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Explaining Persistent Pain

Definitions

IASP definition (revised 2020): pain is an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage (Raja et al., 2020).
Persistent pain is pain lasting or recurring beyond about 3 months. ICD-11 (WHO) classifies chronic primary pain (MG30) as pain in one or more body regions that is associated with significant distress or functional disability and is not better explained by another condition (Treede et al., 2019).

Nociceptive Pain

Neuropathic Pain

Nociplastic Pain

Pain stemming from actual or threatened non-neural tissue damage. Peripheral sensory receptors detect mechanical, thermal, or chemical irritation within muscles, joints, or connective tissues.

Pain caused by a verifiable primary lesion or disease affecting the somatosensory nervous system, frequently presenting as burning, shooting, or lancinating dermatomal sensations.

Pain arising from altered sensory processing and central amplification without identifiable tissue injury or structural nerve pathology, characteristic of persistent widespread pain states.

Types of pain

Integrative Science

The Biopsychosocial Foundation

The model builds on Engel (1977), applied to pain by Gatchel et al. (2007). Pain is understood as an output of the nervous system that is shaped by tissue state, but also by threat appraisal, attention, emotion, learning, behaviour and context. Pain intensity and tissue findings are only loosely correlated in persistent pain.

Biological Domain

Psychological Domain

Social Domain

Nervous system sensitisation, neuroimmune activation, peripheral nociceptive input, autonomic balance, poor sleep, genetic variations, and neurochemical pain modulation pathways.

Cognitive appraisal of threat, fear-avoidance beliefs, hypervigilance toward physical sensations, emotional distress, attentional focus, and mental health history.

Work stress, healthcare validation, familial reinforcement patterns, isolation, cultural understandings of illness, and systemic life stressors.

Modern pain management takes into consideration, not only direct tissue damage, but also the intersection of biological, psychological, and social factors and their influence on the pain experience. Persistent pain often continues well after tissue has healed, sustained by a sensitised nervous system, threat-related beliefs, fear of movement, disrupted sleep, stress, and the responses of family, workplaces and health services. Because these factors interact and reinforce one another, effective care is rarely limited to a single treatment. It combines education, skill-building and graded return to meaningful activity, delivered collaboratively with the client’s medical and allied health team. Approaches such as CBT, clinical hypnosis, physical activity coaching, mindfulness, stress regulation, and traditional medicine each target different parts of this system, with the shared aim of improving function, mood, confidence and quality of life, and not pain intensity alone.

Self-Reinforcing Loops

Core Maintenance Cycles

The Fear-Avoidance Cycle

Boom-Bust Cycle

Stress-Sleep-Sensitivity Cycle

Pain → interpretation → fear and hypervigilance → avoidance → disuse, disability and low mood → increased pain and sensitivity.

Good-day overactivity → flare up → rest and withdrawal → deconditioning and frustration → repeat.

Stress and poor sleep leads to lower pain thresholds and increased sympathetic arousal. This amplifies pain and further disrupts sleep.

Persistent pain is often sustained by three interacting maintenance cycles. In the fear-avoidance cycle, pain is interpreted as threatening, which leads to fear and hypervigilance, avoidance of movement, deconditioning and low mood, and ultimately greater pain sensitivity (Vlaeyen & Linton, 2000). In the boom-bust cycle, a good day prompts overactivity, which triggers a flare and a period of rest and withdrawal, leaving the person less conditioned and more frustrated before the pattern repeats. In the stress-sleep-sensitivity cycle, stress and poor sleep lower pain thresholds and increase sympathetic arousal, which amplifies pain and further disrupts sleep. These cycles overlap and feed one another, so a useful formulation identifies which are most active for each client and targets them in a deliberate order.

Clinical Assessment

The 4Ps: Formulation Framework

A biopsychosocial case formulation maps the dynamic trajectory of persistent pain across four key phases, clarifying therapeutic targets and intervention points.

Factor 1

Factor 2

Factor 3

Factor 4

Predisposing

Precipitating

Perpetuating

Protective

Early adversity, family pain models, prior injuries, temperament, genetics.

Injury, surgery, illness, major stressor.

Core maintenance cycles, beliefs about pain, sleep, inactivity, healthcare messages.

Individual resilience resources including strong therapeutic alliance, psychological flexibility, social support, and balanced activity pacing.

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