When pain keeps sounding the alarm

Real pain does not require ongoing damage

The term nociplastic pain is used for pain arising from altered nociception when there is not clear evidence that ongoing tissue damage or a lesion of the somatosensory system fully explains it. It can overlap with nociceptive or neuropathic pain, and it is not a diagnosis that should be made casually or used to stop appropriate medical investigation.

A useful formulation asks what is contributing now. There may still be structural change, inflammation, sensitisation, fear of movement, disrupted sleep, lowered activity, threat monitoring and understandably strong memories of pain flares. None of these cancels the others. The point is to expand the number of treatment levers available.

This explanation can be difficult to hear if psychology has previously been presented as the consolation prize after medicine “found nothing”. Psychological treatment for pain should begin by taking the experience seriously and working alongside appropriate medical and rehabilitation care.

The five-year result that deserves attention

A randomised trial published in 2022 compared pain reprocessing therapy with placebo injection and usual care for people with primary chronic back pain. The therapy combined education about pain, reappraisal of threatening sensations, exposure to feared movement and emotional work. The initial results were unusually large, which made both interest and scepticism appropriate.

In 2025, researchers reported the five-year follow-up. Benefits in pain intensity remained greater for the pain reprocessing group than for usual care, although the groups were smaller by then and follow-up results always need caution. It remains one trial with a selected group, not evidence that all chronic pain is brain-generated or that one therapy suits every condition.

The finding is still important because it challenges the assumption that meaningful psychological gains must be temporary. It suggests that, for at least some people with primary chronic back pain, changing the way sensations are interpreted and approached may alter the course of pain for much longer than the treatment period.

This is not positive thinking

Reappraising pain does not mean repeating “I am safe” regardless of the evidence. It means learning to distinguish signals that require protection from sensations that are unpleasant but not dangerous, often in consultation with medical and physical-health professionals. The person then tests that distinction through carefully graded activity.

Acceptance-based approaches take a related but somewhat different route. They focus less on proving what a sensation means and more on reducing the extent to which pain dictates the whole of life. A 2024 meta-analysis found that acceptance and commitment therapy improved several psychological and quality-of-life outcomes in chronic pain, while the size and certainty of effects varied.

Both approaches can be misused if they become another demand to override the body. Pacing is not avoidance, and persistence is not always courageous. The practical task is flexible: build capacity where the system has become overprotective, and respect limits where the body genuinely needs protection.

What therapy can add

Therapy may address catastrophic predictions, fear of movement, attentional narrowing, sleep, grief for a changed life, anger at the healthcare system and the strain pain places on relationships. For some people, earlier experiences of threat or chronic stress have made the nervous system especially quick to protect, although trauma should never be assumed simply because pain is persistent.

A good outcome is not always “no pain”. It may be less pain, fewer flares, greater confidence in the body, a wider life or less time spent negotiating with symptoms. That can sound modest beside a cure, but it is often substantial in the life of a person who has been organised around preventing the next alarm.