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Principles of Pain Management

Original Editor - Stacy Schiurring

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Introduction

Pain is a major cause of disability worldwide and has significant economic and social costs.[1][2][3] It is a complex, multidimensional experience, with sensory, emotional, psychological, and social components.[2] The International Association for the Study of Pain (IASP) developed a task force with the objective of defining pain in a way that conveys its complexity within medical practice.[4]

The IASP task force defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”[4]

This definition is expanded upon to include six key contextual factors:[4]

  1. Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
  2. Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
  3. Through their life experiences, individuals learn the concept of pain.
  4. A person’s report of an experience as pain should be respected.
  5. Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
  6. Verbal description is only one of several behaviours to express pain; the inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

The effects of pain can be far-reaching and vary from person to person. Because of this, pain management programmes must be evidence-based and personalised to meet each person's unique needs.

Acute vs Chronic Pain

Acute pain plays an important physiological role in protecting the body from perceived or real danger.[5] However, when pain becomes persistent or chronic, it can be debilitating and greatly impact a person's quality of life.

Acute pain occurs suddenly and has a known cause, such as a trauma, surgery or other medical procedure. It can last from minutes after injury to up to six months. Acute pain often serves a protective function or acts as a warning sign that something is wrong and potentially indicates the need for medical intervention. The perception of acute pain stops once the underlying cause of the pain has been treated or healed.[6]

Chronic pain is ongoing pain that lasts for more than six months. It is pain that outlasts the normal timeframe of healing and can be considered a disease state. Chronic pain can arise from physical or psychological states. It has no biological purpose and has no recognisable end-point.[6][7]

Paradigm Shift

Current research is pointing to the need for a paradigm shift in pain management from treatment to rehabilitation. The goal of pain rehabilitation practices should be to optimise a patient's quality of life rather than merely alleviating pain. To achieve this, there must be a collaborative relationship between clinicians, researchers, and patients, where careful observation of a patient's experience informs rehabilitation practices. Recognising pain as a complex, perceptual experience influenced by various factors, including psychological and social contexts is key to successful pain rehabilitation.[8]

Pain Mechanisms

Identifying and understanding the underlying mechanism of a person's pain can assist clinicians in providing individualised management plans.[9]

The International Association for the Study of Pain (IASP) classifies pain based on several underlying mechanisms: (1) nociceptive, (2) neuropathic, (3) nociplastic, and (4) central pain. Please take a look at Table 1 for a summary of these pain mechanisms.

These mechanisms provide a framework for understanding the different types of pain and guiding research and clinical practice in pain management. The IASP also acknowledges that pain is influenced by psychological and social factors, which can modulate the pain experience and contribute to chronic pain conditions.[10]

Table 1. Pain mechanisms.
Definition Mechanism Characteristics
Nociceptive Pain Pain resulting from actual or potential tissue damage detected by nociceptors[10][11] Triggered by harmful stimuli (e.g. injury, inflammation) that activate receptors
  • Quality: sharp, aching, or throbbing
  • Localisation: well-localised to the area of injury
  • Examples: pain from a sprained ankle, cut, or surgical wound
Neuropathic Pain Pain caused by damage or dysfunction in the nervous system, specifically the somatosensory system[12] Results from abnormal processing of pain signals due to nerve injury or disease
  • Quality: burning, tingling, shooting, or electric shock-like sensations
  • Localisation: often poorly localised and can occur in areas remote from the injury site
  • Examples: diabetic neuropathy, post-herpetic neuralgia, or pain from spinal cord injuries
Nociplastic Pain Pain arising from altered nociceptive processing without clear evidence of tissue damage or nerve injury[13] Frequently involves central sensitisation, where the nervous system becomes hyper-responsive to pain stimuli
  • Quality: diffuse, aching, or widespread
  • Localisation: can be widespread, often not linked to specific damage
  • Examples: fibromyalgia, chronic headaches, non-specific low back pain, and some types of chronic pain syndromes
Central Pain Pain resulting from dysfunction in the central nervous system, regardless of peripheral input[14] Often occurs after an injury or disease affecting the brain or spinal cord, leading to abnormal pain processing
  • Quality: varies widely but may include burning or aching sensations
  • Localisation: may not correspond to a specific area and can affect broad regions
  • Examples: central post-stroke pain, pain after spinal cord injury, and conditions like multiple sclerosis

If you are interested in learning more, you can find detailed information on pain mechanisms here.

