How would you describe your pain?

I feel like I'm being annoying when I ask my patients to describe their pain. It just hurts! The description is actually important, as there are different kinds of pain and they are treated quite differently. There are two main categories of pain that I treat (more exist, but they are mainly in the worlds of abdominal and pelvic pain). Understanding these can help us who suffer from chronic pain disorders if and when we feel something new. I'll circle back to this point at the end.

The two primary types of pain that people experience are nociceptive pain and neuropathic pain.

Nociceptive pain is the more common form of pain. It arises from the activation of specialized nerve fibers called nociceptors throughout the body. These nociceptors detect harmful stimuli such as heat, pressure, or chemicals, signaling the presence of tissue damage or injury to the brain. The signal is relayed from the nociceptor to a peripheral nerve, then the spinal cord, and then up to the brain, where the pain is perceived.

Nociceptive pain is classically described as sharp, aching, throbbing, or dull, and typically localized to the site of the injury or damage. The intensity of the pain usually corresponds to the severity of the injury. A paper-cut hurts less than a fractured bone. Nociceptive pain is usually temporary and resolves as the underlying injury or damage heals.

In contrast to nociceptive pain, neuropathic pain stems from dysfunction or damage to the nervous system itself. It can arise from a wide variety of conditions. If the nervous system is damaged, (i.e. trauma to a nerve itself), a persistent signal can be sent to the brain. In addition, neuropathic pain can occur when the nervous system becomes hypersensitive for whatever reason and can send pain signals to the brain even in the absence of any actual tissue damage. There are other mechanisms that have been demonstrated and theorized about how neuropathic pain can develop, but there is a lot we still do not know and in detail explanation is beyond the scope of this blog.

Neuropathic pain is typically described differently than nociceptive pain. Patients usually describe their pain as burning, shooting, tingling, or electric shock-like sensations. Neuropathic pain may seem disproportionate or unrelated to the original injury or pathology. My pain syndrome started with simply feeling a pop one day in my ankle and my life has never been the same. Neuropathic pain may persist even after the underlying cause has been treated, and can be less responsive to over the counter and other basic pain medications.

When I examine someone in the office, the main physical exam finding is a change in sensation to either touch or pinprick. For example, if someone has chronic ankle pain, and they report either hypersensitivity or a lack of feeling to either touch or pinprick, that is a big clue that the pain is neuropathic.

Obviously, distinguishing nociceptive vs. neuropathic pain is important for health care providers as proper diagnosis is important and the predominance of one type of the pain is important for treatment options. However, to circle back on the point I made in my opening paragraph, it is also very important for people with chronic pain syndromes to be in tune with our bodies. This awareness can allow us to distinguish whether or not a particular pain pathology is worsening, or if something else is going on. For example, I have chronic neuropathic pain in my right ankle. I am in and out of a wheelchair depending on the severity and my ability to bear weight. After I am in a wheelchair for a prolonged period of time and start walking again, my body needs to relearn walking mechanics. This process stresses my foot and ankle. New aches and pains arise, but they are typically nociceptive in nature. One time after about a year in a wheelchair, I started walking again and started experiencing significant pain along the bottom of my foot. I realized that this was not a worsening of my neuropathic pain, but rather plantar fasciitis that developed as walking put strain on that unused part of my foot.

Recognizing a new and different type of pain is important for us with chronic pain syndromes because it can alleviate a lot of our anxiety. When we can recognize that our pain syndrome is not worsening, but rather something else is happening that is easily treatable, we can take a deep breath and focus on healing the more easily treatable issue at hand.