Chronic pain is pain that is continuous or recurs for longer than 3 months. It may be chronic secondary pain, in which there is an identifiable disease, such as joint degeneration, nerve injury, inflammatory disease, or cancer, as a factor, or it may be chronic primary pain, in which there is no single disease that explains the pain or its effects sufficiently. Both forms may arise together (IASP (opens in a new tab))

Pain is real whether or not imaging finds a clear cause. The severity of the pain does not directly measure the damage to the tissue. Continuous pain may be influenced by biological factors, the sensitivity of the nervous system, movement and activity, sleep, mood, stress, work, relationships, and previous experience. The proportion of these factors differs in each person and changes over time.

The position of the pain, the mechanism of the pain, and the accompanying factors

Sometimes the pain is passed on from another structure, such as leg pain from the nerves of the spinal cord. In other cases, a neighbouring joint or muscle may change the way an activity is done, but it should not be generalised that a painful knee comes from the foot, that a painful shoulder comes from the neck, or that the pain "moves position" because one part compensates for another.

The terms muscle imbalance, poor body alignment, tight fascia, or dangerous movement should be a hypothesis, not a diagnosis. An overview review of 41 systematic reviews found no shared conclusion that the posture of the spine or exposure to certain physical loads is a cause of lower back pain. The relationships found do not confirm cause and effect (PubMed (opens in a new tab))

A useful assessment should ask what can be adjusted in order to increase function and well-being, instead of endlessly searching for a single hidden mechanical abnormality.

Chronic primary and secondary pain

Chronic secondary pain has a disease or injury that is an accompanying cause and should be assessed and treated where possible. Examples are joint degeneration, rheumatoid disease, continuous pain after surgery, pain from a pathological condition of the nerves, and pain from cancer.

Chronic primary pain is a state in its own right, in which another disease cannot explain the pain or its effects sufficiently. It does not mean that the pain is imaginary, arises from the mind, or is unimportant.

NICE advises that the doctor and the patient use clinical judgement together when deciding how far to search for the disease or injury that is the cause, and accepts that primary and secondary pain may arise together. The diagnosis should be reviewed when the symptoms change (NICE (opens in a new tab))

What should a responsible assessment have?

An assessment that holds the patient as its centre may review:

The onset, the pattern, the severity, what triggers and what relieves, and the change over time
Injuries, surgery, diseases, medicines, and the response to treatment in the past
Strength, the range of movement, sensation, reflexes, walking, balance, and the relevant activities
Sleep, fatigue, mood, stress, a history of events that hurt the mind, alcohol or addictive substances, and the social context
Work, the burden of caring for others, relationships, activities, and what the patient wants to go back to doing
Danger signals or test results that may indicate infection, a fracture, inflammatory disease, cancer, or a neurological disease that is progressing

Examining posture, recording the gait, testing strength, or a pain score can give information but do not identify the "root" of the pain by themselves. Clinical examination has uncertainty and should be interpreted together.

Imaging and diagnostic ultrasound are useful when the result is likely to help indicate a specific diagnosis or change the treatment. Degeneration of joints, intervertebral discs, tendons, and other structures may be found in people who have no pain, so an image should not be used to prove that the body is damaged or out of alignment.

The sensitivity of the nervous system

In some people, pain is triggered more easily or remains after the period in which the tissue would be expected to heal. This may be related to the processing of pain, the assessment of threat, disturbed sleep, distress, and reduced activity. "A state of sensitivity to pain" is a possible mechanism, not a conclusion that the pain is only in the brain.

Explaining pain should confirm the patient's experience and support safe activity. It should not diminish the symptoms, promise to "reset" the nervous system, or claim that a single technique can change the pathways of pain permanently.

Care according to the evidence

Knowledge, activity, and exercise

Care begins from a shared understanding of the state, the goals, and the alternatives. Activity may be paced and increased little by little, instead of stopping until the pain goes away. The form and the amount of exercise should match the diagnosis, the capability, the preferences, and the response. There is no single posture or programme that is correct for everyone.

For chronic primary pain, NICE recommends a supervised group exercise programme that takes account of needs, preferences, and capabilities, together with support for continuing physical activity for general health. Another form may be chosen when a group programme is not available or is not suitable.