Maladaptive Neuroplasticity

Maladaptive neuroplasticity refers to the process by which the nervous system undergoes changes in response to injury or persistent pain. These changes ultimately contribute to the worsening or maintenance of pain rather than its alleviation.[8] In regards to chronic pain, maladaptive neuroplasticity plays a significant role in altering pain perception and processing and can lead to increased sensitivity to pain over time.[15]

"Chronic pain also is associated with abnormal intracortical inhibitory mechanisms whereby body-related neural representations become less precise, an abnormality thought to be important in some of the multiple system dysfunctions that are seen in people with chronic pain. That this increased sensitivity and decreased precision may contribute to the problem of pathological pain has generated promising new approaches to rehabilitation." - Lotze and Moseley, 2015[8]

Key features of maladaptive neuroplasticity:[8][15]

  • Central sensitisation: involves heightened sensitivity of the central nervous system (CNS), where even normal sensory inputs can trigger exaggerated pain responses. This can lead to chronic pain conditions.
  • Altered pain processing: changing the way pain signals are interpreted in the brain often leads to a persistent perception of pain, even in the absence of ongoing tissue damage.
  • Impaired inhibition: the ability of the CNS to inhibit pain signals diminishes, meaning the brain has less control over pain perception, which can result in an increased experience of pain.
  • Structural brain changes: chronic pain can lead to physical changes in brain regions involved in pain processing, emotional regulation, and cognition, which may reinforce the pain experience.
  • Development of hyperalgesia and allodynia: maladaptive neuroplasticity can cause hyperalgesia (increased sensitivity to painful stimuli) and allodynia (pain from non-painful stimuli), leading to discomfort from stimuli that would normally be harmless.

The Biopsychosocial Model for Pain Management

"In a truly biopsychosocial framework of pain, the things we say, do, think, and hear are all potential modulators of pain itself and may all be suitable targets for rehabilitation. Clearly, then, the relationship we develop with the patient in pain is critical." - Lotze and Moseley, 2015[8]

The IASP recognises pain as a complex interplay of biological, psychological, and social elements. Because of this complexity, a holistic approach to assessment and treatment is necessary.[10]

The biopsychosocial model can be used to look holistically at the factors influencing a person's pain. It is a comprehensive framework that captures physical, as well as psychological and social dimensions. The biopsychosocial model contrasts with purely biomedical approaches, which primarily focus on the biological causes of pain, such as tissue damage or injury.[16]

Components of the Biopsychosocial Model

Biological factors: include (1) the physiological mechanisms of pain, such as nociceptive pathways, neuroplasticity, and genetic predispositions to pain; (2) health and underlying medical conditions, such as arthritis or neuropathy, that contribute to pain; and (3) the role of pharmacological treatments and their efficacy in managing pain.[17]

Psychological factors: include (1) cognitive processes (i.e. our thoughts and beliefs about pain) that can affect pain perception. For example, catastrophising (expecting the worst) can exacerbate pain experiences; (2) emotional factors (e.g. anxiety, depression and stress) that can influence pain perception and coping mechanisms; and (3) our behavioural responses to pain (e.g. avoidance behaviours / maladaptive coping strategies) that can impact pain outcomes.[17]

Social factors: include (1) social support (e.g. emotional and practical supports) from family, friends, and the community that can influence pain management; (2) cultural beliefs about pain and healthcare that can affect how individuals perceive and respond to pain; and (3) socioeconomic status (e.g. access to healthcare, financial resources, and occupational factors), which can impact pain management and outcomes.[17]

The biopsychosocial model in pain management allows clinicians to develop a more holistic understanding and comprehensive view of a person's pain perception—one that accounts for the complexity of human experiences. By addressing psychological, social and biological factors, clinicians can help their patients achieve better pain management outcomes and improved quality of life. The biopsychosocial model also encourages active patient involvement in treatments, fostering self-management and coping strategies.[17]

Pain Management Interventions

Every person's pain perception is unique to their personal experience. Pain management care plans and interventions should, therefore, be tailored to each person's needs.[18] This is best accomplished using a multidisciplinary team approach and the biopsychosocial model.

