Adult therapy
Chronic Pain in Adults
What chronic pain is, what research says about why some pain lasts, which treatments have evidence, and how to find a physical or occupational therapist.
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- Evidence Based
- Patient Focused
Chronic pain is pain that persists or keeps coming back for more than three months.1 In 2023, 24.3% of US adults had chronic pain, and 8.5% had pain that frequently limited their life or work.2 Some lasting pain comes from ongoing tissue damage or inflammation, some from damage or disease of the nerves, and some from changes in how the nervous system processes pain, a kind researchers call nociplastic and only partly understand. One person can have more than one kind.1,3,4 A UK guideline recommends exercise for chronic primary pain, and a US guideline cites high-quality evidence for exercise in back pain, fibromyalgia and hip or knee osteoarthritis; both list psychological therapies among the options,1,5 and reviews of trials find modest benefits: small to moderate for exercise, small or very small for cognitive behavioral therapy.6,7
Chronic pain conditions: guides for adults
Each guide below covers one condition or approach in depth. The sections after them answer the broader questions about long-lasting pain.
Widespread, nerve and long-term pain
Fibromyalgia
Widespread pain, fatigue and poor sleep: diagnosis, exercise and treatment goals.
Learn more →Complex regional pain syndrome
Pain far stronger than the injury, changes in the limb, and why early treatment matters.
Learn more →Persistent low back pain
Back pain past three months: what helps, and what scans can and cannot show.
Learn more →Pacing and activity management
How to break the boom-and-bust cycle and build activity back up.
Learn more →Migraine or sensory overload
Telling a migraine from an overstimulation headache, and when a headache needs a doctor the same day.
Learn more →Jaw pain (TMJ disorder)
TMJ disorder symptoms, physical therapy techniques and exercises to do at home.
Learn more →Pelvic pain
Causes of pelvic pain and painful sex, and how pelvic floor problems are treated.
Learn more →Peripheral neuropathy
Numbness, burning pain and balance: what rehabilitation can do.
Learn more →Back, neck, joint and tendon pain
Neck pain
Causes, what a scan can and cannot show, what relieves it, and when to worry.
Learn more →Sciatica
Leg pain from a nerve root: home care, exercises, treatment and healing time.
Learn more →Knee osteoarthritis
Exercise, physical therapy, weight, braces, medicines and injections for knee arthritis.
Learn more →Hip osteoarthritis
Groin and night pain, exercise and physical therapy, and treatment without surgery.
Learn more →Rotator cuff pain and tears
Cuff pain versus a tear, night pain, exercises, and when surgery is considered.
Learn more →Frozen shoulder
The stages, how long each lasts, and the evidence for each treatment.
Learn more →Tendinopathy
Achilles, patellar and rotator cuff tendon pain, and how loading exercise is used.
Learn more →Plantar heel pain
Why the first steps hurt most, home care, physical therapy and recovery time.
Learn more →Hand and wrist pain
Hand therapy after an injury or surgery, for arthritis and carpal tunnel, and splints.
Learn more →What is chronic pain, and how common is it?
The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” Its notes add that pain is always a personal experience, influenced to varying degrees by biological, psychological and social factors, and that pain and nociception, the nerve process that encodes harmful stimuli, are different things.3,8
Pain is called chronic when it persists or recurs for more than three months.1,9 A UK guideline, following the World Health Organization’s ICD-11, separates chronic primary pain, where no underlying condition adequately accounts for the pain or its impact, from chronic secondary pain, where one does, and the two can coexist. Fibromyalgia and complex regional pain syndrome are counted as chronic primary pain.1 Chronic secondary pain falls into six groups: pain related to cancer, nerve damage (neuropathic), the internal organs (visceral), an injury or surgery, headache and face pain, and musculoskeletal pain from another disease.9
In the US National Health Interview Survey, 24.3% of adults had chronic pain in 2023, meaning pain on most days or every day in the past three months, and 8.5% had high-impact chronic pain that frequently limited life or work activities. Chronic pain rose with age, from 12.3% of adults aged 18 to 29 to 36.0% of those 65 and older, and was more common in women (25.4%) than in men (23.2%).2
Why does pain persist after an injury heals?
