By Scott Harris and Rachel Zaimont
Pain is a complicated biological process, particularly for people with immune-mediated diseases like spondyloarthritis (SpA). In recent years there have been major breakthroughs in our understanding of pain and how to treat it. Important research continues to advance our knowledge, but the fact is that pain is still a reality of daily life for millions of people.
Although there is still debate over how to classify different forms of pain, it can generally be divided into three broad subcategories: nociceptive, neuropathic, and nociplastic. These can occur individually or in combination with one another.
Let’s take a closer look at the three types of pain, why and where they occur, and how each one is best treated.
Nociceptive pain is the most common form of pain, and is generally caused by damage to body tissues due to an injury or inflammation. It’s the kind of pain you experience when you hit your head or prick your finger. It is also the most common form of pain in rheumatological and musculoskeletal diseases such as SpA. It can be achy, sharp, or throbbing.
There is good news for those with SpA who have nociceptive pain: It often responds well to exercise and physical therapy, non-steroidal anti-inflammatory medications (NSAIDs), biologics such as TNF and IL inhibitors, and inflammation-reducing injections. However, some people with well-controlled inflammation still continue to experience pain. In these cases, other types of pain may be occurring.
Neuropathic pain feels like an electric shock, accompanied by aching, burning, tingling, numbness, or similar sensations. It is typically caused by nerve damage, or nerve pressure. Diabetes is a common cause of neuropathic pain. Many other diseases and conditions are also linked to this kind of pain. In a 2018 study1 published in Clinical Rheumatology, some people with ankylosing spondylitis (AS) were found to experience neuropathic pain.
Medical treatment for neuropathic pain includes medication, physical therapy, counseling, and injections. Anti-inflammatory medications are usually not effective in treating this kind of pain. Instead, anti-seizure drugs, antidepressants, and topical creams, ointments, and patches are often used. Local nerve block injections are sometimes given by pain management specialists. More severe cases may be treated with peripheral nerve, spinal cord, or brain stimulation. In some cases surgery may be warranted.
Nociplastic pain is somewhat more mysterious, and the most recent target of intense study. The central nervous system is thought to play an important role in this type of pain. These pain sensations can be intense and widespread throughout the body, and can be accompanied by fatigue and other symptoms including sleep, memory, concentration, and mood disturbances. Fibromyalgia is the most common example. This type of pain can occur by itself, or in combination with other types of pain, as is sometimes the case in chronic low back pain.2
Nociplastic pain is seen as a scale or spectrum, with different people experiencing different levels of so-called “fibromyalgianess.” Nociplastic pain can amplify the symptoms of diseases like SpA. When a person with SpA experiences pain that is disproportionate to the amount of joint damage observed on imaging, the person might have nociplastic pain. Some 11-17% of people with SpA have nociplastic pain, according to a 2017 study.3
It is important to recognize and diagnose this type of pain in a SpA patient, since it responds to different treatments than nociceptive pain. Anti-inflammatory medications, biologics, and even opioids have not been found to be effective in treating nociplastic pain. There are several medications FDA-approved to treat fibromyalgia symptoms, including duloxetine (Cymbalta), milnacipran (Savella), and pregabalin (Lyrica). These medications can reduce the sensation of nociplastic pain, improve fatigue, and promote better sleep. Other types of medications may also be used, including antidepressants—although the use of these drugs does not mean you are depressed.
It is recommended that chronic pain patients only start one new treatment at a time, and try each treatment for several months. This way, you can keep track of what is working, what isn’t working, and what may be causing side effects.
The best treatment approach for nociplastic pain involves a combination of physical activity, self-care, and cognitive behavioral therapy—lifestyle changes that can benefit everyone with SpA.
Biologically, pain is the body’s way of alerting our brains to potential danger or injury. It is one way the body protects itself from harm.
Pain is felt when special neurons called nociceptors are activated by damage to body tissue or another stimulus the body perceives as a threat. These nociceptors secrete molecules that convert to nerve signals and convey information about the location and intensity of the threat. These signals are then transmitted to the spinal cord and finally on to the brain.
Simply put, these signals cause the body to enter a kind of fight-or-flight mode. The body releases stress chemicals that communicate to the brain that you are in danger. When the underlying trigger is resolved—in other words, when the painful stimulus or threat is no longer present—the body stops producing these chemicals and returns to normal.
As those living with SpA know, however, pain is not always this simple.
If the pain stimulus doesn’t go away, stress chemicals continue to flood the brain, and the body remains in fight-or-flight mode. When this state persists, the brain receives the message that the body is still not safe. The nociceptors in the central nervous system may undergo permanent changes over time. This is often called “central sensitization,” which is another term for nociplastic pain.
In this situation, although the pain may have originally been of the nociceptive type—that is, caused by an injury, inflammation, or tissue damage—it develops into something else: pain that is caused by the central nervous system itself. This pain can therefore be more difficult to diagnose and treat.
Chronic pain can be nociplastic, nociceptive (driven by ongoing inflammation), neuropathic, or any combination of the three.4 Chronic pain is defined as pain that lasts beyond the time it normally takes for body tissue to heal, usually three to six months. Instead of behaving as the body’s protective response, chronic pain can actually cause further damage to the body and become a disease, itself.
