Nociplastic Pain: When the Pain System Overreacts

You’ve been in pain for months, maybe even years, but tests show nothing abnormal. Doctors can’t find any clear signs of injury, and yet the pain is very real. To gain a better understanding, check out our tool for deciphering your pain. This situation can be incredibly frustrating, especially when you start to doubt yourself or when others doubt you.

Your pain deserves to be taken seriously. Nociplastic pain refers to a change in how the nervous system processes signals. It can contribute to persistent pain, even when there is no visible injury to fully explain it.^{1, 2} Treatment can help relieve symptoms and allow you to resume your activities.

• Your pain is real, even if tests show no visible injury.
• The nervous system can become more sensitive to stimuli, much like a smoke detector that goes off easily. This comparison illustrates sensitivity; it does not prove that tissues never contribute to pain.
• Nociplastic pain can contribute to chronic pain, which lasts longer than three months. The criteria used to identify it still need improvement.³
• Treatment may include education, a gradual return to activities, and support for sleep or stress management.⁴ In fibromyalgia, aerobic exercise—which increases breathing and heart rate—likely improves quality of life. It may also slightly reduce pain and make daily activities easier.⁵

This guide explains what nociplastic pain is and how healthcare professionals assess it. Our article on how pain works explains the role of the nervous system.

Is it possible to experience real pain without a visible injury?

Pain can be real even if tests do not reveal an injury that explains it. However, a normal test result is not sufficient to conclude that the pain is nociceptive.⁶

Persistent pain with no clear explanation from medical tests can be frustrating. You may feel misunderstood when your symptoms are downplayed. Your experience deserves to be heard, even if the cause remains unclear.⁷

The term “nociplastic pain” helps describe some possible mechanisms. It does not replace an evaluation of any illnesses or injuries that may also be contributing to your pain.^{1, 6}

What is Nociplastic Pain?

Nociplastic pain is associated with a change in the neural processing of sensory input, with no clear evidence that tissue injury or damage to the sensory system explains this pain.⁷

Official Definition

The official definition refers to a change in nociception—the nervous system’s processing of stimuli that may threaten or damage tissue. Nociception and pain are two different phenomena.⁷ When discussing nociplasty pain, there is no clear evidence that this pain can be explained by:

• actual or potential injury to tissues other than nerves, which activates their nerve sensors;
• an injury or disease of the system that transmits and processes bodily sensations.^{2, 1}

Several mechanisms can coexist. A person may experience nociplastic pain as well as pain related to an injury, inflammation, or nerve damage.⁶

Central sensitization refers to an increased response of certain nerve cells in the brain and spinal cord. The spinal cord is a cord of nervous tissue within the vertebral column; it transmits messages between the brain and the body. This sensitization can contribute to increased sensitivity to pain.⁸

A Recent Classification

Kosek and his colleagues coined the term " nociplastics " in 2016.¹ The International Association for the Study of Pain incorporated it into its terminology in 2017.⁶ This term describes a pain mechanism; it is neither a specific diagnosis nor a synonym for central sensitization.

The classification distinguishes three major pain mechanisms, which may occur in combination:

• Nociceptive: related to actual or potential injury to tissues other than nerves, involving the activation of their nerve receptors.
• Neuropathic: caused by damage to or a disease of the system that transmits and processes sensations.
• Nociplastics: related to a change in nociception, with no clear evidence that the two preceding mechanisms fully explain the pain.^{2, 7}

How to Recognize Nociplastic Pain?

The professional assesses persistent and widespread pain, signs of increased sensitivity, and other possible causes to identify a nociplastive component.⁶ None of these factors alone is sufficient.

Clinical Criteria

The criteria proposed in 2021 for muscle and joint pain identify four elements that indicate possible nociplastive pain:

• Chronic pain that lasts more than three months.
• Pain that is widespread or diffuse, rather than limited to a small area.
• Pain that cannot be fully explained by nociceptive or neuropathic mechanisms.^{6, 9}
• Increased sensitivity in the painful area during the examination, such as pain upon light touch or pain that persists after such stimulation.

A diagnosis is likely when these four elements are accompanied by increased sensitivity already present in daily life and at least one associated symptom among those described below.⁶ These criteria guide the diagnostic process; they do not constitute a definitive test.

Typical Characteristics

• Sensitivity to touch (even light touch)
• Sensitivity to pressure
• Sensitivity to movement
• Sensitivity to heat or cold

• Significant fatigue
• Sleep disturbances with frequent awakenings
• Difficulty concentrating ("brain fog")
• Sensitivity to sound, light, or smells

• Allodynia: pain caused by a stimulus that is normally painless, such as light touch.
• Painful sensations that persist after stimulation
• Pain that seems disproportionate to the movements made

Pain triggered by light touch is a sign of increased sensitivity. It can occur in various types of pain and, on its own, does not confirm nociplastic pain.¹⁰ The signs must be interpreted in conjunction with the patient’s history of symptoms and the physical examination.¹¹

Is fibromyalgia an example of nociplastic pain?