There is no single answer. The International Association for the Study of Pain describes three kinds of pain by how they arise, and a person can have more than one kind at once.3,4
- Nociceptive pain arises from actual or threatened damage to tissue outside the nervous system,3 as with ongoing inflammation or tissue damage.4
- Neuropathic pain is caused by a lesion or disease of the nerves that carry sensation, in the body or in the spinal cord and brain.3
- Nociplastic pain arises from altered nociception without clear evidence of tissue damage, or of nerve disease, causing it.3 A 2021 review in The Lancet describes it as a third category suggested by pain researchers. It can occur alone, as often happens in fibromyalgia or tension-type headache, or mixed with the other kinds, as might occur in chronic low back pain.4
How nociplastic pain arises is not settled. The Lancet review says its mechanisms “are not entirely understood, but it is thought that augmented CNS pain and sensory processing and altered pain modulation play prominent roles,” and that it shows “a decreased responsiveness to peripherally directed therapies such as anti-inflammatory drugs and opioids, surgery, or injections.”4 A UK guideline says the mechanisms of chronic primary pain “are only partially understood and the definitions are fairly new.”1
One proposed contributor is central sensitization, defined as “increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input.” Clinically, it may only be inferred indirectly, from phenomena such as hyperalgesia, which is increased pain from a stimulus that normally provokes pain, or allodynia, which is pain from a stimulus that does not normally provoke pain.3 In experiments it can be set off in healthy volunteers, and it is “prolonged but reversible.” Findings in fibromyalgia, osteoarthritis, headache, jaw joint disorders, nerve pain and pain after surgery have been interpreted as showing a contribution from it, and a 2011 review said that diagnostic criteria to establish it in patients would greatly assist treatment choice, and that objective biomarkers would be highly beneficial.10
Scans have limits too. In a review of 33 studies of 3,110 people with no back pain, the share with disc degeneration rose from 37% at age 20 to 96% at age 80, and disc bulges from 30% to 84%; the authors write that many such findings are likely part of normal aging and unassociated with pain.11
What helps chronic pain? What the evidence shows
Pain is influenced by biological, psychological and social factors, and the CDC’s 2022 guideline notes that how well a treatment works varies with the type of pain or condition being treated. It calls a multimodal and multidisciplinary approach, attending to physical and behavioral health, critical, and prefers non-opioid treatments for chronic pain.5
- Exercise and physical activity. An overview of 21 Cochrane reviews found some benefit for pain and physical function, mostly small to moderate and not consistent across reviews. The evidence was low quality, and the reviews could not compare types of exercise directly. In the studies that reported them, side effects were mostly soreness or muscle pain that eased after a few weeks.6 The CDC guideline cites high-quality evidence that exercise therapy for back pain, fibromyalgia and hip or knee osteoarthritis reduces pain and improves function right after treatment, with gains lasting at least two to six months.5 A UK guideline recommends offering a supervised group exercise program for chronic primary pain.1
- Exercise for chronic low back pain. A 2021 Cochrane review found, with moderate certainty, that exercise probably reduces pain compared with no treatment, usual care or placebo, by about 15 points on a 100-point scale at the first follow-up (95% CI 12 to 18), a clinically important amount. Its effect on daily function was smaller, below the review’s threshold for an important difference.12
- Psychological therapies. A 2020 Cochrane review of 75 trials found that cognitive behavioral therapy (CBT), the most studied, has small or very small benefits for pain, disability and distress. For behavioral therapy and acceptance and commitment therapy (ACT), the reviewers were very uncertain about benefits or lack of benefits.7 A UK guideline lists ACT or CBT for pain as options for chronic primary pain, delivered by trained professionals.1
- Learning how pain works. In a 2019 review of 12 trials (755 people) of pain neuroscience education for chronic musculoskeletal pain, its effects on pain and disability had low clinical relevance, while its effect on fear of movement was clinically relevant in the short term.13
- Pacing. Pacing aims to break boom-bust cycling, a swing between high activity that increases symptoms and the days of low activity that follow. In a survey of 92 health professionals in England’s National Health Service, the most endorsed aim of pacing was achieving meaningful activities; the authors conclude it should enable more meaningful activity rather than avoid symptoms, and note that no widely used guideline standardizes how it is taught.14
