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A review published in serves as a tool for managing nociplastic pain in patients with rheumatic diseases.

The authors looked at the three general categories of pain: nociceptive, neuropathic, and nociplastic -- and focused on identifying the latter. They offer strategies for approaching and managing chronic pain.

The following excerpts have been edited for length and clarity.

What was the review's overarching objective?

Nociplastic pain describes pain characterized by altered nociceptive processing (e.g., hypersensitivity), suggestive of dysregulation of CNS pain processing pathways. This term is essentially synonymous with older terms such as central sensitization or centralized pain. Nociplastic pain is a broad term, which likely encompasses many different CNS pathways that lead to amplified processing of pain signals, decreased inhibition of pain, or both.

Prototypical nociplastic pain conditions include rheumatic diseases and fibromyalgia, irritable bowel syndrome, and tension headaches. In addition to pain, these conditions are frequently associated with fatigue, memory problems, poor sleep quality, and/or mood disturbances.

Patients referred to rheumatology frequently report pain as a primary symptom. This narrative review provides specific tools to aid in the assessment and management of pain.

The study outlines the role of patient education in managing chronic pain in people with rheumatic diseases.

It's important that clinicians validate that pain is a very real and very personal experience, while emphasizing that multiple factors (e.g., biological, psychological, social) can influence the intensity and impact of pain. As noted, pain may or may not be intrinsically related to the underlying autoimmune process. This likely differs from patient to patient and across time within individual patients. Regardless, pain is always an important part of the patient experience.

Patients with an underlying systemic rheumatic disease need to understand that pain may not always be a result of inflammation and/or joint damage. Several studies have shown that patients with rheumatoid arthritis and fibromyalgia have higher mean Disease Activity Scores (DAS28) than rheumatoid arthritis patients without fibromyalgia; scores often remain above the lower limit for mild rheumatoid arthritis disease activity.

Since composite disease activity measures appear to be affected by both nociceptive and nociplastic pain, consider the potential influences of nociplastic pain on disease activity assessments and, when nociplastic pain is the primary issue, help patients understand that managing the nociplastic pain may be more effective than changing or intensifying immunosuppressive therapy.

What is the latest thinking on pharmacological treatment of nociplastic pain in patients with systemic inflammatory diseases?

Data regarding the effectiveness of pharmacologic treatments in this setting are limited. The medications with the best evidence base for treating nociplastic pain include:

• Low nighttime doses of tricyclic antidepressants (including the tricyclic, cyclobenzaprine)
• Serotonin and norepinephrine reuptake inhibitors (SNRIs, such as duloxetine and milnacipran)
• Gabapentinoids

What are the best non-pharmacologic interventions?

Study authors recommended the following interventions:

• Exercise and cognitive behavioral therapy (CBT) have the greatest evidence for success in fibromyalgia. For pain conditions in which nociplastic pain predominates, consider prescribing aerobic, muscle strengthening, and mind-body exercises (e.g., qigong or tai chi). Supervised sessions with 50- to 60-minute duration, 2-3 times a week, for 13 weeks are recommended.
• CBT. There is a strong bidirectional link between mood disorders and persistent pain. High levels of pretreatment pain catastrophizing (e.g., "This is the worst pain," "I can think of nothing else," and "There's nothing I can do") are highly associated with poor treatment outcomes for pain-relieving interventions. Fortunately, pain catastrophizing is modifiable, and patients can be referred for CBT, acceptance commitment therapy, and other psychologic and support services.
• Sleep. If nociplastic pain is identified, sleep quality may be a high-yield area to address. Poor sleep is a predictor of subsequent pain and is noted in 90% of patients with fibromyalgia. Nonrestorative sleep has been shown to be the strongest predictor of chronic widespread pain. The severity of sleep disturbance correlates with pain severity, reduced pain inhibition, and fatigue. Treatments include adherence to strict sleep hygiene and referral to a sleep clinic or CBT for persistent sleep issues.
• Support. Higher levels of social support diminish pain severity and improve adjustment in patients with chronic pain conditions. It is important to identify the specific type of support that is needed. This could include spousal support, referral to a subspecialist, and/or referral to physical or occupational therapy to address fear of movement.
• Tracking. Encourage patients to track progress of self-management behaviors and corresponding symptom response, i.e., "What behaviors have the patient feeling good; what are triggers to flares?"

On follow-up visits, it is important to assess progress toward goals and barriers. As the patient's situation improves or changes, treatment priorities and goals may change as well.

Read the review here and commentary on the clinical implications here.