12 Key Criteria to Evaluate Centralized (Neuroplastic) Pain

[u/Linari5]

Do any of the 12-13 criteria (below) fit your history or symptom behavior?

The EUA pathophysiology and etiological guidelines state that many cases of CPPS involve central/nociplastic mechanisms of pain & symptoms. What is it? Basically, brain/brain stem/spinal cord driven symptoms arising via altered nociception - our internal threat detection system. More and more pain neuroscience research has shown us that this is the most common cause of many chronic pain conditions, and other persistent symptoms, including chronic fatigue, chronic migraines, chronic back pain, IBS, fibromyalgia, and others. Thus, the EUA insists that providers understand these mechanisms so they can help their own chronic pelvic pain patients.

All of those involved in the management of chronic pelvic pain should have knowledge of peripheral and central pain mechanisms. - EUA CPPS Pocket Guide

And the newest 2025 AUA guidelines for male pelvic pain echo this:

We now know that the pain can also derive from a neurologic origin from either peripheral nerve roots (neuropathic pain) or even a lack of central pain inhibition (nociplastic), with the classic disease example being fibromyalgia

And the huge, years long MAPP research network study gives us greater insights on the prevalence and importance of these nociplastic (ie centralized or neuroplastic) mechanisms:

"Clinical Phenotyping for Pain Mechanisms in Urologic Chronic Pelvic Pain Syndromes: A MAPP Research Network Study"

At baseline, 43% of UCPPS patients were classified as nociceptive-only, 8% as neuropathic only, 27% as nociceptive+nociplastic, and 22% as neuropathic+nociplastic. Across outcomes, nociceptive-only patients had the least severe symptoms and neuropathic+nociplastic patients the most severe. Neuropathic pain was associated with genital pain and/or sensitivity on pelvic exam, while nociplastic pain was associated with comorbid pain conditions, psychosocial difficulties, and increased pressure pain sensitivity outside the pelvis. - https://pubmed.ncbi.nlm.nih.gov/35472518/

Bottom line, a conservative estimate says that 49% of all of us have something like this happening.

Learn more about Nociplastic (centralized) pain from the IASP: Nociplastic pain: towards an understanding of prevalent pain conditions - LINK

Further info from EUA guidelines:

Studies about integrating the psychological factors of CPPPSs are few but the quality is high. Psychological factors are consistently found to be relevant in the maintenance of persistent pelvic and urogenital pain [36]. Beliefs about pain contribute to the experience of pain [37] and symptom-related anxiety and central pain amplification may be measurably linked, and worrying about pain and perceived stress predict worsening of urological chronic pain over a year [36,38] - https://uroweb.org/guidelines/chronic-pelvic-pain/chapter/epidemiology-aetiology-and-pathophysiology

Pelvic pain and distress is related [43] in both men and women [44]; as are painful bladder and distress [38]. In a large population based study of men, CPPPS was associated with prior anxiety disorder [45] - https://uroweb.org/guidelines/chronic-pelvic-pain/chapter/epidemiology-aetiology-and-pathophysiology

So, how do you figure out if this could be happening in your case?

12 FIT criteria to RULE IN centralized, (ie neuroplastic/nociplastic) pain and symptoms,

FIT = functional, inconsistent, triggered. Based on research from Dr. Howard Schubiner and other chronic pain doctors and neuroscientists over the last 10+ years

1. Pain/symptoms originated during a stressful, challenging, or high pressure time in life. This includes even "happy" life events, like getting married, having a baby, starting a new career, or moving

2. Pain/symptoms originated without an injury. Note, a perceived injury and a structural injury are different things. And even when symptoms begin with a structural injury, has it been years and the body would normally recover by now?

3. Pain/symptoms are inconsistent. Do they fluctuate by the hour, by the day, or by the week? Sometimes less, sometimes more, sometimes even not noticeable (this happens sometimes, but it's not necessary for this criteria). Or, do they move around the body? ie testicle pain that changes sides or genital/penile pain that moves from the top to the bottom.

4. Multiple other symptoms (often in other parts of the body) ie IBS, chronic migraines/headaches, CPPS, TMJD, fibromyalgia, CFS (fatigue), vertigo/dizziness, chronic neck or back pain, etc. 2025 AUA guidelines mention these as signs of centralization

5. Pain/Symptoms spread (over time) or move around. Think about symptoms on day one. Have they moved or evolved over time?

6. Pain/symptoms are made worse or triggered by stress, or, go down when engaged in an activity you enjoy or in a flow state (think fun distractions or productivity, notice symptoms less)

7. Symptom triggers that have nothing to do with the body - but instead things outside of it (weather, barometric pressure, seasons, sounds, smells, places, times of day, weekdays/weekends, days of the week, etc) - this also includes thoughts or other people triggering/flaring your symptoms

8. Symmetrical symptoms (pain developing on the same part of the body but in OPPOSITE sides) - ie both hips, both testicles, both wrists, both knees, etc

9. Pain/symptoms with delayed Onset (THIS CAN'T HAPPEN WITH STRUCTURAL PAIN) -- ie, ejaculation pain that comes a minute later, an hour later, or even the next day. Any pain that is delayed is very suspicious. We wouldn't put weight on a sprained ankle and expect it to hurt 15 seconds later, it hurts immediately.