- Sleep. Sleep and pain are generally seen as linked in both directions. A 2013 review found that, in population studies followed over time, sleep problems reliably predict new and worsening chronic pain, and that small, detailed studies support sleep problems being a stronger predictor of pain than pain is of poor sleep, though many questions about cause and effect remain.15
- Other non-drug treatments, by condition. The CDC guideline lists, among others, mind-body practices, massage and acupuncture for neck pain; CBT, tai chi, qigong, acupuncture and multidisciplinary rehabilitation for fibromyalgia; and spinal manipulation for tension headache.5 For chronic primary pain, the UK guideline allows a single course of acupuncture under set conditions, and advises against TENS, ultrasound and interferential therapy because there is no evidence of benefit.1
- Medicines. The CDC guideline prefers non-opioid treatments for subacute and chronic pain, and asks clinicians to discuss realistic benefits and known risks before starting opioids.5 For chronic primary pain, the UK guideline lists certain antidepressants as an option for adults after a full discussion of benefits and harms, and advises against starting opioids, anti-inflammatory drugs, paracetamol (acetaminophen) or gabapentinoids, among others.1 Decisions about medicines belong with your prescriber.
Physical and occupational therapy for chronic pain
The CDC guideline calls a multimodal and multidisciplinary approach to pain critical,5 and a UK guideline defines a pain management program as one with at least a physical and a psychological component, delivered by trained people who coordinate with each other.1
- A doctor or other clinician assesses the pain. The UK guideline asks for a person-centered assessment of what contributes to the pain and how it affects the person’s life, and notes that a diagnosis of chronic primary pain may change with time.1
- A physical therapist works on movement and exercise. Exercise therapy is “a prominent modality in physical therapy,” the CDC notes,5 and Medicare describes physical therapy as helping to restore or improve movement, or to maintain function or slow decline.16 More on physical therapy for adults.
- An occupational therapist works on daily activities. A paper from the American Occupational Therapy Association describes the role in pain care as focused on function, from self-care to meal preparation, shopping and childcare, using activity pacing, energy conservation, ergonomic training and adaptive equipment, and helping people fit exercise and relaxation into their routines.17 More on occupational therapy for adults.
- A psychologist or another trained professional may offer CBT or ACT for pain.1
How is progress measured?
The CDC guideline, written for clinicians weighing opioid treatment, suggests following function, pain and quality of life with tools such as the three-item PEG scale (average pain, and how much pain interferes with enjoyment of life and with general activity), and asking about goals that matter to the person, such as walking the dog, returning to part-time work or attending family events. It notes that clinically meaningful improvement has been defined as a 30% improvement in scores for both pain and function.5
What to expect over time
A UK guideline asks clinicians to explain that symptoms are likely to fluctuate, with flare-ups; that a reason for the pain may not be found; that the pain may not improve, or may get worse and need ongoing management; and that “there can be improvements in quality of life even if the pain remains unchanged.” When symptoms change, as in a flare-up, it recommends a reassessment, and notes that a cause for a flare-up may not be identified.1
Evidence on the long term is thin. The evidence reviewed for the CDC guideline was sparse on long-term improvement in pain or function for any chronic pain treatment, though some non-drug therapies kept their benefit for up to 12 months after a course ended.5
Pain red flags: when to get checked promptly
Does Medicare cover PT and OT for chronic pain?
Medicare Part B helps pay for medically necessary outpatient physical and occupational therapy when your doctor or another provider, such as a nurse practitioner or physician assistant, certifies that you need it. After the Part B deductible, you pay 20% of the Medicare-approved amount, and there is no limit on how much Medicare pays for medically necessary outpatient therapy in a calendar year.16,23
In 2026, once a year’s therapy passes $2,480 for physical therapy and speech therapy combined, or a separate $2,480 for occupational therapy, each claim must confirm that the therapy is medically necessary, backed by your records. Claims above $3,000 can be selected for a targeted medical review.24
The CDC notes that non-drug pain therapies “are not always or fully covered by insurance.”5 More on Medicare coverage for therapy, therapy without insurance and seeing a physical therapist without a referral.