Fibromyalgia is an example of a condition that can involve nociplastic pain, with pain in multiple areas of the body, fatigue, and sleep disturbances.²

A Recognized Disease

Fibromyalgia may be accompanied by the following symptoms, among others:

• Widespread pain affecting multiple body regions
• Pressure-sensitive tender points
• Chronic Fatigue
• Sleep Disorders
• Difficulty concentrating or remembering things.

A study compared 16 people with fibromyalgia and 16 people without the condition. When the same amount of pressure was applied to the thumbnail, functional magnetic resonance imaging (fMRI)—a technique that indirectly measures brain activity—showed more widespread activation in certain regions of the brain among people with fibromyalgia. When the researchers adjusted the pressure to produce pain of similar intensity, the activation patterns were similar.¹² This finding supports a difference in sensitivity; it does not provide a standalone diagnostic test.

Other conditions that may involve a nociplastic component

A nociplastic component or signs of sensitization are also examined in the following situations. Their presence must be assessed in each individual:

• Irritable bowel syndrome, which is characterized by abdominal pain and changes in bowel habits, such as diarrhea or constipation.^{6, 13}
• Chronic pelvic pain, located in the pelvic region and persistent. Our guide to pelvic pain syndrome in men describes a specific condition.
• Tension headaches, which are often described as a feeling of pressure or tightness.¹⁴
• Chronic fatigue syndrome, a condition characterized by severe fatigue and worsening symptoms following physical or mental exertion.¹⁵
• Some cases of chronic back pain or neck pain

Research on pelvic pain in women notes, in particular, increased sensitivity, but does not determine whether these changes are a cause or a consequence of the pain.¹⁶ The mechanisms must also be distinguished in cases of back or neck pain and in the other problems mentioned.⁴ For irritable bowel syndrome, research describes interactions between signals from the gut and their processing by the nervous system.⁸

What is central sensitization?

Central sensitization increases the response of certain nerve cells in the brain and spinal cord to the signals they receive.⁸ It can contribute to increased sensitivity, but it is not synonymous with nociplastic pain.⁶

An amplified nervous response

Central sensitization can increase the duration, intensity, or extent of a pain response. Experiments show a nervous system response that may persist after stimulation and then subside.⁸ This can result in:

• greater pain in response to the same stimulus;
• pain caused by a stimulus that is normally painless;
• pain that persists after stimulation or tenderness that spreads beyond the stimulated area.

What factors can influence pain?

Experiments show that neural activity originating in the tissues can trigger central sensitization.⁸ For a person living with persistent pain, the assessment also takes biological, psychological, and social factors into account. These factors do not all contribute to pain in the same way.⁷

• A Swedish study of twins aged 42 or older estimated that heredity and shared family environment together accounted for about half of the differences in predisposition to persistent, diffuse pain. Here, “predisposition” refers to the likelihood of experiencing this type of pain. The study did not directly measure central sensitization.¹⁷
• Medical history, including any infections or injuries, should be reviewed when relevant.
• The neural mechanisms that can amplify or reduce the response to stimuli.⁸

• Prolonged stress
• A difficult emotional experience, if that plays a role in your situation.
• Repeated concerns about the most serious consequences of pain.

• Stressful environment
• Lack of support
• Difficulties at work or constraints that limit opportunities for rest and recovery.

A biopsychosocial approach takes into account the body, thoughts, emotions, and life circumstances. It helps in selecting care tailored to your needs; it does not mean that you are responsible for your pain.^{9, 7}

Is nociplastic pain “all in your head”?

Nociplastic pain is a real experience, even if no visible injury fully explains it. A normal examination does not prove that the tissues play no role or that you are imagining your symptoms.^{6, 7}

Let's validate your experience

Your pain deserves to be acknowledged:

• Your pain is real. Your account is an important part of the evaluation.
• Your symptoms aren't imaginary. A normal test result doesn't mean they aren't real.
• You don't choose to be in pain. Pain isn't a measure of your strength of character.
• The research investigates the mechanisms underlying this pain. Imaging results in fibromyalgia show differences in how different groups of people process stimuli.¹² However, your pain does not need to be visible on an image to be taken seriously.

Normal test results can help rule out certain conditions being investigated. However, they do not, on their own, prove that the pain originates solely from the nervous system. An injury or illness may coexist with a nociplastic component.⁶

There is no single routine laboratory or imaging test that can confirm nociplastive pain on its own. The history of symptoms and a physical examination guide the evaluation.⁹ The criteria still have room for improvement: a study of 81 people found, in particular, that they did not identify all expected cases of fibromyalgia.³

Why this misunderstanding persists

Tests look for specific abnormalities or diseases; they do not directly measure the full experience of pain. A useful assessment links the test results to your symptoms, your activities, and the findings from the examination.^{6, 7}

How is nociplast pain treated?

