Nociplastic pain, hypermobility, and a sensitized nervous system

Estimated reading time: 8 minutesDoes your pain ever feel bigger than the injury or linger after it has healed? Maybe it shows up with no injury at all or spreads in ways that don’t make anatomical sense. Ordinary smells, sounds and bright lights can feel like too much, and stress can turn up the volume on the pain itself.

That’s often nociplastic pain, and it comes from a nervous system that’s become sensitized, not from new damage in your tissues. I asked Dr. Leslie Russek to explain why this happens in hypermobility and hEDS, and what actually helps calm it back down.

Dr. Russek is a scientific advisor for The Zebra Club who has joined me previously to explain that there are 3 types of pain – neuropathic, nociceptive, and nociplastic. Each type of pain requires a different approach to management.

Chronic pain is a common experience for those of us with hypermobility or EDS. The good news is, there are things we can do to address each type. Here we explore some research and Dr. Russek shares her insights on how to manage nociplastic pain in hypermobility.

Nociplastic pain is due to sensitive nerves that have changed to become better at processing pain. This pain needs to be managed quite differently than neuropathic and nociceptive pain, or “Issues with the Tissues.”

You can have a combination of the different types of pain, and the “mixed pain” has been used to describe conditions that might have components of all 3 types of pain (1).

The definition of nociplastic pain

Dr. Russek describes nociplastic pain simply: it’s pain caused by changes in the nervous system that amplify or perpetuate pain, independent of tissue damage.

The International Association for the Study of Pain defines it more formally as pain arising from altered function of pain-related sensory pathways in the peripheral and central nervous system, causing increased sensitivity (1).

Pain signaling is a complex system. There are theories about how this sensitization may happen that include: hyperresponsiveness in pain perception in the brain, decreased pain inhibition in the brain, differences in pain signaling to and from the spinal cord, immune system activation of glial cells (cells around the nerves), differences in peripheral nerve signaling, and more (2).

There is also no known cause, though it is thought that the biopsychosocial model of pain is important. This includes biological factors, psychological factors, and social factors all working together to influence how we experience pain.

A sensitized nervous system is in a constant state of alarm, though what drives that varies by system. Peripheral nerves are usually sensitized by inflammation, so managing inflammation can help calm them.

The central and autonomic nervous systems, on the other hand, tend to become sensitized from ongoing stress and anxiety, poor sleep, or a history of trauma. Common predisposing factors for nociplastic pain include a family history of pain, a history of trauma, and prior pain experiences — often some combination of the three (1).

What does the research say about nociplastic pain in hypermobility?

There have been a few studies on the nociplastic pain mechanisms involved in hEDS, and research is growing. Here is what they found:

• A study of 22 women with hEDS found a significant increase in sensitivity to pressure-induced pain.
  • The women with hEDS reported pain at much lower pressure levels than controls, which researchers say may indicate a sensitized central nervous system (3).
• Researchers comparing 20 people with hEDS to non hypermobile controls found an increased sensitivity to repeated painful stimuli in the hEDS group. This is called temporal summation of pain (TSP), or pain increasing over time (4).
  • TSP happens when the same stimulus feels more painful the more it’s repeated. It’s a normal phenomenon, but in chronic pain, it’s often exaggerated and kicks in earlier — which is exactly what researchers saw in the hEDS group.
• A study of 23 hEDS patients compared to matched controls found altered endogenous pain inhibitory control in hEDS (5) — a deficit in the body’s own natural pain-suppressing system.
  • Normally, the body has a built-in ability to dial down pain signals. In this study, that system didn’t work as well in people with hEDS, which researchers say may contribute to central sensitization.
• A 2025 study extended this research to adolescents for the first time, finding increased pain sensitivity across the whole body — not just at the site of any specific joint issue — in 37 teens with HSD/hEDS compared to 47 healthy controls (6).
  • Teens with HSD/hEDS also reported significantly higher fatigue, anxiety, depression, and pain catastrophizing than controls, ages 13–17. This suggests these patterns aren’t limited to adults — they can show up early.
• The largest study yet, a 2026 study of 150 adults with hEDS/HSD, found that central sensitization was independently linked to a specific trio of symptoms: fatigue, pain, and cardiac dysautonomia (7).
  • Notably, anxiety and depression were common too, but weren’t independently linked to central sensitization once fatigue, pain, and dysautonomia were accounted for — evidence this isn’t “just” anxiety. That said, this study looked at one group at a single point in time rather than comparing to healthy controls, so it shows a strong link, not proof that one causes the other.