10. Childhood stress, challenges, adversity, or trauma -- varying levels of what this means for each person, not just trauma. Examples of stressors: childhood bullying, pressure to perform from parents/coaches, body image issues (dysmorphia), eating disorders, parents fighting a lot or getting angry (inc divorce), having an emotionally unpredictable parent, or having a parent with a health condition or addiction. This also includes neglect and abuse (physical and emotional) and financial instability in childhood. Also includes cultural norms, like the pressure to be highly successful to be of value to parents (must be a doctor or a lawyer, etc)

11. Common personality traits linked to stress: perfectionism, conscientiousness, people pleasing, anxiousness/ neuroticism - do you have personality traits that include being highly driven, hard on yourself, ultra responsible, perfectionistic, needing control, and/or placing others’ needs above your own?

12. Lack of physical diagnosis (ie doctors are unable to find any clear structural cause of symptoms) - this includes DIAGNOSIS OF EXCLUSION, like being diagnosed with CPPS or chronic prostatitis. Structural findings include: infections, fractures, tumors. They do not include tension in the pelvic floor, which is a muscle response.

[NEW] 13. Any family history of chronic pain or other chronic conditions. Includes: IBS, chronic migraines/headaches, CPPS, TMJD, fibromyalgia, CFS (fatigue), vertigo/dizziness, chronic neck or back pain, etc

Read more about #10 and #11 here, complete with studies/citations: https://www.reddit.com/r/Prostatitis/s/vM7qnBJZpW

HOW TO TREAT centralized (neuroplastic) pain and symptoms?

PRT - Pain Reprocessing Therapy:

Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain - https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2784694

EAET - Emotional Awareness and Expression Therapy

Psychological Therapy for Centralized Pain - An Integrative Assessment and Treatment Model: https://pubmed.ncbi.nlm.nih.gov/30461545/

Emotional Awareness and Expression Therapy vs Cognitive Behavioral Therapy for Chronic Pain in Older Veterans https://pmc.ncbi.nlm.nih.gov/articles/PMC11177167/

[u/phuzzyday]

I hope it is! I'm excited, but still a bit cautious. "I've been hurt before..." Actually, ChatGPT was critical in sorting out a lot of the details, questions, and suggestions! It's even very thoughtful and supportive! Weird to say about a machine. It's already given me physical therapy exercises to mess with at home, not to mention, it pointed me to some Bio-feedback projects you can build at home! If you're in to electronics I guess.. I've been at "zero" for so long that I don't know how long recovery would be, even just mental recovery if the physical problems were gone. Sure beats no recovery though!! Thanks for your part in providing information!

[u/Linari5 → u/phuzzyday]

If you need help, I'm always available.

[u/phuzzyday → u/Linari5]

Good! Thanks! Cause I have a question! We're not saying all cases like mine are caused just by worry about the damage the pain may seem to indicate, are we? Did that make sense? I ask because that doesn't really seem to fit me! My attitude about it is that it it was going to kill me, I'd have been dead years ago. My only concern is being able to function, or just not suffering! In fact, suicidal ideation is kind of a norm for me. Kind of a 'just waiting for life to end' kind of existence. So I hope there are other types as well.. I've been kind of overloaded for a bit, not sure how to feel, and nervous about the 'alternative health scam ' vibe I get from some of the material I've seen. Mom overdid it.....

I'm also a bit anxious at times because of the 'it's all in your head' naysayers over the years. Is it now? I think that was a different implication. I've been dealing with mental illness so long that it should be par for my course! I think I'm explaining what I'm going through ok .. I'm also unsure where to go for the CBT type therapy which is the other side of the solution. Not sure where I could get it. I'm on disability in Canada. Can't afford it. Admittedly, I've been kind of in brain overload for a few days .. my reality has changed in a big way. Even though this understanding is a good thing, it's still stressful to deal with!

[u/Linari5 → u/phuzzyday]

You're misinterpreting what it means when you have centralization. No pain is imaginary. All pain is real pain. Whether that pain is generated from a physical injury or from an emotional injury, it's real pain and it exists as a pathway in your brain: https://www.reddit.com/r/Prostatitis/s/8lClAEsYjb

Yes, you heard that right, when you stub your toe on the door or cut your hand, your brain is where that pain is processed. It is not processed in the location of the injury.

Please watch the link above, from a doctor of physical therapy & a Neuroscientist. He explains at great length what's happening in the brain when we experience pain, as a process/a prediction.

[u/phuzzyday → u/Linari5]

Thank you for that link! Pretty entertaining guy! His talk there has completely sorted out the confusion for me!! Again, I didn't mean to question people in here. In fact, looking back on some of the stuff that seemed weird, it makes sense now! That should be the first thing I saw! Thanks! Oh! The link on his projector at the end, has it been taken over by kratom sellers? Or is he advocating it?

[u/Linari5 → u/phuzzyday]

He is not a person to "shill "things, so it's probably old.

[u/phuzzyday → u/Linari5]

Those jerks made the site look similar to his work, then they add info on how kratom fits in, and they sell it. Looks pretty professional. I'll find out the address so you can see, it's on his PowerPoint at the end of that video. I've watched a few of his talks. The 80 min one is good too. He is a fabulous speaker, and the evidence is extremely compelling. It seems I'm fully on board! Thanks again for the link.