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Frequently Asked Questions
What is chronic pain?
Pain that persists or recurs for more than three months.1,9 In 2023, 24.3% of US adults had it, and 8.5% had pain that frequently limited life or work activities.2
Is chronic pain real, or is it in my head?
Pain is always a personal experience, influenced to varying degrees by biological, psychological and social factors, and the international definition says a person’s report of pain should be respected.8 When tests come back normal, a UK guideline asks clinicians to be sensitive to the risk of invalidating the person’s experience of pain.1
Why does pain continue after an injury has healed?
There is no single answer. Pain can come from ongoing tissue damage, from damage or disease of the nerves, or from altered pain processing without clear tissue or nerve damage (nociplastic pain), and a person can have more than one kind.3,4 The mechanisms of nociplastic pain are not entirely understood.4
What is nociplastic pain?
Pain that arises from altered nociception without clear evidence of tissue damage, or of nerve disease, causing it.3 It is thought to involve augmented pain processing in the central nervous system, though the mechanisms are not entirely understood; it can occur alone, as often in fibromyalgia, or mixed with other kinds of pain.4
What is central sensitization?
Increased responsiveness of pain-signaling neurons in the central nervous system to their normal or subthreshold input. Clinically, it may only be inferred indirectly, from phenomena such as hyperalgesia or allodynia.3 A 2011 review describes it as prolonged but reversible, and said that diagnostic criteria to establish it in patients would greatly assist treatment choice, and that objective biomarkers would be highly beneficial.10
Does exercise help chronic pain?
It can, modestly. An overview of 21 Cochrane reviews found some benefit for pain and physical function, mostly small to moderate and not consistent, from low-quality evidence; side effects were mostly soreness that eased after a few weeks.6 The CDC guideline cites high-quality evidence for exercise therapy in back pain, fibromyalgia and hip or knee osteoarthritis.5
Does understanding why pain persists actually reduce it?
In trials, not by much. In a 2019 review of 12 trials, pain neuroscience education had effects on pain and disability of low clinical relevance, while its effect on fear of movement was clinically relevant in the short term.13
Who treats persistent pain?
Care can involve a team: a doctor, a physical or occupational therapist, and a psychologist or another trained professional for CBT or ACT. US and UK guidelines describe multidisciplinary care with physical and psychological parts.1,5
What is pacing, and why does it matter?
Pacing aims to break boom-bust cycling, where a burst of high activity increases symptoms and is followed by days of low activity. Health professionals in one survey saw its main aim as achieving meaningful activities rather than avoiding symptoms.14
Why does sleep matter for chronic pain?
Sleep and pain are generally seen as linked in both directions, and sleep problems reliably predict new and worsening chronic pain, though many questions about cause and effect remain.15
Do scans explain persistent back pain?
Not on their own. Findings that look like wear are common in people with no back pain and become more common with age: in a review of 3,110 people without symptoms, disc degeneration rose from 37% at age 20 to 96% at age 80.11 Long-lasting back pain may also involve nociplastic pain, which arises without clear evidence of tissue damage.3,4
What is fibromyalgia?
A long-lasting disorder that causes pain and tenderness throughout the body, fatigue and trouble sleeping. Scientists do not fully understand its cause, but people with it have an increased sensitivity to pain.25 It is counted as chronic primary pain.1
What is complex regional pain syndrome?
A condition that usually affects an arm or a leg after an injury, with ongoing pain that is much stronger even after the injury has healed, and sometimes changes in the skin, temperature, nails or hair. Treatment usually works best when it is started early.21
How is progress measured in chronic pain care?
By function and quality of life as well as pain. The CDC guideline mentions the three-item PEG scale, which rates average pain and how much pain interferes with enjoyment of life and general activity, and goals that matter to the person, such as walking the dog or returning to part-time work.5
Does Medicare cover physical therapy for chronic pain?
Medicare Part B helps pay for medically necessary outpatient physical therapy that your doctor or another provider certifies you need. After the Part B deductible, you pay 20% of the Medicare-approved amount.16
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Sources
- 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 (NICE guideline NG193, published April 7, 2021; United Kingdom). Checked November 4, 2026.
