The concept of nociplastic pain—where to from here?

Abstract Nociplastic pain, a third mechanistic pain descriptor in addition to nociceptive and neuropathic pain, was adopted in 2017 by the International Association for the Study of Pain (IASP). It is defined as “pain that arises from altered nociception” not fully explained by nociceptive or neuropathic pain mechanisms. Peripheral and/or central sensitization, manifesting as allodynia and hyperalgesia, is typically present, although not specific for nociplastic pain. Criteria for possible nociplastic pain manifesting in the musculoskeletal system define a minimum of 4 conditions: (1) pain duration of more than 3 months; (2) regional, multifocal or widespread rather than discrete distribution of pain; (3) pain cannot entirely be explained by nociceptive or neuropathic mechanisms; and (4) clinical signs of pain hypersensitivity present in the region of pain. Educational endeavors and field testing of criteria are needed. Pharmacological treatment guidelines, based on the three pain types, need to be developed. Currently pharmacological treatments of nociplastic pain resemble those of neuropathic; however, opioids should be avoided. A major challenge is to unravel pathophysiological mechanisms driving altered nociception in patients suffering from nociplastic pain. Examples from fibromyalgia would include pathophysiology of the peripheral as well as central nervous system, such as autoreactive antibodies acting at the level of the dorsal root ganglia and aberrant cerebral pain processing, including altered brain network architecture. Understanding pathophysiological mechanisms and their interactions is a prerequisite for the development of diagnostic tests allowing for individualized treatments and development of new strategies for prevention and treatment.