Neuroplastic Pain and the Referring Surgeon: Adjunctive Resources for Central Sensitization

By Dr. Chris Lakhiani, MD, FACS · August 2026

1. The Clinical Problem

1.1 Nociplastic pain in contemporary taxonomy

The International Association for the Study of Pain (IASP) recognizes nociplastic pain as pain arising from altered nociception, without clear evidence that ongoing tissue damage or a lesion of the somatosensory system fully explains the experience.^1,2 It is a mechanistic descriptor rather than a declaration that pain is psychogenic, imagined, or unimportant. Nociceptive, neuropathic, and nociplastic contributions may coexist in the same patient; the useful question is which mechanism is currently dominant and actionable.

Prevalence estimates are necessarily imprecise because there is no single biomarker or universally applied case definition. Chronic pain itself affects roughly one in five adults in population studies, and central-sensitization features are common across chronic musculoskeletal, pelvic, and post-injury pain populations.^3,4 In a referral practice, the clinically relevant group is not every patient with chronic pain, but those whose symptom burden, examination, and available testing are poorly accounted for by an active peripheral lesion.

1.2 The surgeon's dilemma

Surgeons are appropriately trained to identify disease that benefits from anatomic correction. The dilemma arises when a plausible imaging abnormality, prior injury, or history of nerve symptoms exists, but the magnitude, distribution, variability, or persistence of pain no longer maps to an operative target. More intervention in that setting can reinforce threat beliefs, add iatrogenic tissue injury, and fail to improve the actual pain mechanism. Conversely, prematurely applying a mind-body formulation risks missing a treatable compression, infection, inflammatory disease, malignancy, or mechanical pathology. The assessment must remain a diagnostic synthesis, not a diagnosis of exclusion by frustration.

2. Neurophysiological Basis of Central Sensitization

2.1 Wind-up and central gain

Repeated nociceptor input can produce temporal summation (“wind-up”) in dorsal horn circuits, with NMDA receptor-dependent changes in synaptic efficacy and excitability. The result is an increased central response to normal or subthreshold afferent input, manifesting clinically as allodynia, hyperalgesia, aftersensations, and an expanded pain field.^4,5 This is a biological process; its reversibility is central to the rationale for behavioral and cognitive interventions.

2.2 Descending modulation and top-down amplification

Pain is not a passive readout of peripheral tissue. Descending systems can inhibit or facilitate nociceptive transmission, and chronic pain may be associated with impaired endogenous inhibition or disproportionate facilitation.⁵ In practical terms, attention, expectation, sleep disruption, fear, and a repeated appraisal of danger can alter the gain applied to incoming signals. These influences neither negate a peripheral lesion nor imply voluntary control of symptoms.

2.3 Predictive coding and the Bayesian brain

Predictive-processing models describe perception as an inference in which prior expectations are continuously updated by sensory evidence. In chronic pain, persistent threat priors may become over-weighted relative to benign sensory evidence, biasing the system toward a pain-protective interpretation.^6,7 This framework helps explain why a carefully delivered structural reassurance, graded return to movement, and direct reappraisal of pain can be therapeutically meaningful rather than merely reassuring.

2.4 Fear-avoidance and threat appraisal

Fear of movement, hypervigilance, catastrophizing, and avoidance can maintain disability even after a triggering injury has healed. The fear-avoidance model is not universal and should not be used to blame patients; it identifies modifiable learning processes that may amplify pain and reduce re-engagement with valued activity.⁸ For a related discussion of the limits of a normal electrodiagnostic study in peripheral nerve pain, see the earlier professional article, Peripheral Nerve Decompression for Pain with Normal Electrodiagnostics.

