The Concept of Nociplastic Pain – Where To From Here? Insights from ISSPCON 2026 by Dr Chinmoy Roy

At ISSPCON 2026, Dr Chinmoy Roy delivered a thought-provoking and academically rigorous lecture titled “The Concept of Nociplastic Pain — Where To From Here?” The session explored the evolving understanding of pain mechanisms, critically examined the scientific foundation of nociplastic pain, and highlighted the ongoing controversies surrounding its clinical application.

The lecture encouraged clinicians to rethink how persistent pain is classified and emphasized that mechanistic clarity must always precede diagnostic labeling. In an era where chronic pain remains one of the most complex challenges in medicine, understanding the underlying mechanism is essential for appropriate treatment.

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Pain Classification: Why Mechanism Matters Most

Pain can be classified in several ways — by duration, anatomical region, character, or speed of transmission. However, the most clinically relevant classification is by underlying mechanism, because mechanism determines treatment.

Traditionally, pain has been divided into nociceptive and neuropathic categories. More recently, the term nociplastic pain has been introduced to describe pain that does not fit neatly into either structural tissue injury or demonstrable nerve damage. Despite these categories, some pain states still remain idiopathic, reflecting the limits of current diagnostic tools.

Mechanism-Based Pain Classification

Nociceptive pain arises from actual or threatened damage to non-neural tissue with activation of peripheral nociceptors. It is usually proportional to the intensity of injury and often improves with rest, anti-inflammatory medication, or healing of the underlying pathology. It may be well localized when superficial and poorly localized when deep. Importantly, nociceptive pain serves a protective biological function.

Neuropathic pain, in contrast, is caused by a lesion or disease of the somatosensory nervous system. It may result from demyelination, axonal injury, ectopic discharges, or central sensitization secondary to nerve injury. Clinically, it follows a neuroanatomically plausible pattern and is often described as burning, shooting, electric shock-like, or stabbing. Sensory examination may reveal both positive and negative sensory signs.

Nociplastic pain is defined as pain that arises from altered nociception despite no clear evidence of tissue damage activating peripheral nociceptors and no demonstrable lesion of the somatosensory system. It is thought to involve central sensitization, altered pain modulation, and dysfunction of descending inhibitory pathways.

Neuropathic vs Nociplastic Pain: Clinical Distinctions

Neuropathic pain typically follows dermatomal or nerve distribution patterns. Objective evidence may be found on imaging, nerve conduction studies, or other neurophysiological testing. Pharmacologic management often includes gabapentinoids, TCAs, SNRIs, sodium channel blockers, and targeted interventional procedures.

Nociplastic pain, however, tends to be regional, multifocal, or widespread and does not follow neuroanatomical boundaries. Patients frequently describe deep aching, soreness, stiffness, or heaviness. Imaging and neurophysiological tests are usually normal. Sensory examination may show hypersensitivity without dermatomal sensory loss.

Treatment strategies differ significantly. Nociplastic pain responds best to exercise therapy, cognitive behavioral therapy, sleep optimization, and multidisciplinary rehabilitation. Medications have a limited role, and strong opioids are generally not recommended. Addressing comorbidities such as sleep disturbance, fatigue, mood disorders, and sensory hypersensitivity is crucial.

Clinical Criteria for Nociplastic Pain - The Concept of Nociplastic Pain

For musculoskeletal conditions, possible nociplastic pain is considered when pain persists for more than three months, is regional or widespread rather than discrete, cannot be fully explained by nociceptive or neuropathic mechanisms, and is accompanied by hypersensitivity within the painful region.

The condition may be graded as “possible” or “probable,” but not “definite.” Probable nociplastic pain requires additional features such as a history of pain hypersensitivity and associated comorbidities including sleep disturbances, fatigue, cognitive problems, mood disorders, or increased sensitivity to light, sound, or odors.

Importantly, multiple overlapping conditions such as fibromyalgia, irritable bowel syndrome, temporomandibular disorders, complex regional pain syndrome type I, and bladder pain syndrome may coexist.

The Controversy Surrounding Nociplastic Pain

A major focus of the lecture was the controversy surrounding the concept.

One concern relates to pathophysiology. The idea that central sensitization can persist autonomously without ongoing peripheral input remains debated. Some argue that persistent central sensitization likely requires continuous nociceptive input from inflammation, nerve injury, or other peripheral pathology.

Another issue is the possibility of occult neuropathy. Increasing evidence suggests that conditions often labeled as nociplastic, such as fibromyalgia or CRPS I, may involve small-fiber neuropathy or subtle peripheral nerve abnormalities that current diagnostic methods fail to detect. Brain imaging changes may represent secondary neuroplastic adaptations rather than primary central dysfunction.

Psychological and emotional stress can amplify pain perception and produce hypersensitivity, but sensitization alone may not generate pain without a stimulus. Emotional modulation of pain does not necessarily justify a distinct mechanistic category.

There is also the risk of diagnostic complacency. Nociplastic pain is a mechanism, not a diagnosis. Labeling persistent pain as nociplastic may reduce clinical vigilance and lead to missed diagnoses such as tumors, compressive neuropathies, or inflammatory conditions. Given high rates of misdiagnosis in chronic pain, premature categorization may worsen outcomes.

Semantic concerns also exist. The term “plastic” implies biological adaptation, yet nociplastic pain is described as maladaptive. Ambiguous phrases like “no clear evidence” introduce uncertainty and weaken conceptual clarity.

A Balanced Perspective

The concept of nociplastic pain remains theoretically evolving. It may reflect limitations in current diagnostic technologies rather than a completely independent pain mechanism. Persistent pain without identifiable pathology may represent subtle neuropathic or inflammatory processes that are currently undetectable.

Therefore, nociplastic pain should be viewed strictly as a mechanistic descriptor, not as a definitive clinical diagnosis.

Future Directions

Future research must focus on refining pathophysiological understanding and developing more sensitive diagnostic tools. Advances in imaging, neurophysiology, and biomarker research may help detect subtle neural injury, neuroinflammation, and neuroimmune interactions.

Improved diagnostics may eventually reclassify many conditions currently considered nociplastic as neuropathic or nociceptive. Continued exploration rather than premature categorization is essential.

Take-Home Messages

Chronic pain classification is evolving, and ICD-11 recognizes chronic primary pain, often overlapping with nociplastic pain, alongside secondary nociceptive and neuropathic categories. However, pathophysiology remains heterogeneous, and altered nociception likely results from complex interactions between peripheral and central nervous systems and immune mechanisms.

Increased knowledge is a prerequisite for the development of reliable diagnostic tests and more effective treatment strategies.

Conclusion

Dr Chinmoy Roy’s presentation at ISSPCON 2026 provided a balanced and intellectually rigorous examination of the concept of nociplastic pain. Rather than accepting the category uncritically, the lecture emphasized scientific scrutiny, diagnostic vigilance, and continued research.

The concept of nociplastic pain may represent an important step in understanding chronic pain, but it must be applied cautiously. Clinical reasoning, thorough evaluation, and ongoing inquiry remain the foundation of responsible pain medicine.