24 Chronic Pain

Chronic Pain

Chronic pain, defined as pain that occurs on ≥ 50% of days over a period of at least 6 months or as pain that persists for at least 3 months. Such pain often becomes the sole or predominant clinical problem in some patients (Treede et al., 2019).

  • Chronic primary pain is characterized by disability or emotional distress and not better accounted for by another diagnosis of chronic pain. Here, you will find chronic widespread pain, chronic musculoskeletal pain previously termed “non-specific” as well as the primary headaches and conditions such as chronic pelvic pain and irritable bowel syndrome.
  • Chronic secondary pain is organized into the following six categories:
    1. Chronic cancer-related pain is chronic pain that is due to cancer or its treatment, such as chemotherapy.
    2. Chronic postsurgical or post-traumatic pain is chronic pain that develops or increases in intensity after a tissue trauma (surgical or accidental) and persists beyond three months.
    3. Chronic neuropathic pain is chronic pain caused by a lesion or disease of the somatosensory nervous system. Peripheral and central neuropathic pain are classified here.
    4. Chronic secondary headache or orofacial pain contains the chronic forms of symptomatic headaches and follows closely the ICHD-3 classification.
    5. Chronic secondary visceral pain is chronic pain secondary to an underlying condition originating from internal organs of the head or neck region or of the thoracic, abdominal or pelvic regions. It can be caused by persistent inflammation, vascular mechanisms or mechanical factors.
    6. Chronic secondary musculoskeletal pain is chronic pain in bones, joints and tendons arising from an underlying disease classified elsewhere. It can be due to persistent inflammation, associated with structural changes or caused by altered biomechanical function due to diseases of the nervous system.


Chronic pain is a condition, affecting an estimated 20% of people worldwide. The current scientific consensus is that symptoms are caused by ongoing neuro-inflammation and hyper-vigilance of the central nervous system. More specifically sustained glial cell activation and elevated levels of certain inflammatory substances.


A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Incorporate one or more of the following chronic pain outcome measurements when assessing and monitoring patient progress:

  • Patient Global Impression Change
  • Pain Self Efficacy Scale
  • Self-Rated Recovery Question
  • Patient Specific Functional Scale
  • Brief Pain Inventory (BPI)
  • Numeric Pain Rating Scale (NPRS)
  • Visual Analogue Scale (VAS)
  • Michigan Body Map
  • Perceived Stress Questionnaire (PSQ)
  • McGill Pain Questionnaire (MPQ) or The Revised Short McGill Pain Questionnaire Version-2 (SF-MPQ-2)
  • Multidimensional Pain Inventory
  • Short Musculoskeletal Function Assessment (SMFA)



Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

Ascribing a patient’s pain solely to a tissue-driven pain problem is an oversimplification of a complex process. This insight provides us with an opportunity to re-frame our clinical models. Gently stretching the muscles, neurovascular structures, and investing fascia activates endogenous pain modulating systems that help to modulate neuro-immune responses.

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Exercise therapy is safe and beneficial for physical and psychosocial health in people with multiple comorbidities (Bricca et al., 2020). Regular physical activity have been shown to significantly reduce symptoms of anxiety, reduce pain, and improve function (Bull et al., 2020; Pedersen & Saltin, 2015). The world health organization recommends adults should undertake 150-300 min of moderate-intensity, or 75-150 min of vigorous-intensity physical activity, or some equivalent combination of moderate-intensity and vigorous-intensity aerobic physical activity, per week. These guidelines highlight the importance of regularly undertaking physical activity (both aerobic and muscle strengthening activities) emphasizing the value of any activity, of any duration, and any intensity (Bull et al., 2020).


Clinical practice guidelines recommend the use of massage therapy as part of a multi-modal approach for patients with chronic pain (Busse et al., 2017; Skelly et al., 2020). It is not suggested that massage therapy alone can control symptoms but can be utilized to help relieve pain & reduce anxiety when integrated with standard care.

The Mysterious Science of Pain – Joshua W. Pate

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for chronic pain based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

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