Treatment for nociplast pain may include education, gradual activity, support for sleep and stress management, and sometimes medication.⁹Physical therapy for chronic pain helps tailor activities and exercises to your specific situation.

Complementary Treatments

The treatment plan depends on the issues you want to address: pain, sleep, mobility, work, or leisure activities. Several approaches can be used in combination.⁹

Explanations of how pain works help people understand their symptoms and choose appropriate activities. In studies on persistent muscle and joint pain, this education can reduce certain fears related to movement; the average effects on pain and functional ability are more modest.¹⁸ These explanations take into account injuries or illnesses that may also contribute to the symptoms.

Regular exercise can be gradually adapted to your abilities. In fibromyalgia, aerobic exercise trials lasting 6 to 24 weeks show a likely improvement in quality of life and possible modest benefits regarding pain and daily activities, compared with no exercise program.⁵ Walking, cycling, or swimming are examples of activities that can be adjusted according to your tolerance.

If you have chronic fatigue syndrome, you’ll need to take a special approach to your activities. Energy management is about respecting your limits and avoiding a worsening of symptoms after exertion. A program that systematically increases exercise is not recommended; a professional familiar with this condition can guide you.¹⁹

Pain psychology tools can help you manage anxiety, stress, and fear of movement. A professional will recommend them based on your needs, with specific goals such as resuming an activity you have been avoiding.⁹

Stress, anxiety, and fear can influence the experience of pain. Their role varies from person to person. Taking them into account does not diminish the importance of physical factors.⁷

Sleep and pain can interact. In an experiment involving 20 volunteers without chronic pain, two sleepless nights lowered the heat pain threshold: heat became painful sooner. This experiment did not result in any reports of pain.²⁰ It does not allow us to predict the effect of every single bad night’s sleep on an individual. Persistent sleep disturbances should be discussed with a healthcare professional.

In fibromyalgia, duloxetine, milnacipran, and pregabalin can provide significant relief for some people. A meta-analysis of reviews estimates that about one in ten additional people experience at least a 50% reduction in pain compared to a placebo, a treatment without an active ingredient. These findings apply to adults with moderate to severe pain and trials lasting 4 to 12 weeks.²¹

The data do not allow us to determine the drug’s effectiveness beyond six months. This does not mean that the drug necessarily stops working at that point. Side effects may occur; your prescriber will reassess the benefits and risks with you. For nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, data specific to fibromyalgia remain limited and highly uncertain.²¹

The Limitations of a Single-Cause Approach

• A local injection or surgery may be appropriate for a specific disease or injury. It is less effective in addressing a nociplastic component when it targets only a local abnormality. Mixed mechanisms therefore require careful evaluation.^{2, 6}
• A massage or manual manipulation—a manual adjustment of the joint—may be part of your treatment. The evaluation also determines how to support your return to your usual activities.⁴
• Avoiding all activities indefinitely can limit your daily life. A gradual return to activity aims to find a manageable level, without requiring you to ignore a significant worsening of your condition or a new symptom.
• Decisions regarding additional tests are based on the symptoms and the initial examination. A new symptom must be evaluated on its own merits; it should not be automatically attributed to nociplastic pain.⁶

Is it possible to recover from nociplastic pain?

Nociplastic pain can improve with appropriate care, although the degree of improvement and the time it takes to recover vary. The goals focus on pain and the activities that matter to you.⁹

Your system can change

The nervous system can modify its responses. The sensitization observed in some experiments may decrease after stimulation.⁸ This ability does not guarantee individual results. Treatment focuses primarily on achieving concrete improvements, such as:⁴

• gradually resume an activity that had become difficult;
• better manage periods when symptoms worsen;
• reduce your symptoms;
• improve your quality of life.

Time and perseverance

Progress may be gradual and uneven. The plan is adjusted based on your results and your tolerance. A more challenging period does not mean you have failed; it may simply require adjustments to your activities or care.

What are the key points to remember about nociplastive pain?

Nociplastic pain refers to a change in how the nervous system processes sensory input, resulting in real pain that cannot be fully explained by an injury or a neurological disorder. Treatment combines the approaches most appropriate for your situation.

• Your pain is real, even if the tests don't provide a complete explanation for it.
• A routine examination does not settle everything: it does not, on its own, confirm nociplastic pain.
• Central sensitization can contribute to pain, without being synonymous with nociplastive pain.
• Treatment approaches can complement one another: explanations, activities, sleep, psychological support, and sometimes medication.
• Improvement is possible, but the extent and timing of that improvement cannot be predicted for each individual.

If this description sounds familiar, an evaluation can help clarify the possible causes and your needs. Physical therapy can support you as you resume your activities, as part of a personalized plan.

Additional Resources

The following resources explain chronic pain, how it works, its psychological aspects, nerve-related pain, and strategies for daily life.

• Understanding Chronic Pain
• The Neuroscience of Pain
• The Psychology of Pain
• Neuropathic pain
• Pain Management Strategies

References

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