3. Pain Reprocessing Therapy — Evidence Base

3.1 Model and mechanism

PRT was developed by Alan Gordon and colleagues at the Pain Psychology Center in Los Angeles. It aims to alter the perceived threat value of pain through psychoeducation, cognitive reappraisal, and somatic tracking: observing sensations with curiosity and safety rather than alarm. The proposed therapeutic mechanism is extinction learning — repeated disconfirmation that benign sensations or movements signal tissue danger — rather than denial of symptoms.^9,10

3.2 Boulder Back Pain Study

In the Boulder Back Pain Study, Ashar et al. randomized 151 adults with primary chronic back pain to four weeks of PRT, open-label placebo, or usual care. At post-treatment, 33 of 50 participants randomized to PRT (66%) reported pain scores of 0 or 1 on a 0–10 scale, compared with 20% in placebo and 10% in usual care; between-group benefits were largely maintained at one year.⁹ The trial included longitudinal functional MRI and supports the proposition that changing pain-related beliefs can be associated with substantial symptom improvement in selected primary chronic back-pain patients. It does not establish PRT as a substitute for evaluating structural pathology or as a uniform treatment for all chronic pain phenotypes.

3.3 Relationship to EAET, CBT-CP, and ACT

PRT is one member of a broader family of psychologically informed pain treatments. EAET emphasizes processing emotions, interpersonal conflict, and trauma-related avoidance; CBT for chronic pain (CBT-CP) focuses on skills, pacing, cognitive coping, and functional restoration; ACT emphasizes psychological flexibility and values-directed action rather than symptom control. EAET trials have shown promising results, including superiority to CBT in a randomized trial among older veterans with chronic musculoskeletal pain, while CBT-CP and ACT have a broader, generally modest evidence base across chronic pain conditions.^11,12,13,14

4. Patient-Facing Book: The Way Out

4.1 Role as pre-referral psychoeducation

Gordon’s The Way Out: A Revolutionary, Scientifically Proven Approach to Healing Chronic Pain (Avery, 2021) is an accessible introduction to the PRT framework.¹⁵ For a patient who has had an appropriate evaluation and is struggling to understand a neuroplastic formulation, it can establish common language before formal behavioral-health referral. Its case examples and somatic-tracking exercises are often more approachable than a technical discussion of predictive coding.

4.2 Boundaries and clinical utility

The book is not sufficient for patients with an active nociceptive driver, and it is not a substitute for structured therapy in complex cases. I sometimes recommend it to patients I have evaluated and cleared of surgical pathology, framing it as a resource that may help the nervous system learn safety — not as evidence that their pain was “all in their head.” If pain changes, progresses, or becomes associated with focal neurologic deficit, systemic symptoms, or a new injury, reassessment is required.

5. Practitioner Directories

5.1 American Association of Pain Psychology (AAPP)

The American Association of Pain Psychology directory is a national, multidisciplinary starting point for locating pain-focused clinicians. AAPP was established in 2010 to support education, networking, advocacy, and a biopsychosocial approach to pain medicine.¹⁶ Referring clinicians should note the organization’s own disclaimer: directory membership is not an endorsement or evidence of competency in pain psychology.¹⁷ It is a membership directory, not a credentialing examination.

5.2 Pain Reprocessing Therapy Center directory

The Pain Reprocessing Therapy Center directory identifies providers who have completed its training tracks and separates medical providers, mental-health clinicians, health coaches, and manual therapists.¹⁸ Directory category and training status are useful filters; they do not replace verification of state licensure, discipline-specific scope, insurance participation, or relevant clinical experience.

5.3 Pain Psychology Center

The Pain Psychology Center in Los Angeles is the clinical practice where PRT was originally developed by Alan Gordon and colleagues. The Center specializes in the treatment of chronic pain via mind-body approaches including PRT, and offers both in-person and telehealth services within its licensed jurisdictions. It is a useful direct-access resource for patients seeking care from the practitioners closest to the source of the PRT method.

5.4 Psychology Today and provider vetting

Psychology Today’s chronic-pain search may expand geographic options, particularly for telehealth, but training backgrounds are heterogeneous.¹⁹ When vetting a provider, ask: What license and state authority do you hold? What is your training in chronic pain, PRT, EAET, CBT-CP, or ACT? How do you screen for active structural or medical pathology? Do you coordinate with the referring physician and physical therapist? What is your approach when pain worsens, psychiatric acuity rises, or the diagnosis changes?

6. PelvicSense: Digital Program for Chronic Pelvic Pain

6.1 Program and intended role

PelvicSense is a structured three-month digital home program created by Evelyn Hecht, PT, a pelvic physical therapist with more than 25 years of experience. Its components include pain neuroscience education, calming audio, breath training, gentle movement, and progressive core strengthening.²⁰ It should be considered an adjunct to — not a replacement for — pelvic examination, medical evaluation, pelvic-floor physical therapy, and condition-specific treatment.