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Chronic pain: “Pain that persists or recurs for more than 3 months.” Chronic primary pain is pain “in which no underlying condition adequately accounts for the pain or its impact”; “Chronic primary pain and chronic secondary pain can coexist.” “The mechanisms underlying chronic primary pain are only partially understood and the definitions are fairly new.” ICD-11 counts fibromyalgia, complex regional pain syndrome, chronic primary headache and orofacial pain, chronic primary visceral pain and chronic primary musculoskeletal pain as chronic primary pain. Recommendations: a person-centered assessment “to identify factors contributing to the pain and how the pain affects the person's life” (1.1.1); “an initial diagnosis of chronic primary pain may change with time” (1.1.6); discuss that symptoms are likely to fluctuate with flare-ups, that a reason for the pain may not be identified, “the possibility that the pain may not improve or may get worse and may need ongoing management” and “there can be improvements in quality of life even if the pain remains unchanged” (1.1.15); “be sensitive to the risk of invalidating the person's experience of chronic pain” (1.1.16); “Offer a reassessment if a person presents with a change in symptoms such as a flare-up of chronic pain. Be aware that a cause for the flare-up may not be identified” (1.1.22). For chronic primary pain, from age 16: offer a supervised group exercise program (1.2.1); consider acceptance and commitment therapy (ACT) or cognitive behavioral therapy (CBT) for pain, delivered by trained professionals (1.2.3); consider a single course of acupuncture or dry needling under set conditions (1.2.5); do not offer TENS, ultrasound or interferential therapy “because there is no evidence of benefit” (1.2.6); for adults, consider one of six antidepressants “after a full discussion of the benefits and harms” (1.2.7); do not initiate antiepileptic drugs including gabapentinoids (outside a trial for complex regional pain syndrome), benzodiazepines, non-steroidal anti-inflammatory drugs, opioids or paracetamol, among others (1.2.10). A pain management program has “2 or more components, including a physical and a psychological component, delivered by trained people”. - Lucas JW, Sohi I. National Center for Health Statistics. Chronic Pain and High-impact Chronic Pain in U.S. Adults, 2023 (NCHS Data Brief No. 518, November 2024). Checked November 4, 2026.
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National Health Interview Survey: “In 2023, 24.3% of adults had chronic pain, and 8.5% of adults had chronic pain that frequently limited life or work activities (referred to as high-impact chronic pain) in the past 3 months.” “Women were more likely to have chronic pain (25.4%) and high-impact chronic pain (9.6%) than men (23.2% and 7.3%, respectively).” Chronic pain rose with age, “from 12.3% among those ages 18–29 to 36.0% among those age 65 and older”. Chronic pain is based on answers of “most days” or “every day” to how often a person had pain in the past 3 months. - International Association for the Study of Pain. Terminology. Checked November 4, 2026.
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Nociception: “The neural process of encoding noxious stimuli.” Nociceptive pain: “Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors.” Neuropathic pain: “Pain caused by a lesion or disease of the somatosensory nervous system.” Central neuropathic pain: “Pain caused by a lesion or disease of the central somatosensory nervous system.” Nociplastic pain: “Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain.” Note: “Patients can have a combination of nociceptive and nociplastic pain”. Central sensitization: “Increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input.” Note on sensitization: “Clinically, sensitization may only be inferred indirectly from phenomena such as hyperalgesia or allodynia.” Allodynia: “Pain due to a stimulus that does not normally provoke pain.” Hyperalgesia: “Increased pain from a stimulus that normally provokes pain.” - Fitzcharles MA, Cohen SP, Clauw DJ, Littlejohn G, Usui C, Häuser W. Nociplastic pain: towards an understanding of prevalent pain conditions. Lancet. 2021;397(10289):2098–2110. doi:10.1016/S0140-6736(21)00392-5 (PMID 34062144). Review.
