Chronic Pain

Acute pain signals tissue damage. When pain persists past the expected healing time, the nervous system itself becomes more sensitive — the volume is turned up — and pain continues in the absence of ongoing damage.

This is why scans can be normal while pain is real and severe, and why treatment aimed only at the tissue often fails. Chronic pain is treated as a condition in its own right rather than as an unresolved acute injury.

Reduced movement, muscle weakening, disturbed sleep, low mood, withdrawal from social contact, and in older adults a direct route to falls and loss of independence. Fear of movement is a central mechanism: activity that hurts is avoided, capacity falls, and less activity is needed to provoke pain.

In older adults especially, pain should not be dismissed as a normal part of ageing. It is treatable and leaving it untreated costs mobility and independence.

Aiming only at reducing pain intensity sets up a treatment that fails, because in established chronic pain the score often moves little and moves last. Aiming at what the person can do produces measurable change much sooner, and pain frequently follows.

We agree the functional targets with you at the start — walking distance, sleep, specific daily activities — and measure those.

Graded activity and paced exercise. Pain neuroscience education — an explanation of how persistent pain works — which on its own has a small effect on pain intensity and is more useful combined with exercise and psychological approaches 4. Sleep management. Manual therapy where it helps someone take part in the active work; electrical treatments such as TENS, ultrasound and interferential therapy are not recommended for chronic primary pain because there is no evidence of benefit 1. Medication review, particularly in older adults where sensitivity and interactions are greater.

In older adults the programme also addresses balance and falls risk directly, because pain-driven inactivity and falls risk feed each other.

In persistent pain the nervous system becomes more efficient at producing pain, and the signal stops corresponding to tissue damage. Scans look the same; the alarm system has changed its threshold.

This is not the same as pain being imagined. It is a real mechanism with real treatment, and it explains why the search for a structural cause on imaging so often fails.

For chronic primary pain — pain lasting more than three months that no underlying condition adequately explains — NICE recommends offering a supervised group exercise programme, and considering cognitive behavioural therapy or acceptance and commitment therapy, a single course of acupuncture, or certain antidepressants 1.

It advises against TENS, ultrasound, interferential therapy and biofeedback, and against starting opioids, anti-inflammatory drugs, paracetamol, gabapentinoids or benzodiazepines for this type of pain 1. Where pain is explained by a condition such as osteoarthritis, the guidance for that condition applies, and the two types can exist together 1.