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Thomas Nemeth

Managing Persistent Pain (Part 2)

In the first article in this series titled ‘Making Sense of Pain’, you can read about what exactly pain is, what it means for pain to be chronic, and how pain can persist in the absence of actual tissue damage or injury (here’s the link). In this article, you will learn about some of the different strategies to help manage pain.

As mentioned previously, managing chronic pain requires managing the whole pain experience, and not just looking for something broken to fix. There is no band-aid or other quick solution to stop chronic pain from happening. The ultimate goal of managing chronic pain is to settle down a sensitised nervous system, and this is done by targeting the biological/physical, psychological, and social factors contributing to a person’s pain experience.

What are biological, psychological, and social factors?

Biological factors

Biological factors, or physical factors, are the things that most people associate with injuries and pain. Your ligament is sprained, muscle is torn, bone is broken, muscles are weak, muscles are tight, nerves are irritated, posture is bad, etc. These things make sense to most people because they all provide a direct explanation for why a person is experiencing pain. After 3 months however, most of these sorts of issues should resolve at the biological level, so when pain continues to persist beyond this point, there is often more to the story

Psychological factors

Psychological factors include an individual’s beliefs, attitudes, and emotions with respect to pain. Certain attitudes and emotions are shown to be more predictive of worse pain and longer-term disability (1)

These include, but are not limited to:

  • Pain hypervigilance or being constantly alert for pain
  • Pain catastrophizing – associating pain with the worst possible outcome
  • Kinesiophobia (fear of movement), which leads to behaviors that avoid movement
  • Maladaptive beliefs – not being open to new experiences, not willing to accept that pain does not necessarily mean damage
  • Reduced sense of control over pain
  • Reduced self-efficacy – low belief in one’s ability to manage their pain
  • Increased anxiety, depression/depressive thoughts, post-traumatic stress, and anger

Social factors

Social factors include the conditions in which we are born, work, live, and grow. Like psychological factors, a number of social factors can increase the likelihood of worse long-term pain and disability. (1)

These include, but are not limited to:

  • Lower education
  • Lower socio-economic status (i.e. lower income and/or living in less affluent area)
  • Recent stressful life events
  • Perceived injustice (i.e. what a person is experiencing is felt as unfair)
  • Absence from work
  • Suspicion or mistrust from other work colleagues
  • Low job satisfaction
  • Social isolation or less support from family and friends
  • Solicitous behavior – hypervigilance from someone else about a person’s physical condition or comfort (i.e. taking over a task, discouraging a person from activity)
  • Reduced trust in a person’s treating medical practitioners
Head Pain

How do you address all of these things?

In short, there is no single approach that can target all of these factors, and that is what makes managing chronic pain so challenging. Adding even more complexity is that each individual experiencing chronic pain presents with a totally unique set of factors contributing to their experience. No medication or chiropractic adjustment will be able to “fix” pain because they cannot account for all of these contributing factors.

As such, an approach that combines a number of different strategies is best (1). Some strategies are outlined below:

STRATEGYWhat is it?What factors does it address?
Goal Setting
Discussing short and long term goals that are specific, measurable, achievable, relevant, and time-bound– Clarifies expectations
– Improves trust in practitioner
– Improves sense of control over experience
EducationPain education and explanation to help re-conceptualise pain (2)Re-shapes unhelpful and maladaptive pain beliefs
PacingWorking out a manageable baseline of activity and slowly progress over time (3)– Improves self-efficacy
– Improves sense of control over experience
– Reduce pain catastrophizing and hypervigilance
– Increase trust in practitioner
Improves success with return to work
– Improves success with return to work
Graded exposurePacing, but with consideration of how fearful the activity is (start with less fearful and build toward most fearful) (3)– Addresses kinesiophobia and reduces fear avoidance
– Reduce hypervigilance and pain catastrophizing
–   Reduces anxiety
–  Re-shapes maladaptive pain beliefs
ExerciseSpecific exercises and functional tasks relevant to a person’s goals, interests, work, and abilities (4).– Improves self-efficacy and control of experience
– Reduce anxiety and depression
– Improve muscle strength and load tolerance of tissues
– Addresses kinesiophobia and reduces fear avoidance
Avoid Passive Treatment StrategiesAvoiding massage, electrotherapy, ultrasound, osteopathic and chiropractic intervention on their own (4).– Improves self-efficacy and sense of control over pain experience
– Reduces hypervigilance and fear of movement
–   Reshapes maladaptive pain beliefs
–   Reduces need for solicitous behavior

As you might appreciate, these strategies will look different for everyone, and not every strategy will work perfectly for every person with pain. A physiotherapist will be able to help individually tailor these strategies to fit with a person’s unique pain experience, and ensure a person feels heard and supported throughout their journey.

In the next article, we will dive further into the world of chronic pain, and explore one of the most common conditions: chronic low back pain.  

Are you experiencing pain? Hit the ‘Book Now’ button below to book a time for physiotherapist’s so that we can offer help to you.


(1). Adams, L. M., & Turk, D. C. (2018). Central sensitization and the biopsychosocial approach to understanding pain. Journal of Applied Biobehavioral Research, 23(2), n/a-n/a. doi:10.1111/jabr.12125

(2). Nijs, J., Paul van Wilgen, C., Van Oosterwijck, J., van Ittersum, M., & Meeus, M. (2011). How to explain central sensitization to patients with ‘unexplained’ chronic musculoskeletal pain: Practice guidelines. Manual Therapy16(5), 413–418.

(3). Macedo, L. G., Smeets, R. J. E. M., Maher, C. G., Latimer, J., & McAuley, J. H. (2010). Graded activity and graded exposure for persistent nonspecific low back pain: A systematic review. Physical Therapy, 90(6), 860-79. doi:

(4). Chou, R., Côté, P., Randhawa, K., Torres, P., Yu, H., Nordin, M., . . . Cedraschi, C. (2018). The Global Spine Care Initiative: Applying evidence-based guidelines on the non-invasive management of back and neck pain to low- and middle-income communities. European Spine Journal, 27(Suppl 6), 851-860.