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Nociplastic pain is “a third category of pain that is mechanistically distinct from nociceptive pain, which is caused by ongoing inflammation and damage of tissues, and neuropathic pain, which is caused by nerve damage”. “The mechanisms that underlie this type of pain are not entirely understood, but it is thought that augmented CNS pain and sensory processing and altered pain modulation play prominent roles.” “This type of pain can occur in isolation, as often occurs in conditions such as fibromyalgia or tension-type headache, or as part of a mixed-pain state in combination with ongoing nociceptive or neuropathic pain, as might occur in chronic low back pain.” It shows “a decreased responsiveness to peripherally directed therapies such as anti-inflammatory drugs and opioids, surgery, or injections”. - Centers for Disease Control and Prevention. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 (MMWR Recommendations and Reports 2022;71(3)). Checked November 4, 2026.
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For outpatients aged 18 and over; chronic pain is pain lasting more than 3 months; it does not cover pain from sickle cell disease or cancer, or palliative and end-of-life care. “Pain is a complex phenomenon influenced by multiple factors, including biologic, psychological, and social factors”; “substantial heterogeneity exists in the effectiveness of various pain treatments, depending on the type of underlying pain or condition being treated”. “A multimodal and multidisciplinary approach to pain management attending to the physical health, behavioral health, long-term services and supports, and expected health outcomes and well-being of each person is critical.” “Nonopioid therapies are preferred for subacute and chronic pain.” “High-quality evidence exists that exercise therapy (a prominent modality in physical therapy) for back pain, fibromyalgia, and hip or knee osteoarthritis reduces pain and improves function immediately after treatment and that the improvements are sustained for at least 2–6 months”. Recommended approaches include “mind-body practices (e.g., yoga, tai chi, or qigong), massage, and acupuncture for neck pain; cognitive behavioral therapy, myofascial release massage, mindfulness practices, tai chi, qigong, acupuncture, and multidisciplinary rehabilitation for fibromyalgia; and spinal manipulation for tension headache”. “Before starting opioid therapy for subacute or chronic pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy”. “Evidence was sparse for long-term improvement of pain or function for any treatment for chronic pain. Some evidence indicated that beneficial effects of some nonpharmacologic therapies persist for up to 12 months after the end of a course of a treatment.” Clinicians can follow function, pain and quality of life with “the three-item PEG (Pain average, interference with Enjoyment of life, and interference with General activity) assessment scale”; “Clinically meaningful improvement has been defined as a 30% improvement in scores for both pain and function”; clinicians can ask about “functional goals that have meaning for them (e.g., walking the dog or walking around the block, returning to part-time work, and attending family events or recreational activities), and then use these goals in assessing benefits of opioid therapy”. “noninvasive nonpharmacologic therapies are not always or fully covered by insurance”. - Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews. 2017;(4):CD011279. doi:10.1002/14651858.CD011279.pub3 (PMID 28436583). Twenty-one reviews (381 studies, 37,143 participants).
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“The quality of the evidence examining physical activity and exercise for chronic pain is low.” “There were some favourable effects in reduction in pain severity and improved physical function, though these were mostly of small-to-moderate effect, and were not consistent across the reviews.” The authors could not directly compare interventions. “most adverse events were increased soreness or muscle pain, which reportedly subsided after a few weeks of the intervention”. - Williams ACdC, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews. 2020;(8):CD007407. doi:10.1002/14651858.CD007407.pub4 (PMID 32794606).
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Seventy-five trials (9,401 participants at treatment end), 59 of them of CBT. “CBT has small or very small beneficial effects for reducing pain, disability, and distress in chronic pain”. For behavioral therapy and ACT, “we are very uncertain about benefits or lack of benefits of these treatments for adults with chronic pain”. - Raja SN, Carr DB, Cohen M, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020;161(9):1976–1982. doi:10.1097/j.pain.0000000000001939 (PMID 32694387).
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Pain: “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” Notes: “Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.” “Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.” “A person’s report of an experience as pain should be respected.” - Treede RD, Rief W, Barke A, et al. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain. 2019;160(1):19–27. doi:10.1097/j.pain.0000000000001384 (PMID 30586067). Developed with the World Health Organization.
