When Pain Is Real but the Injury Is Gone: The Science of Neuroplastic Pain

When Pain Is Real but the Injury Is Gone

Chronic pain is real. Patients should not have to defend that.

Many people with chronic pain live in an exhausting medical gap. The pain continues, but the scan does not explain it. The injury should have healed, but the body still reacts as if it has not. Labs may be unrevealing. Specialists may disagree. Friends may offer advice. The patient keeps living inside a body that feels unsafe.

Medicine has not handled this category well.

Some pain is caused by active injury or disease. Structural damage, inflammatory disease, autoimmune illness, infection, nerve injury, endocrine disease, medication effects, poor sleep, metabolic dysfunction, and neurologic disease all belong in the evaluation when the history points in that direction.

But not all persistent pain is a sign of ongoing tissue damage.

In some patients, the original injury, illness, inflammation, or threat has passed. The nervous system keeps producing a danger signal anyway. The pain is not fake. The alarm system is overprotective.

This is the clinical territory of neuroplastic pain, also discussed in the medical literature as nociplastic pain.

Real Pain, Learned Danger

Pain is generated through the nervous system. That does not make it psychological in the dismissive sense. It makes it physiologic.

The brain is not a floating thought machine. It is an organ. It receives signals, makes predictions, tracks threat, assigns meaning, and prepares the body to protect itself. Sometimes it gets that prediction wrong.

The International Association for the Study of Pain defines nociplastic pain as pain arising from altered nociception without clear evidence of actual or threatened tissue damage, or disease of the somatosensory system, that would fully explain the pain.

That definition is useful because it avoids the lazy binary patients know too well: either the pain is structural, or it is “just stress.”

There is a third category. The body is producing a real symptom through a nervous system that has learned danger.

That can happen after a real injury. It can happen after infection. It can happen after surgery, trauma, prolonged stress, grief, fear, medical threat, or years of bracing. The trigger may be physical, emotional, inflammatory, hormonal, or all of those at once.

The symptom pattern often gives clues. Pain moves. It flares with stress or fear. It worsens when attention locks onto it. It persists after expected tissue healing. It varies more than a purely structural model would predict. The intensity does not match the findings. The patient’s life has often been shaped by pressure, vigilance, trauma, loss, or repeated medical uncertainty.

None of that proves neuroplastic pain. It makes the diagnosis worth considering.

Why Schubiner’s Work Is Worth Reading

Dr. Kathryn Retzler and I have both read or listened to Dr. Howard Schubiner’s work, including Unlearn Your Pain. Dr. Retzler is currently taking the approved CME course.

The work is interesting because it is clinically more disciplined than most “mind-body” language. It does not require denying the body. It requires paying closer attention to how the body and brain learn protection.

Schubiner’s approach is especially relevant for patients whose symptoms have continued despite reasonable evaluation, treatment, and time. Chronic back pain, migraine, fibromyalgia, irritable bowel syndrome, pelvic pain, chronic fatigue-type syndromes, and other overlapping symptom patterns can sometimes involve learned danger signaling.

The word sometimes does a lot of work here.

Neuroplastic pain should not be used as a shortcut around medical evaluation. A patient with new neurologic symptoms, unexplained weight loss, fever, inflammatory signs, progressive weakness, night pain, chest pain, severe headache, pelvic pain, abdominal pain, or a changing clinical picture needs appropriate medical workup.

Calling symptoms neuroplastic because the first round of testing was normal is not careful medicine. It is another form of dismissal.

The Evidence

In a randomized clinical trial published in JAMA Psychiatry, Pain Reprocessing Therapy was studied in patients with primary chronic back pain. After treatment, 66% of patients receiving Pain Reprocessing Therapy were pain-free or nearly pain-free, compared with 20% receiving placebo and 10% receiving usual care.

That trial does not apply to every person with back pain. It studied selected patients with primary chronic back pain. The distinction is important clinically. Structural disease, inflammatory disease, fracture, malignancy, infection, neurologic compromise, and other medical causes still need to be recognized.

But the finding is hard to ignore. In the right patients, changing the brain’s interpretation of pain can change the pain itself.

Related evidence exists for Emotional Awareness and Expression Therapy in fibromyalgia. In a randomized trial comparing Emotional Awareness and Expression Therapy, cognitive behavioral therapy, and fibromyalgia education, EAET showed benefit and was described by the authors as an additional treatment option for fibromyalgia.

This is not fringe. It is underused.

Long COVID, Briefly

Long COVID should not be folded neatly into a neuroplastic pain model. That would be sloppy.

Some patients have immune, vascular, autonomic, inflammatory, endocrine, sleep, cardiopulmonary, or post-viral drivers. Some have post-exertional malaise, where exertion produces a delayed crash. Those patients should not be pushed into simplistic exercise plans or told they are afraid of activity.

Still, infection can teach the nervous system danger. The acute illness may pass while the autonomic nervous system, sleep, threat perception, fatigue signaling, pain pathways, and fear-learning networks remain activated. In some Long COVID patients, neuroplastic mechanisms may be one part of the picture.

One part. Not the whole explanation.

How We Think About This Clinically

HormoneSynergy® lives in the evaluation side of medicine. We are interested in thyroid function, menopause and hormone physiology, glucose regulation, inflammation, sleep, cardiovascular risk, body composition, cognition, medications, and the long list of clinical details that change how a person feels in their body.

That makes neuroplastic pain more relevant, not less.

If the body is inflamed, treat the inflammation. If sleep is broken, address sleep. If thyroid function is off, evaluate thyroid. If menopause has changed pain, migraine, sleep, mood, or musculoskeletal health, take that seriously. If autonomic dysfunction is present, do not pretend it is mindset. If structural disease is present, do not talk around it.

But when the medical picture does not explain the symptom pattern, the nervous system should not be ignored.

A patient can need medical evaluation and nervous system retraining. A patient can have a real post-infectious trigger and learned danger signaling. A patient can have hormone disruption, poor sleep, trauma history, central sensitization, and chronic pain in the same body.

Clean categories are convenient. Patients are rarely that simple.

Neuroplastic pain gives clinicians another lens. Used well, it can reduce unnecessary procedures, fear, overmedicalization, and years of chasing damage that is no longer there. Used poorly, it becomes another way to minimize suffering.

We are interested in the first version.

Editorial Transparency

Dr. Kathryn Retzler and Daniel Soule have both read or listened to Dr. Howard Schubiner’s work, including Unlearn Your Pain. Dr. Retzler is currently taking the approved CME course. This article reflects HormoneSynergy’s clinical interest in neuroplastic pain while maintaining the need for appropriate medical evaluation before symptoms are attributed to learned danger signaling.

Related HormoneSynergy® Resources

• Longevity Medicine Resource Library
• Bioidentical Hormone Therapy for Women and Men
• DEXA Bone Density & Body Composition Testing
• Cleerly® CCTA Heart Plaque Testing

References

• Ashar YK, Gordon A, Schubiner H, et al. Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain. JAMA Psychiatry. 2022.
• Lumley MA, Schubiner H, Lockhart NA, et al. Emotional Awareness and Expression Therapy, Cognitive Behavioral Therapy, and Education for Fibromyalgia. Pain. 2017.
• International Association for the Study of Pain. IASP Terminology: Nociplastic Pain.
• Centers for Disease Control and Prevention. Long COVID Signs and Symptoms.
• Centers for Disease Control and Prevention. Long COVID Clinical Guidance.