6.2 Evidence and patient selection

The program reports a two-year independent study in participants with provoked vestibulodynia, endometriosis, and persistent genital arousal disorder (PGAD), with a reported average three-point reduction on a 0–10 pain scale after three months.²⁰ A registered study describes pain-intensity and catastrophizing outcomes at baseline, completion of the three-month program, and follow-up.²¹ These data are encouraging but should be described as program-associated findings, not as proof of efficacy equivalent to a large independent randomized trial.

6.3 Relevance to nerve-surgery practice

Pelvic pain populations frequently seen by peripheral nerve surgeons — including pudendal neuralgia and chronic prostatitis/chronic pelvic pain syndrome (CPPS) — can have mixed mechanisms. A pelvic program that targets pain-related threat, breathing, movement, and gradual re-engagement may be particularly useful when the evaluation supports a central-sensitization component alongside, or after treatment of, peripheral pathology. PelvicSense also states that it is listed on the VA Market Research Database and is in the procurement process; veterans should confirm local availability with their VA care team.²⁰

7. Practical Integration for the Surgeon

7.1 When to consider the framing

A neuroplastic pain formulation is worth considering after a focused history, examination, and appropriate investigation have addressed meaningful surgical disease. It is especially helpful when symptoms are non-anatomic or highly variable, pain spreads beyond an initial injury territory, objective findings do not track with the severity of disability, symptoms are strongly influenced by threat, stress, or attention, or prior technically appropriate interventions have failed to produce the anticipated change.

7.2 Diagnostic criteria for centralized pain following peripheral nerve injury (Raasveld & Eberlin, 2026)

For the peripheral nerve surgeon specifically, Raasveld, Eberlin, and colleagues at Massachusetts General Hospital recently published the first systematic review of diagnostic approaches for centralized pain after peripheral nerve injury (PNI), synthesizing 28 studies covering 6,189 patients.²² Their evidence-based framework proposes five clinical criteria, offered here for use at the point of surgical decision-making:

Criterion #5 has particular utility in the surgical decision. A well-placed diagnostic block that produces less than 50% relief is unlikely to be followed by durable relief from decompression, neurectomy, or neuroma revision of that target. In such cases, the operative pathway alone is unlikely to succeed — the treatment plan should incorporate the resources described in Sections 4–6 rather than defaulting to another operation.

7.3 Red flags and yellow flags

7.4 Decision pathway

7.5 Language that validates rather than invalidates

A useful introduction is: “Your pain is real, and we have taken your symptoms seriously. The current evaluation does not show a surgical problem that explains the ongoing level of pain. The nervous system can remain protective after an injury, and there are evidence-based treatments that can help reduce that alarm response while we continue appropriate medical care.” Avoid “nothing is wrong,” “it is just stress,” or an implication that the patient has caused the problem.

8. Limitations and Considerations

PRT and related approaches are contraindicated as sole treatment for active structural pathology, autoimmune disease, malignancy, infection, or acute injury. They are also not an appropriate first-line standalone approach for patients with severe or persistent mental illness, active substance dependence, or acute psychiatric risk; those patients require coordinated assessment and treatment at the relevant level of care.

Individual response is variable. The evidence base is strongest for select conditions, particularly primary chronic back pain, and more limited for post-surgical pain, complex regional pain syndrome, and many neuropathic-pain states. The central-sensitization construct itself is heterogeneous and should not be used to erase plausible peripheral contributors. These considerations favor combined, staged, and multidisciplinary care rather than a binary “structural versus mind-body” algorithm.

9. Conclusion

The surgeon’s role is not simply to operate or to decline surgery. It is to identify a surgically remediable pain generator when one is present, recognize when central amplification is likely contributing materially to symptoms, and direct the patient toward credible adjunctive care without minimizing the experience of pain. Thoughtful use of PRT-informed education, vetted clinician directories, and pelvic-specific programs can make referral more concrete and can support combined surgical and mind-body care when that is clinically appropriate.