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“Chronic pain is defined as pain that persists or recurs for more than 3 months.” “In conditions such as fibromyalgia or nonspecific low-back pain, chronic pain may be conceived as a disease in its own right”, called chronic primary pain; in six other groups pain is secondary to an underlying disease: “chronic cancer-related pain, chronic neuropathic pain, chronic secondary visceral pain, chronic posttraumatic and postsurgical pain, chronic secondary headache and orofacial pain, and chronic secondary musculoskeletal pain”. - Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2–S15. doi:10.1016/j.pain.2010.09.030 (PMID 20961685). Review.
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“Nociceptor inputs can trigger a prolonged but reversible increase in the excitability and synaptic efficacy of neurons in central nociceptive pathways, the phenomenon of central sensitization.” It “can be readily and rapidly elicited in human volunteers”. Changes in pain sensitivity in patients with fibromyalgia, osteoarthritis, headache, temporomandibular joint disorders, neuropathic pain, post-surgical pain and other conditions “have been interpreted as revealing an important contribution of central sensitization”. “Diagnostic criteria to establish the presence of central sensitization in patients will greatly assist the phenotyping of patients”, and “objective biomarkers of central sensitization will be highly beneficial”. - Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR American Journal of Neuroradiology. 2015;36(4):811–816. doi:10.3174/ajnr.A4173 (PMID 25430861).
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Thirty-three articles reporting imaging findings for 3,110 people without symptoms: disc degeneration rose from 37% at age 20 to 96% at age 80, and disc bulge from 30% to 84%. “Many imaging-based degenerative features are likely part of normal aging and unassociated with pain.” “These imaging findings must be interpreted in the context of the patient's clinical condition.” - Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews. 2021;(9):CD009790. doi:10.1002/14651858.CD009790.pub2 (PMID 34580864).
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249 trials; pain and function re-scaled to 0 to 100. Against no treatment, usual care or placebo, pain at the earliest follow-up was 15.2 points lower (95% CI 12.2 to 18.3), “a clinically important difference”. “We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain.” “The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference.” - Watson JA, Ryan CG, Cooper L, et al. Pain neuroscience education for adults with chronic musculoskeletal pain: a mixed-methods systematic review and meta-analysis. Journal of Pain. 2019;20(10):1140.e1–1140.e22. doi:10.1016/j.jpain.2019.02.011 (PMID 30831273).
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Twelve randomized controlled trials (755 participants): effects on pain and disability “had low clinical relevance” in the short and medium term; “The treatment effect of PNE for kinesiophobia was clinically relevant in the short term”. - Antcliff D, Keenan AM, Keeley P, Woby S, McGowan L. Survey of activity pacing across healthcare professionals informs a new activity pacing framework for chronic pain/fatigue. Musculoskeletal Care. 2019;17(4):335–345. doi:10.1002/msc.1421 (PMID 31430038).
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Survey of 92 healthcare professionals in English National Health Service pain and fatigue services. Boom-bust cycling is a swing between high activity, which increases symptoms, and the days of low activity that follow. “The most endorsed aim of pacing was ‘achievement of meaningful activities’”; “pacing should enable increases in meaningful activities, as opposed to attempting to avoid symptoms”; “there are no widely used guidelines to standardize how pacing is delivered”. - Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. Journal of Pain. 2013;14(12):1539–1552. doi:10.1016/j.jpain.2013.08.007 (PMID 24290442). Review.
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“many questions remain about the direction of causality”; “The prevailing view has generally been that they are reciprocally related.” “A key trend emerging from population-based longitudinal studies is that sleep impairments reliably predict new incidents and exacerbations of chronic pain.” “Microlongitudinal studies employing deep subjective and objective assessments of pain and sleep support the notion that sleep impairments are a stronger, more reliable predictor of pain than pain is of sleep impairments.” - Medicare.gov. Physical therapy services. Checked November 4, 2026.
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“Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient physical therapy”. “Physical therapy helps to restore or improve physical movement in your body after an injury, illness, or surgery. You can also get this therapy to help improve or maintain your current function, or slow your rate of decline.” Your doctor or other health care provider (including a nurse practitioner, clinical nurse specialist, or physician assistant) must certify that you need it. “After the Part B deductible, you pay 20% of the Medicare-approved amount for these services when they're medically necessary.” “There's no limit on how much Medicare pays for your medically necessary outpatient therapy services in one calendar year.” - American Occupational Therapy Association and Alliance to Advance Comprehensive Integrative Pain Management. The Role of Occupational Therapy in Comprehensive Integrative Pain Management. Checked November 4, 2026.
