Neuroplastic Symptom Questionnaire
If you have not taken the NSQ, click below:
The NSQ is designed to offer a better understanding of your symptoms (Sx), an explanation for why they have not improved despite treatment, and to uncover a pattern to the Sx that is reflective of a neuroplastic process in the brain and nervous system that is amplifying, perpetuating, or even causing your Sx. The more “yesses”, the more likely the issue is not just the tissue!
What does “neuroplastic” mean? It is a term the implies the nervous system (neuro) is adaptable or changeable (plastic). The brain is a learning organ, helping our system to efficiently stay balanced and protected, even predicting what will happen next, given what we have experienced previously. When neuroscientists say, “neurons that fire together, wire together”, they mean, whatever we have experienced repeatedly in the past (i.e. practiced) our brain adapts to better navigate in the present. That is helpful when we are learning how to read, play music, or ride a bike, but if we’ve experienced a lot of physical, mental, or emotional stress or pain, over time the brain changes to become more sensitive and protective – we call this “neuroplastic sensitization” – like a burglar alarm that our brain has turned up because of past break-ins, so it gets triggered too easily and goes off too loudly, even when it’s just a cat walking by and there isn’t a break-in now. But there are clues to a neuroplastic pattern that differ from a structural/pathological pattern, particularly in the amount of variability, fear, and triggering in which they show up.
The NSQ is built to detect this phenomenon and this is important for the following reasons:
- In all the healing arts, effective treatment is based on accurate diagnosis, especially when root causes are addressed, instead of just managing/coping with symptoms.
- Neuroplastic symptoms are common & occur in all humans to varying degrees.
- Because they are caused by the brain, neuroplastic symptoms may never or minimally/temporarily respond to physical treatment (due to placebo/mindbody factors).
- Conversely, purely structural/pathological issues will not respond to neuroplastic reprocessing & Insight Medicine.
- Ruling out purely structural problems & uncovering factors such as nervous system sensitization, contextual stress, symptom inconsistency, fear-amplification, & triggering (for which the NSQ specifically assesses) can effectively diagnose or rule-in a neuroplastic process.
- If symptoms are neuroplastic, though they might be severe, they are not dangerous & they can be resolved/cured (not just managed), when treated with neuroplastic reprocessing and Insight Medicine.
[Of course, the NSQ does not include every stressor, nor is it meant to be used instead of sound medical evaluation and diagnosis. It is also not meant to be dismissive or minimizing in ANY way. It attempts to detect a non-structural pattern to your Sx. If you have doubts or concerns, please consult a trusted clinician, PT, mental health professional, or other provider trained to diagnose neuroplastic Sx, or simply do what it takes to complete your medical workup]
The following details how and why each question of the NSQ assesses for neuroplastic sensitization.
When a number of Sx are present, this increases the odds of a neuroplastic process because it is less likely that multiple diseases are present at once. Instead, the autonomic nervous system (ANS) may be activating a stress response (you may have heard of fight, flight, freeze reactions) because it is connected to all our numerous body systems (digestive, cardiopulmonary, urinary, hormonal, etc) and its function is to balance and protect us. ALL symptoms, such as pain, fatigue, anxiety, & depression – even things like hunger, fatigue, itchiness – are protective signals coming from the brain, like an alarm, alerting us to threats such as tissue damage, calorie deficit, & need for rest. Emotions have the same effect, e.g. embarrassment causing vasodilation of the arteries in the face, AKA blushing. The ANS is a key part of why and how stress of any kind, and at any time in our life, can be reflected in the body – it is the mind-body connection.
Studies have noted the up to 40% of primary care visits involve some kind of neuroplastic or ANS process. And across all specialties, pain in its many forms is the most common reason someone seeks medical attention. All pain comes from the brain, however when structural/pathological causes have been ruled out, most chronic pain is neuroplastic in origin. At times, however, a provider may have diagnosed you with one of the above diagnoses, yet if you have treated this issue and are still suffering, it may, in fact, not be the cause of your Sx. Thus, answering “yes” to this question increases the chances the nervous system is a key player. If you say no or still have strong doubts, then it may be best to finish your medical workup.
Frequently neuroplastic Sx have been present for quite some time. If a Sx has come and gone in the past, without an obvious cause, it is likely the brain was already sensitive and there may have been ANS activation trying to respond to some stressor. All of the Sx listed here involve protective neuroplastic circuits, yet their causes are unclear (i.e. there is no lab test or MRI that shows the severity of pain felt, if someone is anxious/depressed/addicted, how much fatigued they experience, etc). Numerous PRIOR neuroplastic Sx increase the likelihood that CURRENT Sx are neuroplastic.
Most commonly when Sx are caused by disease in a particular organ or body system, the Sx show up in that area or in a predictable way (i.e. a broken leg will hurt every time you take a step). However neuroplastic Sx often follow an erratic or unpredictable pattern, changing daily or weekly in severity, sometimes being triggered, sometimes not. The more variability, the more neuroplasticity is at play.
This question reflects your experiences of stress in childhood. And with a nervous system that is built to efficiently learn and protect, prior adversity dramatically increases the likelihood of an overprotective brain and an overactive ANS (fight/flight/freeze). The Adverse Childhood Experience (ACE) study (hyperlink) demonstrated VERY STRONG links from past stress and trauma to over 40 chronic adult conditions.