When considering medication prescription, the American Society of Interventional Pain Physicians (ASIPP) has established a ten-step process for opioid prescribing, which includes comprehensive assessments, risk stratification, and ongoing monitoring of medication effectiveness and side effects. Due to the ongoing opioid epidemic, there is a growing emphasis on non-opioid pharmacotherapies. Common alternatives include non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, and topical analgesics.[8]

Multidisciplinary Pain Management

Pain management often involves a team of healthcare providers, including physicians, psychologists, physiotherapists, and social workers, working collaboratively to address the multifaceted nature of pain. Evidence suggests this integrated approach yields better outcomes than isolated treatments. Examples of a multidisciplinary team approach can include, but not be limited to:

  • medical (biological) interventions: pain medications or physiotherapy to address the biological aspects of pain management
  • psychological interventions: cognitive behavioural therapy (CBT) to modify negative thought patterns, improve coping strategies, and manage emotions, as well as mindfulness, motivational interviewing and acceptance and commitment therapy (ACT)
  • social support strategies: involving family members in treatment discussions or connecting patients with support groups to enhance social support

This team-based, biopsychosocial approach not only improves pain management but also enhances patient engagement, self-efficacy, and quality of life.[19]

Rehabilitation Interventions

The following sections highlight a range of evidence-supported rehabilitation interventions for pain. For acute injuries, the PEACE and LOVE framework has been proposed to optimise soft tissue recovery. If you would like to learn more about this framework, please see: PEACE and LOVE.

Pain Neuroscience Education

Pain education / pain neuroscience education (PNE) is an important part of chronic pain management. Pain education is grounded in the science of how the brain and nervous system interpret nociception or danger signals to produce pain. Improving a person's understanding of pain mechanisms and triggers has been found to improve their perception of pain.[20] If you would like to learn more about pain education, please see: Patient Education in Pain Management.

Exercise Interventions

"An acute bout of physical activity and exercise can increase pain in individuals with chronic pain, but regular exercise is an effective treatment." - Sluka et al., 2018[21]

Exercise interventions are a key part of pain management. There is currently no consensus on the most effective exercises for pain management. However, research suggests that tailoring exercises to each patient's individual needs and pain symptoms is important. Thus, many unique factors must be considered when prescribing exercises for patients with pain, including (1) exacerbation of pain with exercise, (2) patient compliance, and (3) factors related to central sensitisation that could affect pain responses and exercise tolerance.[22] Care plans should also be frequently re-assessed to ensure they remain effective.

Current recommendations for patients with pain syndromes span a wide range of commonly utilised exercise interventions and education topics. Group exercise programmes focusing on strengthening, stretching, and aerobic training were found to be beneficial for pain management, improved social outreach, and improved general participant well-being.[18][22] [20] Gentle forms of physical activity and exercise, including walking, bicycling, water-based treadmill walking, and balance and coordination exercises, also produced improvements in patient pain scores.[22] [20]

Research suggests that exercising more frequently correlates with better pain relief. However, sessions that are too long (i.e. increased duration) may diminish any benefits.[22] From a neuroscience perspective, regular physical activity has been found to alter central pain inhibitory pathways. It also has a protective effect against developing chronic, long-lasting pain. The type of exercise may be less important than the act of being active.[21]

Mindfulness training, including activities such as Tai Chi, yoga, and body awareness training, can also have benefits for people with pain.[22][20]

"Regular physical activity can be achieved through regular lifestyle activity or by structured exercise. In chronic pain, prescribed exercise is an effective treatment for most pain conditions, and use of exercise and physical therapy has long been recognised for its effectiveness in reducing disability and health care costs." - Sluka et al., 2018[21]

Adjunct treatments

Certain adjunct treatments can complement education and exercise-based approaches. For instance, a single course of acupuncture or dry needling[18] can be useful in the management of pain. Manual therapy can also provide short-term benefits. For people with chronic pain, it may be beneficial to use manual therapy as a technique to facilitate active treatments, like exercise, rather than as a standalone intervention.[23] However, research does NOT recommend the use of electrical physical modalities such as TENS, interferential therapy and ultrasound.[18]

Lifestyle Factors

There is also increasing evidence on the role of diet and sleep as potential ways to further influence pain.