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“The role of an occupational therapy practitioner within a comprehensive integrative pain management program uniquely focuses on function. This includes ADLs, instrumental activities of daily living (IADLs) (e.g., meal-prep, shopping, childcare), and other daily life activities.” Interventions include “Activity pacing and energy conservation strategies”, “Ergonomic and body mechanic training” and “Adaptive equipment selection and training”. A patient may learn relaxation in pain psychology and exercises from a physical therapist but struggle to fit them into daily routines; “Occupational therapy practitioners can address this challenge with the patient by analyzing activity patterns, problem-solving barriers, and facilitating sustainable carryover.” - MedlinePlus Medical Encyclopedia (National Library of Medicine). Low back pain - chronic (review date April 1, 2025). “Contact your provider if you have severe back pain that does not go away. Contact them right away if you have numbness, loss of movement, weakness, or bowel or bladder changes.” Checked November 4, 2026.
- MedlinePlus Medical Encyclopedia (National Library of Medicine). Joint pain (review date January 14, 2026). Contact your provider if: “You have fever that is not associated with flu symptoms.” “You have lost 10 pounds (4.5 kilograms) or more without trying”. “You have severe, unexplained joint pain and swelling, particularly if you have other unexplained symptoms.” Checked November 4, 2026.
- Centers for Disease Control and Prevention. Information for Caregivers (Still Going Strong, August 4, 2025). Checked November 4, 2026.
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“Falls in people age 65 and older are common and can lead to serious injury”; “Older adults should be checked by a healthcare provider for signs and symptoms of a TBI if they have fallen or were in a car crash.” Blood thinners “increase the risk for bleeding in the brain after a TBI”. - National Institute of Neurological Disorders and Stroke. Complex Regional Pain Syndrome (last reviewed May 28, 2026). Checked November 4, 2026.
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“Complex regional pain syndrome (CRPS) is a condition that usually affects a limb (an arm or a leg) after an injury and causes ongoing pain that is much stronger even after the injury has healed.” “The limb is often very sensitive so that even light touch to it may feel painful.” “The affected limb may also show changes in skin, temperature, nails, or hair, along with unusual sweating.” “Treatment usually works best when it is started early.” “Physical therapy and gentle movement of the affected limb can be important for treating CRPS.” - 988 Suicide & Crisis Lifeline. 988 Lifeline. “Call, text, or chat with a 988 Lifeline counselor for help during difficult moments anytime, day or night.” “The 988 Lifeline is available 24/7/365. Your conversations are free and confidential.” Checked November 4, 2026.
- Medicare.gov. Occupational therapy services. Checked November 4, 2026.
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“Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient occupational therapy if your doctor or other health care provider certifies you need it”. “Therapy to help you perform activities of daily living (like dressing or bathing).” “After you meet the Part B deductible, you pay 20% of the Medicare-approved amount for these services when they're medically necessary.” - Centers for Medicare & Medicaid Services. Therapy Services (page last modified March 10, 2026). Checked November 4, 2026.
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“For CY 2026 this KX modifier threshold amount is: $2,480 for PT and SLP services combined, and $2,480 for OT services.” Above it, claims carry the KX modifier “as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record”. The targeted medical review threshold is $3,000; “not all claims exceeding the MR threshold amount are subject to review”. - National Institute of Arthritis and Musculoskeletal and Skin Diseases. Fibromyalgia (last reviewed May 2024). Checked November 4, 2026.
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“Fibromyalgia is a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping. Scientists do not fully understand what causes it, but people with the disorder have an increased sensitivity to pain.” “Brain imaging studies and other research have uncovered evidence of altered signaling in neural pathways that transmit and receive pain in people with fibromyalgia.”
Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider about your individual situation. If you are worried about immediate safety, call or text 988 (US). Never start, stop, or change a dose without medical guidance.