Nociplastic pain is a recently recognized mechanism in which the nervous system itself becomes hypersensitive, producing real, measurable pain even after tissues have healed. It is identified using published clinical criteria that assess pain characteristics, sensory hypersensitivity, associated symptoms like fatigue and poor sleep, and clinical exam findings. When present it requires more than just a tissue-based approach.
You saw a doctor with a back injury months ago. The scan looked relatively normal. The tissue should have healed by now. But the pain is still there - sometimes worse than ever - and nobody can seem to explain why.
If this sounds familiar, you are not alone. And you are not imagining it.
Modern pain science has identified a mechanism that explains exactly this pattern. It is called nociplastic pain, and understanding it may be the most important step toward getting the treatment that actually works for you.
The Three Types of Pain
For most of medical history, pain was understood in two categories:
- Nociceptive pain - pain caused by actual tissue damage. You twist your ankle, the ligament tears, it hurts. The pain matches the injury.
- Neuropathic pain - pain caused by damage to the nervous system itself. A pinched nerve, for example, sending pain signals down the leg.
But researchers kept encountering patients whose pain did not fit either category. The tissue had healed. The nerves were intact. Yet the pain was real, measurable, and sometimes severe.
In 2017, the International Association for the Study of Pain (IASP) formally recognized a third type: nociplastic pain - pain that arises from changes in the way the nervous system processes pain signals, even when there is no clear tissue damage or nerve injury causing it.[1] This is one of the conditions that Dr. Murphy evaluates and treats at Rhode Island Spine Center.
What Is Actually Happening in Your Body
In nociplastic pain, the nervous system itself has changed. Think of it this way: your pain alarm system has become overly sensitive. Signals that should register as mild discomfort - or not register at all - are being amplified and interpreted as significant pain.
This is not a psychological problem. It is a measurable change in how neurons in the spinal cord and brain process incoming signals.[2] Researchers call this central sensitization - the central nervous system has become hyperreactive to normal stimulation.
Here is what is important to understand: nociplastic pain can be triggered by an initial injury. Acute pain from a real tissue injury can, over time, induce changes in the nervous system that cause the pain to persist long after the tissue has healed. So the original injury was real. The ongoing pain is real. But the mechanism driving the ongoing pain has shifted from the tissue to the nervous system.[3]
This also means that nociplastic pain often coexists with nociceptive or neuropathic pain. You can have a real structural problem and nociplastic amplification happening at the same time.
How Do We Identify It?
In 2021, an international team of pain researchers led by Kosek published clinical criteria for identifying nociplastic pain in musculoskeletal conditions. The criteria provide a structured way for clinicians to assess whether this mechanism is contributing to a patient’s pain.[4]
The assessment looks at four areas:
1. Pain characteristics
- The pain is chronic (lasting more than three months)
- It is regional rather than in a single specific spot
- It cannot be fully explained by a tissue injury or nerve problem
2. Pain hypersensitivity on history
- You report that normally non-painful things - light touch, mild pressure - cause pain
- Pain spreads beyond the original area
3. Associated symptoms
- Sensitivity to sound, light, or odors
- Sleep disturbance
- Persistent fatigue
- Difficulty concentrating or “brain fog”
4. Clinical findings
- Mechanical or dynamic allodynia (pain from stimuli that normally should not be painful)
- Pain that persists or worsens after a clinical examination that provokes it
When criteria 1 and 4 are present, nociplastic pain is possible. When all four criteria are met, it is probable.[4]
Why Does This Matter for Your Treatment?
This matters because the treatment for nociplastic pain is fundamentally different from the treatment for a tissue injury.
If your pain is being driven by central sensitization, treatments need to address both the source of pain in the spine as well as the nociplastic pain in the central nervous system.
Effective management of nociplastic pain typically involves:[5][6]
- Education - understanding what is happening in your nervous system is itself therapeutic. Patients who understand the mechanism report less fear, less avoidance, and better outcomes.
