Does Structural Damage Rule Out Neuroplastic Pain or PRT?

But my MRI actually showed something.

This is usually where the neuroplastic pain conversation gets a little more complicated. Because maybe your MRI did show arthritis. Or disc degeneration. Or a bulging disc. Maybe you have an old injury that you can point to and say, “There. That’s when all of this started.” And when someone starts talking about the brain and nervous system after you’ve spent months or years looking at an image that quite literally shows something different about your body, it makes sense to wonder whether any of this applies to you at all. If there’s something structural there, doesn’t that mean the pain must be structural too?

Sometimes, yes. But bodies are annoyingly unwilling to be that simple. A structural change can contribute to pain without necessarily explaining all of it, and a very real injury can be the thing that starts a pain experience without remaining the thing that keeps it going years later. We also know that many of the changes that sound alarming on an MRI—things like disc degeneration and bulging discs—are found in plenty of people who aren’t experiencing pain at all. That doesn’t make those findings meaningless. It just means an MRI gives us one piece of information about what a body looks like. It doesn’t always tell us why that particular body hurts as much as it does, why it hurts today but didn’t yesterday, or why the pain sometimes changes when nothing about the structure possibly could have changed.

PRT doesn’t require pretending your MRI is normal. It asks whether the structural finding explains the whole story.

An abnormal MRI doesn’t automatically mean an abnormal amount of pain

One of the things I find most interesting about pain science is just how common “abnormal” imaging findings actually are. In one systematic review, researchers looked at spinal imaging from 3,110 people who had no pain. At age 20, 37% had disc degeneration and 30% had a disc bulge. By age 50, those numbers had risen to 80% and 60%. By age 80, 96% had disc degeneration and 84% had a disc bulge. The researchers concluded that many degenerative imaging findings are likely part of normal aging and need to be interpreted in the context of the individual person.  

I think this matters because the language used in imaging reports can sound terrifying when you don’t spend your days reading imaging reports. Degeneration. Bulge. Protrusion. Fissure. None of those words exactly scream, “Your body is doing awesome!” And once you know something is there, it can become very difficult not to picture it every time you hurt. You bend over and your back twinges, and suddenly you’re not just experiencing a sensation. You’re imagining the disc. You turn your neck and feel pain, and your mind goes immediately to the arthritis someone showed you on an X-ray three years ago.

That doesn’t mean the arthritis or disc degeneration is irrelevant. Some structural findings absolutely do cause pain, and imaging can provide important information that changes medical treatment. I don’t interpret clients’ MRIs or tell someone that a structural finding is harmless; that’s a conversation to have with an appropriately qualified medical provider. But I do think there is an important question that can sometimes get lost once something appears on a scan: Does this finding adequately explain the way my symptoms are behaving?

Because sometimes it does. And sometimes there are pieces of the story it doesn’t explain very well.

Structural and neuroplastic aren’t opposites

I think this is where we can accidentally make neuroplastic pain much more black-and-white than it actually is. We start imagining two boxes: either your pain is structural and therefore “real,” or it’s neuroplastic and therefore nothing is physically wrong. But that’s not how pain works, and it isn’t how the broader pain science describes it either. The International Association for the Study of Pain recognizes that nociceptive pain—pain related to actual or threatened tissue damage—and nociplastic pain, which involves altered nociception, can exist together in the same person.  

In other words, there can be a both.

Maybe you developed knee pain after an injury. The injury hurt because, well, you injured your knee. Your brain was doing exactly what you would want it to do: creating pain to protect an area that needed time to heal. But during those weeks or months, your brain was also learning. It learned that bending the knee hurt. Stairs hurt. Running hurt. Maybe you started bracing before you stood up or watching every step you took. Maybe every little sensation in that knee began to feel significant because, for a while, it was significant.

Then the tissue heals—but the nervous system doesn’t necessarily receive a memo that says, Okay everyone, we’re good here. Stand down.

The original injury and the learned danger response aren’t mutually exclusive. One can follow the other. And in some cases, there may still be a structural contributor and a nervous system that has become increasingly protective around it. That means the question doesn’t always have to be, Is my pain structural or neuroplastic? A more useful question may be, How much of what I’m experiencing now is actually necessary for protection?

What if the injury happened years ago?

This is one of the places where looking at the whole symptom story can become really useful.

