Chronic pain: what it is, symptoms, causes and how it is managed

NHS inform says chronic pain is pain that lasts longer than 3 months in one or more parts of the body, and that it can cause emotional distress and make daily tasks more difficult. It says chronic pain can be a diagnosed health condition on its own and can also be a symptom of another health condition.

NICE guideline NG193 uses the same 3 month definition and notes that other terms used include persistent pain and long-term pain. It divides chronic pain into chronic primary pain and chronic secondary pain, which can coexist.

NHS inform lists ongoing and persistent pain, poor sleep, low mood, reduced physical activity, fatigue, poor concentration and poor short-term memory, a sense of feeling overwhelmed, and hypersensitivity to light, sound and touch.

It contrasts chronic pain with acute pain. Acute pain can usually be explained, for example following an injury, can usually be reduced by medication and reduces with healing. Chronic pain cannot always be explained, is not always helped by medicine and can cause lasting changes to activities, routines and roles.

NHS inform says traditional treatments like pain medication only have a limited benefit for some people with chronic pain, and that talking to a healthcare professional to find the right strategies and techniques is the best way to self manage your pain.

For chronic primary pain, NICE recommends offering a supervised group exercise programme and encouraging people to stay physically active, and considering acceptance and commitment therapy (ACT) or cognitive behavioural therapy (CBT) for pain delivered by trained professionals. It says to consider a single course of acupuncture or dry needling, within set limits.

NICE says to consider an antidepressant, either amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline, for people aged 18 and over after a full discussion of benefits and harms, explaining that these medicines may help with quality of life, pain, sleep and psychological distress even without depression.

NICE says not to start the following to manage chronic primary pain in people aged 16 and over: antiepileptic drugs including gabapentinoids, antipsychotics, benzodiazepines, corticosteroid trigger point injections, ketamine, local anaesthetics, non-steroidal anti-inflammatory drugs, opioids and paracetamol. It also says not to offer biofeedback, and not to offer TENS, ultrasound or interferential therapy because there is no evidence of benefit.

NICE says that if you are already taking any of these medicines, your prescribing should be reviewed together with you, and that stopping should be discussed including any withdrawal problems. Do not stop a prescribed medicine without speaking to your GP or pain specialist.

The NHS lists ways to reduce pain, including gentle exercise, because everyday activities such as walking, swimming, gardening and dancing can ease some of the pain directly by blocking pain signals to the brain. It says that if you become more active gradually it is unlikely you will cause damage, and that in the long term the benefits of exercise far outweigh any increase in pain.

It also suggests breathing slowly and deeply when in pain, distracting yourself with activities you enjoy, keeping in touch with friends and family, relaxation techniques, keeping to a regular sleep routine because sleep deprivation can make pain worse, and talking therapies. It says self-management courses and pain management programmes are NHS-based training programmes that help people manage day to day, and that many people say they take fewer painkillers afterwards.

• Gentle, gradually increased exercise.

• Slow, deep breathing and relaxation.

• Keeping to a sleep routine.

• Pacing your activities, which NHS inform describes as stopping when an activity becomes painful and building up gradually.

• Talking therapies and self-management courses.

• Contact with friends and family, and support from charities such as Pain Concern.

NHS inform says there is not always an obvious cause for chronic pain. Most people get back to normal after pain following an injury or operation, but sometimes the pain carries on for longer, and sometimes there is no identifiable cause.

It explains that the brain interprets signals from the nerves, and that chronic pain can cause changes in the brain and nervous system so that pain signals continue even when there is no harm or damage, and the signal pathway can become over sensitive, amplifying signals.

NICE says to offer a person-centred assessment to identify factors contributing to the pain and how it affects the person’s life, and to think about a diagnosis of chronic primary pain if there is no clear underlying cause or the pain or its impact is out of proportion to any observable injury or disease.

NICE says the assessment explores how pain affects lifestyle, work and sleep, physical and psychological wellbeing, stressful life events and relationships, and leads to an agreed care and support plan. It advises discussing that symptoms may fluctuate, flare-ups can happen, and that there can be improvements in quality of life even if the pain remains unchanged.

NHS inform says to contact your GP practice if you experience pain for longer than 12 weeks, you think you might have chronic pain, you are concerned about worsening pain, or you already have chronic pain and have developed new symptoms.

NICE says to offer reassessment if there is a change in symptoms such as a flare-up, and to be aware that a cause for the flare-up may not be identified.

NICE guideline NG193 applies to people aged 16 and over. For people aged 16 to 25, it says assessment should take into account age-related differences in presentation, the impact of pain on family interactions, and the impact on education and social and emotional development.

On the NHS the first step is a GP assessment, with NICE recommending a person-centred assessment and shared care and support plan, and access to supervised exercise programmes and psychological therapies. Pain management programmes and self-management courses are available through NHS services, and the NHS pain pages point to charities such as Pain Concern and Action on Pain.

Private pain clinics and physiotherapists are also available. Because chronic pain management relies on a combination of exercise, psychological approaches and a coordinated plan, it is worth asking any provider how it will fit with your GP and how success will be measured beyond pain scores.