Diet is a modifiable factor that may influence chronic pain, and interest is growing in using diet therapy as a complement to conventional treatment. While high-quality evidence remains limited, early findings suggest that anti-inflammatory diets, such as the Mediterranean-style diet (rich in fruits, vegetables, olive oil, nuts, legumes, and key micronutrients) may help reduce pain[24] and the need for analgesics. Reducing processed foods and possibly incorporating intermittent fasting may also provide benefits, though more research is needed.[25]

Sleep plays a crucial role in physical and psychological recovery. Disturbances in sleep, such as difficulty falling or staying asleep, can significantly increase sensitivity to pain. Poor sleep impairs emotional regulation, immune function, and healing processes, making individuals more vulnerable to both acute and chronic pain. Chronic sleep loss has been linked to heightened pain perception and lower pain tolerance. Over time, this can contribute to the development or worsening of chronic pain conditions. The relationship is bidirectional, but evidence strongly supports that inadequate sleep not only predicts pain but also intensifies its severity, creating a self-reinforcing cycle that impacts overall health and well-being.[26] Specific techniques to improve sleep include: (1) keeping a consistent wake / sleep schedule, (2) limiting or strategically timing naps, (3) avoiding stimulants, heavy meals and exercise one to two hours before bed, (4) creating a relaxing bedtime routine, and (5) avoiding screentime for at least an hour before bed.[27][28] If you would like to read more about sleep hygiene, please see: Common Sleep Hygiene Practices.

Additional Resources

Links to Pain Assessments and Questionnaires

Basic Pain Scales:
Functional Outcome Measures:
Psychosocial Outcome Measures

Pain Management Guidelines

"Explaining Pain" Resources

  • Patient Education in Pain Management Phyiopedia Reading Page
  • The following interview with world-renowned pain management specialist Adriaan Louw, PT, PhD, explores how to best communicate with and provide education to patients about their pain conditions.

[29]

Pain Management Curricula

In line with the growing emphasis on evidence-based pain education, the European Pain Federation promotes a biopsychosocial and interprofessional approach, recognising the roles of all healthcare professionals in pain management. EFIC has developed core curricula in pain medicine, physiotherapy, nursing, and psychology, forming the foundation of its educational work. Among these, two physiotherapy-specific documents were published:

