Chronic pain affects more than the area that hurts. It may affect movement, sleep, mood, concentration, relationships, work, and confidence. Good care does not generalise that the pain "arises from thinking", and does not guarantee that a hidden biological explanation will be found and removed as the only thing. Instead it combines the assessment of possible disease or injury, the processing of the nervous system, and the context of the patient's life.

The meaning of chronic pain

The NICE guideline on chronic pain (opens in a new tab) defines it as pain that persists or recurs for more than 3 months. Chronic secondary pain has an underlying disease that explains the symptoms sufficiently, such as joint degeneration or neuropathic pain. Chronic primary pain, on the other hand, has no state that explains the symptoms or their effects sufficiently. Both kinds may arise together, and the classification has an effect on the choice of treatment.

The severity of the pain does not always correspond directly with visible damage to the tissue. Continuing inflammation, injury of the nerves, changed processing of sensation, reduced activity, disturbed sleep, distress, and social pressures may interact with one another. This complexity makes claims of permanently putting right a biological process unsuitable if there is no evidence specific to the diagnosis.

An assessment that holds the patient as its centre considers biological, psychological, and social factors without blaming, namely

Biological: the position and the pattern of the symptoms, disease or injury, neurological symptoms, overall health, sleep, capacity, and the effects of medicines
Psychological: beliefs about the pain, fear of movement, mood, attention, ways of coping, experiences that hurt the mind, and confidence
Social: work and the role of caring for others, finances, relationships, culture, access to services, and support in real life

Carers should ask what matters to the patient and how the pain affects their life. The physical examination and the tests should be chosen in order to answer a clinical question, not to search endlessly for a single abnormality. A normal imaging result does not mean that the pain is not real, and an abnormal result does not prove that that point is the main source of the symptoms.

Agree realistic goals for rehabilitation

The goals may be sleeping more regularly, walking further, going back to valued activities, working with fewer flare-ups, using less relieving medicine, or doing daily routines more independently. Some states may have the pain resolve, but it should not be guaranteed. Meaningful improvement may be in function, participation, confidence, or better self-management, even though some pain remains.

The plan should explain the benefit expected, the harms, the uncertainties, the costs, and the alternatives, as well as how the progress will be measured and the approach when the symptoms change.

The main components of rehabilitation

Physical activity and physiotherapy

The activity should suit the state, the baseline capability, the preferences, and the goals. A graded programme may consist of aerobic work, strength, movement, balance, and training in meaningful activities. The goal is to increase capability without interpreting every temporary increase in pain as evidence that the body is damaged. But severe symptoms, or symptoms that get continuously worse, should not be overlooked as merely a normal flare-up either.

Pacing activity and resting suitably helps maintain balance; it is not lifelong avoidance. The plan should gradually expand what can be done, while following the sleep, the fatigue, the function, and the symptoms.

Psychological approaches for pain

Acceptance and commitment therapy (ACT), or cognitive behavioural therapy (CBT) for pain, may help reduce distress, change unhelpful patterns of avoidance, and return to valued activities. These approaches do not mean that the pain is imaginary, but care for the relationship between the pain and life.

Problems of sleep, isolation, the demands of work, stress in the family, and financial problems may increase disability. Rehabilitation may therefore include strategies for sleep, adjusting work, social support, and coordination with carers or other community services.

Medicines must be reviewed according to the diagnosis

Medicines may be of benefit for some states of chronic secondary pain, but the benefits and the harms differ according to the disease and the individual. The review should consider the function, the side effects, interactions between medicines, dependence on medicine, and whether the goals of treatment are being achieved.

For chronic primary pain, NICE does not recommend starting opioids, gabapentinoids, benzodiazepines, antipsychotics, non-steroidal anti-inflammatory medicines, or paracetamol merely to manage this state. An antidepressant may be considered after discussing the benefits and the harms fully, even without a state of depression. This recommendation does not automatically apply to every kind of chronic secondary pain.

Opioids, gabapentinoids, benzodiazepines, or antidepressants should not be stopped abruptly. If the benefit obtained is limited or the harm is greater, a review and a safe plan for reducing the medicine should be agreed with the prescriber.

Procedures, devices, and claims in regenerative medicine

The image in this article shows an injection using ultrasound guidance. Injection may suit certain diagnoses, but the guidance helps place the needle; it does not prove that the substance injected is effective or suits every kind of chronic pain.

Laser, shock waves, magnetic stimulation, QMR, plasma with a high concentration of platelets, or treatment with cells have different evidence and regulatory status according to the state. They are not a standard set of treatment for chronic pain, and should not be presented as usable for restoration in everyone or as giving a permanent result without evidence specific to the disease. Before a procedure, the standard alternatives, the uncertainties, the adverse effects, and the costs should be explained.

Plan for dealing with flare-ups

A flare-up is a period in which the pain, the fatigue, the stiffness, the function, or the disease activity temporarily gets worse, and a trigger may not always be found. The plan may include temporarily adjusting activity, using the coping methods agreed, reviewing medicines safely, maintaining sleep, and gradually returning to the previous programme.

New symptoms or a pattern that has changed greatly must be assessed anew; it should not be generalised as arising from the chronic pain. An urgent assessment may be needed when there is new weakness, abnormal control of urine or faeces, numbness around the genitals or the anus, fever together with severe pain, unintended weight loss, chest pain, a sudden severe headache, a severe accident, or thoughts of self-harm.

Frequently asked questions

Does chronic pain always mean that the tissue is still damaged

No. Ongoing disease of the tissue or injury of the nerves can cause pain, but the symptoms may persist from changed processing of sensation and other interacting factors. The assessment should search for treatable states without concluding that the severity of the pain directly measures the damage.

Can one exercise while still in pain

In many cases, activity that is suitably chosen and increased gradually is part of the care. The starting point and the progression must correspond with the diagnosis, the current capability, and the warning signals. One should stop and seek advice when there are new neurological symptoms, illness throughout the body, or a clear and continuous worsening.

Does rehabilitation replace medicine or medical treatment

No. Rehabilitation, medicines, psychological care, and treatment specific to the disease may support one another. The components should follow the diagnosis, the evidence, the patient's goals, and shared decision-making.

In summary

Rehabilitation for chronic pain is not a competition between medicines and technology, and it cannot guarantee that there will be no pain again. A useful plan should hold the patient as its centre, consider the biological, psychological, and social factors, care for the relevant medical states, gradually increase function, review medicines safely, and explain the benefits and the limitations of procedures straightforwardly.