Let’s say you hurt your back five years ago and have had pain ever since. The fact that your symptoms began with an injury is important information. It doesn’t disqualify a neuroplastic component. Instead, we might get curious about what happened next. Did the pain remain exactly the same, or did it begin changing? Did it spread? Does it sometimes disappear almost completely and then return? Is it worse during stressful periods? Better on vacation? Does one movement hurt terribly one day and barely bother you another? Are there things you’ve stopped doing because you’re afraid of what will happen afterward?

None of those questions, by themselves, prove that pain is neuroplastic. And I really don’t like treating neuroplastic pain like a checklist where five checked boxes earn you a diagnosis. Bodies are too complicated for that. But patterns can give us information. If the structure is relatively stable while the pain is wildly variable, for example, it makes sense to at least wonder what else may be contributing to the experience.

This is also why I think the phrase It’s all in your brain is so spectacularly unhelpful. All pain involves the brain. That doesn’t make it imaginary. The brain receives and interprets information from the body and determines whether pain is needed as a protective response. In neuroplastic pain, that protective system can become over-responsive—more like an alarm that has become increasingly easy to trigger. There may have been a very good reason for the alarm to start ringing in the first place. The problem is that it learned to keep ringing.

So where does PRT fit if there really is something structural?

Pain Reprocessing Therapy isn’t appropriate because we’ve somehow proven that every physical finding in your body is meaningless. The goal is to help the brain interpret safe sensations as safe and reduce unnecessary fear and protection around pain. That can include learning about how pain works, noticing sensations with less fear through somatic tracking, gradually returning to feared movements or activities, and working with some of the emotional or nervous-system patterns that may be reinforcing a sense of danger.

The main randomized clinical trial of PRT studied 151 adults with primary chronic back pain—not every kind of structural pain and not every chronic symptom. Participants were assessed to determine whether their pain was likely primarily driven by central nervous system processes rather than ongoing tissue injury. Interestingly, among the PRT participants who already had spinal imaging available, all 20 had at least one spinal anomaly, with a median of four findings per person; a study physician assessed those findings as not causal of their pain. After four weeks, 66% of the participants randomized to PRT were pain-free or nearly pain-free, compared with 20% in the placebo group and 10% receiving usual care. The differences were largely maintained at one year, and a later follow-up found significant group differences still present five years later.  

I think that little detail about the imaging is especially helpful. These weren’t necessarily people with pristine spines. They were people whose structural findings, after medical assessment, were not believed to adequately explain their chronic pain. That’s an important distinction. The study doesn’t show that PRT can treat every painful condition that happens to involve a structural abnormality. It shows that having something show up on imaging is not, by itself, evidence that pain must be coming from that finding.

And if there is an ongoing structural contributor, working with a neuroplastic component doesn’t require denying it. The goal isn’t to convince yourself that nothing could possibly be wrong. It may simply mean helping your nervous system stop adding five alarms’ worth of protection to a situation that requires one.

You don’t have to choose between believing your body and believing your brain

I understand why this distinction matters so much to people with chronic pain. If you’ve spent years being told that tests are normal when you know very clearly that you are not fine, finally seeing something on a scan can feel validating. There it is. Proof. And then someone comes along and starts talking about neuroplasticity, and it can sound suspiciously like they’re trying to take the explanation away again.

I’m not interested in doing that.

Your imaging matters. Your medical history matters. The way your symptoms began matters. So does the way they behave now. If something needs medical treatment, PRT isn’t a replacement for that treatment. And if you’re unsure whether a symptom has been adequately evaluated, getting appropriate medical care comes before trying to convince yourself that you’re safe.

But once serious or treatable medical causes have been appropriately evaluated, we can leave room for another possibility too: your body can have structural changes without every bit of pain being a direct measurement of those changes.

You can have arthritis and a sensitized nervous system.

You can have an old injury and learned fear around movement.

You can have a disc bulge and pain that is being amplified by the brain’s prediction that bending is dangerous.

You can even have a structural source of some pain and a neuroplastic contribution making that pain more intense, persistent, or widespread.

The existence of one doesn’t erase the other.

And maybe that’s the question worth leaving with—not Can I prove that absolutely nothing is wrong with my body? but Does my body need as much protection as my brain has learned to give it?

Sometimes, that leaves a little more room to work with.

If you’re wondering whether your own symptoms may have a neuroplastic component, you can start with my Neuroplastic Symptoms Self-Assessment or read How Do I Know If My Symptoms Are Neuroplastic? And if you’d rather talk through your particular symptom history with someone, I offer a free 15-minute connect call to see whether Pain Reprocessing Therapy might be a good fit.