Pain and other protective Sx are unpleasant and biologically we are built to avoid or escape them – animals do this (e.g. do not play with porcupines, find shade occasionally, eat/drink/sleep regularly). However, when much of waking hours is spent preoccupied with the pain or other Sx, thinking of ways to avoid or reduce them, wondering if we’ll be able to function every again, obsessing (maybe in a “pain diary”) about the varying level of the pain or the innumerable things that could be triggering it, then vigilance and dread become our way of life. This is called the Pain/Sx-Fear cycle – first the discomfort, then the focusing, fighting, fixing, fearing, and being frustrated by it – all of which immerses our system in DANGER, so our ANS is always locked into a fight/flight/freeze response secondary to the Sx. This is a hallmark of neuroplastic sensitization.
Often there is no physical, organic connection between many of our triggers and our pain, i.e. weather fronts do not cause joint damage; strong smells or bright lights do not damage the eyes or nervous system; even hormonal shifts are not linked to symptoms due to damage. They may all be associated with the symptoms and strongly linked by belief and repetition, but this is what Ivan Pavlov and his dogs discovered in the 1800’s – they are conditioned responses. They are REAL symptoms, but they are linked to threat/danger in the ANS and are not causing damage. The more triggers you have and the more easily you are triggered, the greater the odds the resulting Sx are neuroplastic.
Put simply, all stressors imply some danger, so our system responds to it by creating a stress response via the ANS (fight/flight/freeze). This is a normal, healthy, protective adaptation. But we are not built to live in constant stress. However many of us do, having experienced significant stress, or sometimes smaller but long-lasting adversity, maybe in the past, or present, or at times our own personalities can add to it (and maybe all of the above…). Whether the stressor is a physical, mental, emotional, financial, relational, spiritual, vocational, or something else, the ANS activates all the same to help us deal with it. At times, we may not even be aware of the, especially when there is a mix of good feelings too (e.g. coming home to your parents’ house, the birth of a child, your first promotion, etc), OR when the Sx themselves become so overwhelming we are unable to think about anything else (i.e. the physical Sx may distract us from unresolved conflict, sadness and resentment over loss of choice, an increase in self-pressure and a lifetime of imposter syndrome). Stress and its resulting physical and emotional responses (i.e. large or sustained threat states) are the biggest factor in all neuroplastic Sx.
Certain personality traits can amplify, perpetuate, or even cause neuroplastic pain because they expose our system to danger, fear, and threat. These can be categorized as worry (vigilance, dread), pressure (impatience, relentless performance, rigid expectations), self-criticism (self-attack, comparison, shame), and doubt (insecurity, low self-esteem, pessimism). If pain and other Sx are danger signals, how we treat ourselves and the boundaries we over/under-enforce can also immerse our system in fear and threat. This activates the ANS yet again and fuels the neuroplastic Sx.
With most injuries and pathological conditions, the related Sx are fairly reliable and centered around the area/organ in question. As well, the body is an amazing self-healing, self-regulating, and adapting machine, so most conditions and their Sx actually REDUCE over time (e.g. a broken leg will likely cause massive pain at first, but as it heals, the pain decreases until it’s eventually gone). But when pain or other Sx persist beyond healing, begin to move around, or even seem to “jump” systems (a process called “Sx substitution” or what some call “Sx whack-a-mole”), this very logically points AWAY from the body and its normal healing process, and towards neuroplastic changes in the brain.
When our body or organs are injured and inflammation results, this often (though not always) causes our brains to produce pain to protect us. This is called nociceptive pain – the experience of pain is linked to tissue damage. Although even with nociceptive pain, some factors like context (survival, fear/force vs fun/choice, etc), and pst experience can dictate the brain’s need to create a lot, a little, or no pain. When pain occurs without a known injury, days after an injury, or persists years after an injury has healed (usually less than 12 weeks max, or a few months for nerve injuries), it is logical to suspect neuroplastic sensitization may be at play.
Similar to the question above, when stress is a trigger, it is the same as saying threat, danger, or fear is present and activating a protection response. Like a trigger on a gun or a key in an ignition, it is just the first step in a whole cascade of responses, which include both emotions and physical responses (like Pavlov ringing a bell, causing the dogs to expect food, which causes salivation – the bell does not “cause” food, it triggers expectation [emotion], which causes the salivary glands to activate). When someone has experienced stress in the past, the brain learns this and responds more and more quickly to future stress making a stronger and stronger association between the triggers, our threat/fear states, and our danger alarms (i.e. Sx). E.g. your boss routinely violates your boundaries, this causes stress to rise inside along with emotions (anger, disgust, fear), which may need to stay inside if you want to keep your job, and this causes adrenaline to rise and blood vessels to constrict some, which causes a migraine. And there also happen to be fluorescent lights overhead, a weather front coming through, and an article you read an article about how poor ergonomics will make . Your system then finds the easiest, least conflicted solution, so now lights, barometric pressure, and crappy chairs “cause” your headaches. This is called “Classical Conditioning.” The reverse is true when you’re having fun or relaxing or it’s simply the weekend! No threat = no need for protection = no Sx. Neuroplastic Sx are simply a reflection of the state of the nervous system.
In nearly every form of treatment there is a placebo effect, and some of these are quite strong. Whether it is treatment to align joints, strengthen the core, eliminate inflammation, balance the Qi, or remove some toxic agent, belief is a significant factor. This has even been shown repeatedly for surgeries! When something is perceived to be helpful, relieving, or powerful, that helps us and our ANS to feel safe, and this is especially true when delivered by a compassionate and competent provider! However with neuroplastic Sx, this is often a much greater effect, and if numerous treatments addressing the perceived problem only provide temporary benefit, there is a strong chance placebo is at play and the diagnosis may be incorrect (e.g. degenerative disc disease vs neuroplastic pain).
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Matt is an osteopathic physician, board certified in both Neuromusculoskeletal Medicine and Family Medicine.