help quiet the nervous system.

The Vagus Nerve

The vagus nerve is one of the cranial nerves. It drives the parasympathetic nervous system to calm the central and autonomic nervous systems. Activating the vagus nerve also provides anti-inflammatory benefits that can decrease inflammatory pain and nerves sensitized by inflammation.

While research into ways to activate the vagus nerve is ongoing, we know that slow diaphragmatic breathing, chanting, and humming are effective. Electrical stimulation to the ear also works but isn’t available to most people; ear massage may produce some of the same benefits as electrical stimulation.

Managing nociplastic pain requires us to decrease the perception of danger, calm the mind, and calm the nervous system.

In the long term, regular exercise helps protect the nervous system from becoming sensitive. The trick for people with HSD/hEDS is finding safe forms of exercise that don’t activate the danger alarm. Nutrition and sleep are also important for a resilient nervous system.

it is important to recognize if some of your pain might be nociplastic due to a sensitive nervous system. If it is, you need to address the sensitive nervous system rather than (or in addition to) hunting for musculoskeletal or visceral causes of the pain. Remember that you can’t fix a flat tire by changing the air filter!

Figure out what kinds of pain you have and pick appropriate strategies to manage them.

September is Pain Awareness Month and I am honored to have Dr. Leslie Russek join me to discuss pain in hypermobility. Dr. Russek PT, DPT, PhD, OCS is not only my colleague and research partner, but also the scientific advisor to The Zebra Club where she regularly shares her vast knowledge of hypermobility spectrum disorders. Find more information, including generous free resources at https://webspace.clarkson.edu/~lrussek/