Why Pain Physicians Must Actively Look for Nociplastic Pain
The Daradia Protocol for Everyday Clinical Practice
Author: Dr. Gautam Das and Team, Daradia: The Pain Clinic, Kolkata, India
Chronic pain management is evolving rapidly, yet one major reason for treatment failure continues to be under-recognition of nociplastic pain. Many patients undergo repeated investigations, injections, procedures, and medication trials—with little or no sustained benefit. The missing link, in many cases, is failure to actively identify nociplastic pain as a dominant or contributing mechanism.
At Daradia: The Pain Clinic, we strongly believe that nociplastic pain must be actively looked for—not passively excluded. This philosophy forms the foundation of the Daradia Nociplastic Pain Protocol.
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Understanding Nociplastic Pain: Beyond Nociceptive and Neuropathic Models
The International Association for the Study of Pain (IASP) introduced nociplastic pain as a third mechanistic pain category, distinct from:
- Nociceptive pain – pain due to tissue injury or inflammation
- Neuropathic pain – pain due to nerve injury or disease
Nociplastic pain, in contrast, arises from altered central nociceptive processing without clear evidence of ongoing tissue damage or nerve lesion.
Key Clinical Reality
Many chronic musculoskeletal pain patients:
- Report pain disproportionate to imaging findings
- Show poor response to interventional procedures
- Present with fatigue, sleep disturbance, mood symptoms, and cognitive complaints
These are not “unexplained” symptoms—they are hallmarks of central sensitization and nociplastic pain.
Why Pain Physicians Must Look for Nociplastic Pain Proactively
Failing to recognize nociplastic pain leads to:
- Repeated low-value interventions
- Escalation of procedures with diminishing returns
- Patient frustration and loss of trust
- Increased healthcare costs without outcome improvement
Pain physicians are uniquely positioned to identify nociplastic pain because they:
- See patients after multiple failed treatments
- Perform detailed pain mechanism assessments
- Decide on appropriateness of interventional therapies
Nociplastic pain should be actively screened at the bedside—just like radicular pain or facet pain.
The Daradia Nociplastic Pain Checklist: A Practical Clinical Tool
To bridge the gap between theory and daily practice, the Daradia team developed a concise, clinic-friendly 10-item checklist, designed for outpatient clinics and interventional pain settings.
Core Domains Assessed
The checklist evaluates:
- Chronicity of pain
- Disproportion between pain and imaging/examination
- Widespread or shifting pain distribution
- Sensory hypersensitivity
- Presence of central symptoms (fatigue, poor sleep, cognitive issues)
- History of central sensitivity syndromes (e.g., fibromyalgia, IBS)
- Limited or short-lived response to peripheral interventions
- Absence of dominant nociceptive drivers
- Absence of dominant neuropathic drivers
- Clinical inconsistency with purely structural pathology
The 3/7 Rule: Interpreting the Checklist
- ≥3 positive items → Suspected nociplastic pain
- ≥7 positive items, in absence of a better explanation → Nociplastic-dominant pain
This simple rule helps clinicians:
- Avoid over-diagnosis
- Maintain diagnostic humility
- Integrate nociplastic reasoning without abandoning structural assessment
Management Philosophy: The Three Pillars of the Daradia Protocol
Management of nociplastic pain is mechanism-based, not structure-obsessed. The Daradia Protocol rests on three core pillars:
1. EXPLAIN – Education and Reassurance
- Helping patients understand pain processing
- Validating symptoms without reinforcing damage beliefs
- Reducing fear, catastrophizing, and medical shopping
2. MOVE – Graded Activity and Functional Restoration
- Individualized, graded physical activity
- Emphasis on confidence and consistency
- Avoidance of pain-avoidant behavior
3. CALM – Central Symptom Modulation
- Sleep optimization
- Mood and stress regulation
- Rational pharmacotherapy targeting central sensitization
This approach reduces dependence on procedures and restores patient agency.
Why This Protocol Matters in Interventional Pain Practice
Nociplastic pain does not mean “no intervention ever”, but it does mean:
- Choosing interventions judiciously
- Setting realistic expectations
- Avoiding repeated low-yield procedures
- Integrating multimodal care
Systematic use of the Daradia checklist helps pain physicians:
- Improve patient selection
- Increase satisfaction and trust
- Practice ethical, evidence-aligned pain medicine
Key Takeaway for Pain Physicians
Nociplastic pain is common, clinically recognizable, and treatable—if we actively look for it.