Together, these studies point to a role for a sensitized nervous system in people with hEDS/HSD. The evidence base is growing, but it’s still early: most of these studies are small or lack a comparison group, so more research is needed to confirm exactly how this works.

Symptoms of nociplastic pain

Common symptoms of nociplastic pain include pain that’s out of proportion to any injury, pain that spreads in ways that don’t make anatomical sense, and sensitivity in senses unrelated to the painful area.

You should suspect nociplastic pain if:

• Pain seems disproportionate to the amount of tissue damage or exists/occurs when there is no or no new tissue damage
• If the pain distribution doesn’t make sense anatomically
  •  For example, nociceptive pain is localized and makes neuroanatomical sense – it may be exacerbated by a specific movement (ie. you sprained your ankle and the ankle hurts when it is moved). Nociplastic pain, on the other hand, is often more generalized and widespread (8).
• Other senses are also over-sensitive, such as sensitivity to smell, sound, or light
• Pain increases when you are stressed or anxious
• You have a history of physical or emotional trauma, especially in childhood.

According to the International Association for the Study of Pain, there are 4 criteria that are assessed for a clinical diagnosis of nociplastic pain (9):

1. Pain – Chronic pain, that has a more widespread distribution that cannot be attributed to neuropathic or nociceptive pain
2. Evoked pain hypersensitivity – dynamic allodynia (pain from movement across the skin), static allodynia (pain from a light touch or pressure on the skin), heat or cold allodynia (pain from hot or cold). Allodynia is pain from something that would not normally produce pain.
3. History of pain hypersensitivity in the region of pain from touch, pressure, movement, heat, or cold
4. Presence of comorbidities: increased sensory sensitivity (sound, light, odor), sleep disturbances, fatigue, cognitive problems

It is considered possible nociplastic pain if you have #1 and #2, and probable if you have all 4 criteria (9).

There are also validated screening tools researchers use to measure central sensitization symptom severity, like the Central Sensitization Inventory (10).

Ways to manage nociplastic pain

Managing nociplastic pain means calming the nervous system. That means teaching it that movement and sensation aren’t dangerous, so it stops overreacting to them.

• You need to feel safe for the danger alarm to quiet down. It may help to put your body into a safe, supported position, such as lying down with appropriate pillows.
• It helps to avoid negative thinking patterns, such as panicking that you will always be disabled by your pain. Every time you think or worry about your pain, a little bit of neurotransmitter is released in your brain to increase pain. Reframing how you think of pain can decrease this.
• Thinking of pain as discomfort can make it less scary.
  • Remind yourself that you have tools to manage your discomfort.
  • Realize that not all discomfort indicates something is dangerous. This doesn’t mean ignoring discomfort because there may be “issues with your tissues” that you can address.
  • Reassure yourself that you have skills to calm your nervous system and that the alarm will quiet when you do so.

Coping skills like this are part of Cognitive Behavioral Therapy (CBT), which can effectively manage nociplastic pain.

More strategies to regulate the nervous system:

• Diaphragmatic breathing
• Slow breathing, meditation, or visual imagery. Some meditations focus on really becoming aware of what you hear, smell, or touch to ground the nervous system
• Small range, slow, and gentle movements in the mid-range of the joints. This can decrease sensitization by showing the brain the feeling of movement can be safe
• Heart Rate Variability (HRV) is a measure of how active the parasympathetic (rest and digest) nervous system is. HRV biofeedback helps some calm their nervous systems.

