Pain

What is Pain?

If you have ever accidentally touched a hot surface, you have experienced nociceptive pain which is meant to alert you to something dangerous. This type of pain usually has a clear cause and is meant to protect us from something that could cause us harm. However, sometimes pain may not be useful or protective — sometimes the pain is from a disorder associated with how pain is produced — that is, the pain system itself is broken.

Here we learn about nociceptive pain (healthy pain), neuropathic pain (pain from damaged nerves), and nociplastic pain (pain created mostly in the central nervous system). Treatment can look very different depending upon which type or types of pain you are experiencing. These videos can help you understand your pain and what might be causing it.

What are the three categories of pain?

Below is a description of each type of pain.

1. Nociceptive pain: Nociceptive pain is an example of the body’s pain mechanism working properly and adaptively. It warns you of threat and danger. Examples include pain stemming from acute injury, pain after surgery, and pain associated with tumors. Short-term inflammatory pain is another example of adaptive pain, where the immune system warns of danger by causing inflammation which can be interpreted by the brain as being painful. Most forms of nociceptive pain are short lived and serve a motivational function to urge you to act in accordance with health, safety, and survival.
2. Neuropathic pain: Neuropathic pain refers to pain associated with damage to either the peripheral or central nervous system. These nervous systems help take nociceptive messages from a site of injury to the brain. If the nerves carrying messages to the brain get damaged, they may fire excessively or in abnormal patterns. The excessive firing or abnormal firing patterns can be interpreted by the brain as sharp or burning pain. Neuropathic pain is a pain disorder that has lost its adaptive function. Examples include diabetic neuropathy, severed nerves, and nerve damage to the brain or spinal cord.
3. Nociplastic pain: Nociplastic pain or “centrally augmented pain” is a disorder of how the brain processes nociceptive signals. In such cases, non-nociceptive or minimally nociceptive signals from the body can become augmented by the brain leading to the production of a painful experience. It should be noted that pain experienced in response to an injury is indistinguishable from pain associated with central augmentation. Both are “real” forms of pain, and both can result in comparable levels of suffering. Many factors can contribute to central pain augmentation including genetics, infections, hormonal abnormalities, physical and/or psychological trauma, repetitive injuries, and sustained physical/psychological stress. Examples of conditions thought to be associated with augmented pain processing include fibromyalgia, some forms of low back pain, and some forms of headache.

Joint and Muscle Pain in Lupus

Pain is a very common symptom of lupus, especially pain in the joints. Pain varies widely in how it feels; it may be felt as a throbbing, aching, cramping, or stabbing. It can also be accompanied by sensations such as stiffness, tenderness, and weakness. Pain can vary widely in severity, from being a mildly uncomfortable sensation to a debilitating condition.

What are common causes of musculoskeletal pain in people with lupus?

Common causes of pain in patients with lupus may be from inflammation, prior damage to tissue, osteoarthritis, musculoskeletal injury, neuropathy or fibromyalgia. It is important to talk with your doctor about your pain to understand the most likely cause because the treatment will depend on the cause. We will discuss the causes of different types of pain below.

Inflammation: Lupus flares can be associated with increased joint pain, swelling and reduced range of motion of joints. Joint inflammation may affect the small joints of the hands, wrists, elbows, toes, knees, and ankles and these areas may appear swollen, red, and warm. Stiffness, tenderness, and weakness in all of these areas may limit movement. Additionally, stiffness in the mornings lasting an hour or longer may be experienced by people with lupus. Other symptoms, such as rash, oral sores, chest pain or hair loss, may occur along with your pain which may suggest this is related to a lupus flare.

Prior damage or osteoarthritis: Sometimes episodes of prior inflammation can cause chronic pain due to damage to tissues, even if there is not active inflammation present. Avascular necrosis is another type of bone damage that can cause pain. Osteoarthritis (“wear and tear” arthritis) is another cause of pain in joint tissue that may be from prior injury to joints or from use of joints over time.

Musculoskeletal conditions and injury: This category includes issues such as tendonitis, tendinopathy or ligament injury and may occur from overuse of areas, deconditioned muscles that don’t support the joint tissues, or from trauma. Common examples include rotator cuff tendinopathy of the shoulders or “tennis elbow.” A doctor can identify these types of injury with an examination of the area or may sometimes use imaging to help confirm the diagnosis. These conditions are usually treated with physical therapy.

Neuropathy: Pain that occurs due to injured nerves can cause sensations of numbness, burning, shooting, or sharp pain and may be associated with weakness or discoordination. Tingling or numb sensations can be felt all over the body but are commonly experienced in the arms, hands, legs, and feet. One common example includes carpal tunnel syndrome which occurs when there is too much pressure on the nerve passing through the wrist. Another example of neuropathy is peripheral neuropathy which may commonly be due to diabetes, alcohol use, or thyroid disease and causes numbness, burning and tingling in the toes, feet and sometimes fingertips.

Fibromyalgia: Many people with lupus also have a condition called fibromyalgia. Fibromyalgia is a condition where the central nervous system amplifies nociceptive input to create pain. This may feel like intense pain in response to mild pressure or aching sensations. This heightened pain response can be anywhere on the body. Some describe sensitivity to touch, sharp or shooting pains throughout the body, or pain when being hugged. Others also experience discomfort with smells, loud noises or bright lights. This occurs because the amplification is of all sensory stimuli not just those that are associated with pain.

Pain Treatment and Management

Doctors and other professionals can use procedures, therapies, medications, and devices to help you modify how the brain processes pain; but the person with the best access to your brain is you. Thus, the best approach for managing chronic pain is a partnership between what your doctor can do (i.e., professional care) and what you can do (i.e., self care). Current approaches to chronic pain management follow a step-by-step algorithm that personalizes treatment to the type of pain you are experiencing at any given time. Below is an example of this step-by-step approach.

• Diagnosis. Chronic pain management starts with careful diagnostics of what type or types of pain you are experiencing. When you experience a new pain symptom, the first healthcare provider to see is a primary care physician. A primary care provider may be able to diagnose and treat your pain, but they also may decide to refer you to a specialist, such as a physical medicine and rehabilitation specialists, orthopedist, or neurologist. When diagnosing pain, a healthcare provider will likely ask you the location and severity of your pain, as well as how often it occurs, how it affects your quality of life, if anything makes it better or worse, and if you experience a lot of stress. Other diagnostic tests may include blood tests, electromyography, X-ray, MRI, nerve studies, reflex and balance tests, or urine tests. The goal of these tests is to identify the cause of the pain. Learn more about talking to your doctor about your pain symptoms.

• Education and Self-Care. Self-management is the foundation of optimal pain care because it can directly impact how your brain produces the experience of pain. Learn more about self-care approaches for your pain symptoms.

• Professional Care. In addition to self-management, your doctor may want to include professional care such as medications, professional therapies, devices, and procedures. These approaches can also work to influence the perception of pain. When managing pain, certain medications may be helpful, including over the counter and prescribed drugs. These include acetaminophen, gabapentinoids, antidepressants, anti-anxiety drugs, muscle relaxers, opioids, and NSAIDs. Various types of therapies can also be helpful in managing pain, including cognitive-behavioral therapy, acupuncture, acceptance and commitment therapy, physical therapy, occupational therapy, emotion awareness and expression therapy, and massage and spa therapy. Your doctor also might prescribe devices to assist in managing your pain, like braces, traction, biofeedback, light therapy, ultrasound, and transcutaneous electrical neuromuscular stimulation. Your doctor can give you detailed explanations of these tests and treatments, so you can make an educated decision on which treatment may be best for you. You can learn more about professional pain treatments.