- Graded exercise - carefully structured physical activity that gradually retrains the nervous system’s response to movement.
Medications may play a supporting role, but the evidence for pharmacological treatment of nociplastic pain is limited, and clinical guidelines emphasize non-pharmacological approaches as first-line management.[6]
How This Fits Into Your Care at Rhode Island Spine Center
At Rhode Island Spine Center, identifying nociplastic pain falls within our CRISP framework - specifically, Diagnostic Question #3, which addresses perpetuating factors. These are the factors that keep pain going after the original cause should have resolved.
Dr. Murphy’s approach is systematic: first, identify the actual factors driving your pain. Then match the treatment to those factors. If central sensitization is a factor, that changes the entire treatment plan - and it explains why previous treatments may not have worked.
If your pain has been severe, persistent, and hard to explain, a thorough evaluation for nociplastic contribution may be exactly what is needed to move your care in the right direction. You can book a visit or take our self-assessment to get started.
Frequently Asked Questions
Is nociplastic pain “real” pain?
Absolutely. Nociplastic pain involves measurable changes in how the nervous system processes signals. Brain imaging studies show altered activation patterns in patients with nociplastic pain. It is as real as pain from a broken bone - it simply arises from a different mechanism.
Can nociplastic pain develop after a back injury?
Yes. This is one of the most common pathways. An acute tissue injury causes persistent nociceptive input to the spinal cord, which over time can induce central sensitization. The original injury heals, but the nervous system remains in a sensitized state, continuing to produce pain.
Does having nociplastic pain mean my original injury was not real?
No. Nociplastic pain frequently develops as a consequence of a real injury. The tissue damage was genuine. What has changed is the mechanism that is now maintaining the pain. The original injury triggered nervous system changes that have taken on a life of their own.
What treatments work best for nociplastic pain?
The strongest evidence supports a combination of patient education, graded exercise, cognitive behavioral therapy, and sleep optimization. Medications may be used in a supporting role, but non-pharmacological approaches are the foundation of effective treatment.
How can I tell if I have nociplastic pain?
You cannot self-diagnose nociplastic pain, but certain patterns suggest it may be a factor: pain that has lasted well beyond normal healing time, sensitivity to things that should not hurt (light touch, mild pressure), associated symptoms like fatigue, poor sleep, and difficulty concentrating, and pain that seems out of proportion to any identifiable structural cause. A clinical evaluation using the published criteria can determine whether nociplastic pain is a contributing factor.
References
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International Association for the Study of Pain (IASP). IASP terminology: nociplastic pain. 2017. IASP ↩
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Nijs J, Lahousse A, Karas A, et al. Nociplastic pain and central sensitization in patients with chronic pain conditions: a terminology update for clinicians. Braz J Phys Ther. 2023;27(3):100515. PMC ↩
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Den Boer C, Dries L, Terluin B, et al. Central sensitization in chronic pain and medically unexplained symptom research: a systematic review of definitions, operationalizations and estimating prevalence. J Psychosom Res. 2019;117:32-40. PubMed ↩
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Kosek E, Clauw D, Nijs J, et al. Chronic nociplastic pain affecting the musculoskeletal system: clinical criteria and grading system. Pain. 2021;162(11):2629-2634. PubMed ↩
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Cleveland Clinic Journal of Medicine. Nociplastic pain: a practical guide to chronic pain management in the primary care setting. Cleve Clin J Med. 2025;92(4):236-245. CCJM ↩
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Fitzcharles MA, Cohen SP, Clauw DJ, et al. Nociplastic pain: towards an understanding of prevalent pain conditions. Lancet. 2021;397(10289):2098-2110. PubMed ↩
Wondering if This Applies to You?
Dr. Murphy finds the real cause of your pain and builds a treatment plan matched to that cause. If you have been dealing with persistent spine pain, a thorough evaluation is the place to start.