Socioeconomic Factors
The stress we encounter from our environment, and from physical or emotional trauma we may experience, is often neglected, but it plays a significant role in the experience of pain.
Housing or employment insecurity, low education levels, and low income all have been associated with chronic pain. Racial discrimination can also directly impact pain. A 2018 study5 found that racial discrimination was a significant source of stress, which in turn was determined to be the primary cause in 4.1 million cases of chronic pain in the U.S.
Similarly, post-traumatic stress disorder and psychological, sexual, or physical abuse can double or even triple the risk of developing chronic, widespread pain. According to the U.S. Department of Veterans Affairs, 15-35% of people with chronic pain also suffer from post-traumatic stress.6
Access to pain care and treatment is also affected by socioeconomic factors including race. Studies over the past 20 years show that Black and Hispanic patients are less likely to receive pain medication in the ER, and that when they do, they receive significantly lower doses. (You can read more from the National Pain Advocacy Center online.)
Gender often presents another barrier to care. Although the majority of people who experience chronic pain conditions are women, women are also more likely to have their pain downplayed, dismissed, and under-treated by clinicians.7
Managing pain often requires a multidisciplinary approach, involving both the body and the mind, and requiring both medical and social support. Below, we’ll explore in more detail ways to manage pain, both physically and emotionally—and in the process improve quality of life.
We know quite a bit about pain management these days. Whether it’s through medications (as discussed earlier in this article), lifestyle, or behavioral changes, you and your healthcare provider can together come up with strategies to lessen pain.
Physical Exam
A physical exam with your healthcare provider is a key starting point for determining what kind or kinds of pain you have, the specific issue or issues that could be causing them, and the best course of treatment to get your symptoms under control.
In treating SpA, your provider will typically assess posture, joint tightness or tenderness, mobility, and other factors. The location and nature of your pain may provide additional clues as to its source. For example, individuals with fibromyalgia (or nociplastic pain) are more likely to report “tenderness,” while “pain” is described more in inflammatory and mechanical pain (or nociceptive pain). A body map is a tool that can provide information on pain location and is an easy and useful way to check for widespread pain.
Healthcare providers also can check for inflammation using a blood test or an ultrasound exam, which can help distinguish pain caused by inflammation from other kinds of pain.
Pain can be assessed in different ways, but one of the most common ways for those with SpA is the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), a simple questionnaire that measures pain and discomfort, among other things.
Once you and your provider have more information on the nature and source of your pain, you can then begin to explore different ways to fight it.
Lifestyle Modifications
Lifestyle adjustments, such as regular exercise and physical therapy, are key to any pain management plan for SpA and can help decrease pain and improve function. Here are a few things to keep in mind:
In addition to specific physiological treatments, there are many strategies available to improve your ability to process and cope with pain—and strengthen your emotional wellbeing. (Painguide.com is a fantastic resource where you can explore a variety of approaches to pain management.)
Depression and anxiety are strongly associated with persistent pain. Many people with rheumatic diseases—as many as 75% in one recent review—have symptoms of depression.
Effective coping strategies include:
Your social support network. It is important to be mindful of the support you do (or do not) receive from your partner, family, friends, employer, and other people in your life. Broad social support has been associated with improved functioning and less severe pain. (Looking for more support? You can learn more about SAA’s in-person and online support groups.)
Behavioral therapy. Are you pulling away from valued hobbies and joyful pursuits? Releasing endorphins through laughter, exercise, and other activities is a vital way to interrupt the body’s chronic pain cycle. Do you notice fear-based behaviors, such as a fear of movement? Physical inactivity is a risk factor for the development of chronic pain and may exacerbate your body’s pain response. Many types of behavioral therapy, including cognitive behavioral therapy, have been shown to be effective tools in the management of pain.8 Behavioral therapies can also help avoid “catastrophizing,” a common cognitive and emotional response that includes magnifying and dwelling on pain. (Examples of this thinking include, “This is the worst pain ever,” “I can think of nothing else,” and “There’s nothing I can do.”) Catastrophizing is the single most significant risk associated with poor treatment outcomes for pain relief.
Behavioral therapy can also help improve resilience. A positive, optimistic attitude reduces pain sensitivity and pain intensity, and can help restore function.
Improve self-efficacy. Lifestyle modifications, behavioral therapy, and social support can make a big difference in pain management, and improve self-efficacy—your belief in your own ability to achieve your desired outcome. Strengthen your self-efficacy even further by practicing mind-body techniques like meditation or deep breathing, both of which have been shown in numerous studies to lower stress, boost coping abilities, and improve chronic pain.
Pain is complex and can affect those with SpA in many different ways. A sound understanding of pain and access to effective pain management tools are critical to wellbeing. We hope this article is a helpful step in your journey to living better with SpA.
The Basics of Pain Management
- • Learn more about your diagnosis, symptoms, and treatment.
- • Identify one or two of your most urgent symptoms or obstacles and create personal functional goals.
- • Identify what kinds of support you need, such as physical therapy, occupational therapy, cognitive behavioral therapy, changing or expanding social support, or a referral to a subspecialist.
- • Improve your sleep with a better sleep routine and a referral to a sleep clinic if necessary.
- • Track self-management behaviors and how your symptoms respond. Which behaviors make you feel better? What triggers a flare?
- • On follow-up visits, assess progress toward goals and barriers to progress. You can always adjust your goals as needed.
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