The Daradia Nociplastic Pain Protocol provides a structured, practical framework to integrate contemporary pain science into real-world clinical practice.
Frequently Asked Questions (FAQ)
1. What is nociplastic pain?
Nociplastic pain is a type of chronic pain caused by altered pain processing within the central nervous system, without clear evidence of ongoing tissue damage or nerve injury. It is distinct from nociceptive and neuropathic pain.
2. How is nociplastic pain different from nociceptive and neuropathic pain?
- Nociceptive pain arises from tissue injury or inflammation.
- Neuropathic pain results from nerve damage or disease.
- Nociplastic pain occurs due to central sensitization and dysfunctional pain modulation, often without structural abnormalities on imaging.
3. Why is nociplastic pain often overlooked in pain clinics?
Nociplastic pain is frequently missed because:
- Imaging findings are minimal or non-specific
- Symptoms appear disproportionate to examination
- It often coexists with mild degenerative or peripheral findings
As a result, treatment remains structure-focused rather than mechanism-based.
4. When should a pain physician suspect nociplastic pain?
Nociplastic pain should be suspected when patients present with:
- Chronic pain disproportionate to imaging findings
- Widespread or shifting pain patterns
- Poor or short-lived response to injections or procedures
- Prominent fatigue, sleep disturbance, mood, or cognitive symptoms
5. Can nociplastic pain coexist with other pain mechanisms?
Yes. Nociplastic pain frequently coexists with nociceptive or neuropathic pain. Many chronic pain patients have mixed pain mechanisms, and identifying the dominant mechanism is essential for effective management.
6. What is the Daradia Nociplastic Pain Checklist?
The Daradia Nociplastic Pain Checklist is a concise, 10-item clinical tool developed to help pain physicians identify nociplastic pain at the bedside. It assesses chronicity, pain disproportion, distribution, central symptoms, response to treatments, and absence of dominant structural drivers.
7. What is the 3/7 rule in the Daradia Protocol?
- ≥3 positive items on the checklist suggest suspected nociplastic pain.
- ≥7 positive items, in the absence of a better explanation, indicate nociplastic-dominant pain.
This pragmatic rule helps integrate nociplastic reasoning into routine practice.
8. Does diagnosing nociplastic pain mean no interventional treatment?
No. Diagnosing nociplastic pain does not exclude interventions. Instead, it helps:
- Avoid repeated low-value procedures
- Set realistic expectations
- Combine interventions judiciously with multimodal care
9. How is nociplastic pain managed in the Daradia Protocol?
Management is organized around three pillars:
- EXPLAIN – patient education and reassurance
- MOVE – graded activity and functional restoration
- CALM – addressing sleep, mood, stress, and rational pharmacotherapy
This approach targets the central pain mechanism rather than structural findings alone.
10. Why is recognizing nociplastic pain important for outcomes?
Early recognition of nociplastic pain:
- Reduces unnecessary investigations and procedures
- Improves patient satisfaction and trust
- Supports mechanism-based, ethical pain practice
- Leads to better long-term functional outcomes
11. Is nociplastic pain the same as psychological pain?
No. Nociplastic pain is a biological pain mechanism involving altered central nervous system processing. While psychological factors may influence symptoms, nociplastic pain is not imaginary or “all in the mind.”
12. Which patients are most likely to have nociplastic pain?
Patients with conditions such as fibromyalgia, chronic low back pain, chronic neck pain, widespread musculoskeletal pain, and central sensitivity syndromes commonly exhibit nociplastic pain features.
13. Can nociplastic pain be cured?
Nociplastic pain is best viewed as a manageable chronic condition rather than something to be “cured.” With appropriate education, activity modulation, and central symptom management, many patients experience significant improvement in function and quality of life.
14. Why should pain physicians actively look for nociplastic pain?
Because nociplastic pain does not reliably reveal itself through imaging or routine tests. Active identification prevents mislabeling, reduces treatment failure, and aligns practice with modern pain science.
This article is reviewed by Dr Sushpa Das
About Daradia: The Pain Clinic
Daradia: The Pain Clinic, Kolkata, is a dedicated center for advanced pain management, research, and physician training. Daradia has been at the forefront of mechanism-based pain medicine, education, and guideline-aligned practice for over three decades.