References

  1. ↑ Alkhatib GS, Al Qadire M, Alshraideh JA. Pain management knowledge and attitudes of healthcare professionals in primary medical centres. Pain Management Nursing. 2020 Jun 1;21(3):265-70.
  2. ↑ 2.0 2.1 Cohen SP, Vase L, Hooten WM. Chronic pain: an update on the burden, best practices, and new advances. Lancet. 2021 May 29;397(10289):2082-2097.
  3. ↑ Franqueiro AR, Yoon J, Crago MA, Curiel M, Wilson JM. The interconnection between social support and emotional distress among individuals with chronic pain: a narrative review. Psychol Res Behav Manag. 2023 Oct 27;16:4389-4399.
  4. ↑ 4.0 4.1 4.2 International Association for the Study of Pain (IASP). IASP Announces Revised Definition of Pain. Available https://www.iasp-pain.org/publications/iasp-news/iasp-announces-revised-definition-of-pain/ (accessed 27 April 2025).
  5. ↑ Mankelow J, Ryan CG, Green PW, Taylor PC, Martin D. An exploration of primary care healthcare professionals’ understanding of pain and pain management following a brief pain science education. BMC medical education. 2022 Mar 28;22(1):211.
  6. ↑ 6.0 6.1 Grichnik KP, Ferrante FM. The difference between acute and chronic pain. The Mount Sinai journal of medicine, New York. 1991 May 1;58(3):217-20.
  7. ↑ National Library of Medicine | StatPearls. Chronic Pain. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553030/ (last accessed 29 October 2024).
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Lotze M, Moseley GL. Theoretical considerations for chronic pain rehabilitation. Physical therapy. 2015 Sep 1;95(9):1316-20.
  9. ↑ Vardeh D, Mannion RJ, Woolf CJ. Toward a mechanism-based approach to pain diagnosis. The Journal of Pain. 2016 Sep 1;17(9):T50-69.
  10. ↑ 10.0 10.1 10.2 International Association for the Study of Pain/Terminology. Available from: https://www.iasp-pain.org/resources/terminology/?ItemNumber=1698 (Accessed on 14 September 2024)
  11. ↑ Fullen BM, Wittink H, De Groef A, Hoegh M, McVeigh JG, Martin D, Smart K. Musculoskeletal pain: current and future directions of physical therapy practice. Archives of rehabilitation research and clinical translation. 2023 Mar 1;5(1):100258.
  12. ↑ van Velzen M, Dahan A, Niesters M. Neuropathic pain: challenges and opportunities. Frontiers in Pain Research. 2020 Aug 7;1:1.
  13. ↑ Kosek E, Clauw D, Nijs J, Baron R, Gilron I, Harris RE, Mico JA, Rice AS, Sterling M. Chronic nociplastic pain affecting the musculoskeletal system: clinical criteria and grading system. Pain. 2021 Nov 1;162(11):2629-34.
  14. ↑ Phillips K, Clauw DJ. Central pain mechanisms in rheumatic diseases: future directions. Arthritis and rheumatism. 2013 Feb;65(2):291.
  15. ↑ 15.0 15.1 Bazzari AH, Bazzari FH. Advances in targeting central sensitisation and brain plasticity in chronic pain. The Egyptian Journal of Neurology, Psychiatry and Neurosurgery. 2022 Apr 1;58(1):38.
  16. ↑ Gliedt JA, Schneider MJ, Evans MW, King J, Eubanks JE. The biopsychosocial model and chiropractic: a commentary with recommendations for the chiropractic profession. Chiropractic & manual therapies. 2017 Dec;25:1-9.
  17. ↑ 17.0 17.1 17.2 17.3 Semmons J. The role of specialist physiotherapy in a pain management clinic–traditional and novel approaches. Anaesthesia & Intensive Care Medicine. 2022 Jul 1;23(7):405-8.
  18. ↑ 18.0 18.1 18.2 18.3 National Institute for Health and Care Excellence/ Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. Available from:https://www.nice.org.uk/guidance/ng193/chapter/Recommendations (Accessed 13 September 2024)
  19. ↑ Venturin D, Battimelli A, di Cara G, Poser A. The multidisciplinary team in the management of chronic pain and pain-related fear: an evidence-based approach in a clinical case. Physiotherapy Theory and Practice. 2025 Feb 1;41(2):447-64.
  20. ↑ 20.0 20.1 20.2 20.3 British Pain Society/ Guidelines for Pain Management Programmes for adults. Available from:https://www.britishpainsociety.org/static/uploads/resources/files/pmp2013_main_FINAL_v6.pdf (accessed 14 September 2024)
  21. ↑ 21.0 21.1 21.2 Sluka KA, Frey-Law L, Bement MH. Exercise-induced pain and analgesia? Underlying mechanisms and clinical translation. Pain. 2018 Sep 1;159:S91-7.
  22. ↑ 22.0 22.1 22.2 22.3 22.4 Ferro Moura Franco K, Lenoir D, dos Santos Franco YR, Jandre Reis FJ, Nunes Cabral CM, Meeus M. Prescription of exercises for the treatment of chronic pain along the continuum of nociplastic pain: A systematic review with meta‐analysis. European Journal of Pain. 2021 Jan;25(1):51-70.
  23. ↑ Louw A, Nijs J, Puentedura EJ. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther. 2017 Jul;25(3):160-168.
  24. ↑ Casini I, Ladisa V, Clemente L, Delussi M, Rostanzo E, Peparini S, Aloisi AM, de Tommaso M. A personalized Mediterranean diet improves pain and quality of life in patients with fibromyalgia. Pain and Therapy. 2024 Jun;13(3):609-20.
  25. ↑ Philpot U, Johnson MI. Diet therapy in the management of chronic pain: better diet less pain?. Pain management. 2019 Jul 1;9(4):335-8.
  26. ↑ Herrero Babiloni A, De Koninck BP, Beetz G, De Beaumont L, Martel MO, Lavigne GJ. Sleep and pain: recent insights, mechanisms, and future directions in the investigation of this relationship. Journal of neural transmission. 2020 Apr;127:647-60.
  27. ↑ NHS. How to fall asleep faster and sleep better. Available from: https://www.nhs.uk/every-mind-matters/mental-wellbeing-tips/how-to-fall-asleep-faster-and-sleep-better/ (accessed 5 June 2025).
  28. ↑ Baranwal N, Yu PK, Siegel NS. Sleep physiology, pathophysiology, and sleep hygiene. Prog Cardiovasc Dis. 2023 Mar-Apr;77:59-69.
  29. ↑ YouTube. Pain Neuroscience Education Plus With Adriaan Louw, PT, PhD | Joe Tatta, PT, DPT. Available from: https://www.youtube.com/watch?v=Iaz_M9T-BrU [last accessed 01 November 2024]
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