Pain may affect, and be affected by, sleep, mood, worry, events that hurt the mind, work, finances, and relationships, without this meaning that "the mind is the cause". Acceptance and commitment therapy, or approaches of cognitive and behavioural therapy, may help some people with chronic primary pain manage distress, activity, and quality of life. Mental health symptoms should receive suitable care.

Medicines

The choice of medicine depends on the diagnosis, the benefit expected, the contraindications, and the previous response. The change expected should be defined and adverse effects reviewed. Adding medicines continually while function does not improve is not rehabilitation.

The guidelines for chronic primary pain differ from those for diseases that are a secondary cause, so the same list of medicines should not be used for every diagnosis. Opioids, gabapentinoids, antidepressants, anti-inflammatory medicines, and other medicines must all be judged and followed up according to the disease.

Devices and procedures in which the patient exerts no effort

Manual treatment, the use of dry needles, laser, shock waves, peripheral magnetic stimulation, and other devices have different evidence according to the diagnosis, the equipment, the parameters, and the outcomes. They should not be lumped together as "restoration to create new tissue", or claimed to increase circulation, repair tissue, stimulate the muscles, or prepare every patient to be ready to exercise.

Devices may be considered as a supplement limited in time when there is an indication and a goal that can be measured. They should be stopped if they do not increase function or if adverse symptoms arise.

Separating the layers of tissue with fluid, injection to stimulate repair, or other injections under ultrasound, are not general treatments for chronic pain. Each method must have its own diagnosis, position, substance injected, review of the evidence, consent, and assessment of risk, separately. Separating the layers of tissue with fluid may be considered in some states of a compressed nerve, while the evidence for injection to stimulate repair differs according to the tissue and the disease. Neither method proves that it releases fascia, creates new nerves, increases the strength of tissue, or prevents recurrence.

Creating and reviewing the plan

Define the problem: state the preliminary diagnosis, the uncertainties, the important factors, and the danger signals
Choose meaningful outcomes: such as sleep, walking, tolerance at work, self-care, exercise, or participation, not a pain score alone
Choose a small number of forms of care: explain the benefit, the risks, the burden, the alternatives, and the time for review
Increase activity: gradually build capability and plan for the normal fluctuations
Review: continue, change, or stop each part according to the benefit that can be measured and the adverse symptoms

A flare-up does not always mean new damage, but a changed pattern of symptoms should be reassessed. NICE advises reviewing the plan, considering new symptoms, and discussing the factors that may be related to the flare-up.

When should a medical assessment be received?

An assessment should be received when the pain is continuous or recurs so that it limits sleep, movement, work, self-care, or the quality of life, when the diagnosis is not clear, or when the treatment does not give a meaningful benefit.

There should be an urgent assessment when there is:

New or worsening weakness, loss of coordination, or being unable to control urination/defecation
Numbness in the area of the genitals and around the buttocks
Fever, a hot swollen joint, or suspicion of infection
A severe accident, suspicion of a fracture, or being unable to bear weight
Weight loss of unknown cause, a history of cancer together with new pain, or severe night pain that does not ease
Chest pain, difficulty breathing, or sudden swelling of a limb
Thoughts of harming yourself or being unable to keep yourself safe

Frequently asked questions

Does chronic pain always arise from damaged tissue?

Not always. Disease or injury of the tissue may play a part, but the severity and the persistence of the pain are also influenced by the nervous system, health, psychological factors, and social factors. The pain is still real.

Can posture or compensation cause chronic pain?

It may be related to the particular activities of the individual, but observation alone does not prove cause and effect. The assessment should test hypotheses that can be adjusted and follow up whether the change makes the important functions better.

Is imaging needed?

It is not needed as a routine. An image is useful when a particular result may change the diagnosis or the treatment, or when there are danger signals.

How does relieving pain differ from rehabilitation?

Relieving pain may help participation in activity. Rehabilitation builds function, confidence, and capability. A good plan may take care of both without waiting for the pain to be zero.

When should the treatment be changed?

When the benefit expected is not obtained within the period of review, when function does not improve, when adverse effects arise, or when the pattern of symptoms changes