The Zebra Club includes many of these strategies to help quiet the nervous system including audio meditations, breath classes, and slow gentle movement.

Addressing the Vagus Nerve

The vagus nerve is one of the cranial nerves. It drives the parasympathetic nervous system to calm the central and autonomic nervous systems. Activating the vagus nerve also provides anti-inflammatory benefits that can decrease inflammatory pain and nerves sensitized by inflammation.

While research into ways to activate the vagus nerve is ongoing, we know that slow diaphragmatic breathing, chanting, and humming are effective. Electrical stimulation to the ear also works but isn’t available to most people; ear massage may produce some of the same benefits as electrical stimulation.

Final thoughts from Dr. Russek

Managing nociplastic pain requires us to decrease the perception of danger, calm the mind, and calm the nervous system.

In the long term, regular exercise helps protect the nervous system from becoming sensitive. The trick for people with HSD/hEDS is finding safe forms of exercise that don’t activate the danger alarm. Nutrition and sleep are also important for a resilient nervous system.

It is important to recognize if some of your pain might be nociplastic due to a sensitive nervous system. If it is, you need to address the sensitive nervous system rather than (or in addition to) hunting for musculoskeletal or visceral causes of the pain. Remember that you can’t fix a flat tire by changing the air filter!

If you can figure out what kinds of pain you have, you can pick appropriate strategies to manage them.

In this video, I walk through ways to turn down the volume on a nervous system that reacts to movement.

FAQ

Why is my nervous system so sensitive?

A sensitized nervous system can develop from ongoing stress, poor sleep, past trauma, or chronic inflammation. In hEDS/HSD, small studies link altered pain processing to lower pain thresholds and reduced natural pain-inhibiting control — not to imagined or psychological pain.

What causes a sensitive nervous system in hypermobility?

A few things seem to play a role: the brain becoming more responsive to pain signals, and the body’s natural pain-inhibiting system not working as well as it should. A 2026 study also found central sensitization in hEDS/HSD was tied to fatigue, pain, and cardiac dysautonomia.

Is nociplastic pain the same as central sensitization?

Not quite. Central sensitization is the nervous-system process thought to drive nociplastic pain; nociplastic pain is the resulting pain phenotype. The terms are closely linked but not interchangeable.

Can a sensitized nervous system be calmed down?

Yes. Strategies like diaphragmatic breathing, gentle mid-range movement, and reframing pain as discomfort can help reduce nervous system sensitivity over time, though it typically takes consistency rather than a single fix.

Does this mean my pain is psychological?

No. A 2026 study of 150 adults with hEDS/HSD found that anxiety and depression weren’t independently linked to central sensitization once fatigue, pain, and cardiac dysautonomia were factored in. This pain isn’t “just” anxiety.

What does nociplastic pain feel like?

It often feels widespread, achy, or burning. The pain is bigger than the injury, spreads in ways that don’t make anatomical sense, and comes with sensitivity in senses that have nothing to do with the painful area.

What triggers central sensitization syndrome?

Common triggers include ongoing stress, poor sleep, physical or emotional trauma, and chronic inflammation. In hEDS/HSD, repeated joint injuries and an already-reactive nervous system can make sensitization more likely to develop.

Is central sensitization permanent?

Not necessarily. While it can persist for years, research and clinical experience suggest the nervous system can become less reactive over time with consistent strategies like graded movement, sleep, stress reduction, and pacing.

Jeannie Di Bon

Jeannie Di Bon is a movement therapist, educator and author specializing in hypermobility, Ehlers-Danlos Syndrome and chronic pain. She is the founder of The Zebra Club app and the creator of the Integral Movement Method.

Leslie Russek

Leslie Russek, PT, DPT, PhD, OCS a professor emeritus at Clarkson University. She is a physical therapist, researcher, and hypermobility specialist. Her research focus includes hEDS/HSD, headaches, and fibromyalgia. Dr. Russek is the scientific advisor of The Zebra Club and a frequent presenter at Zebra Club meet-ups.

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