Most pain settles as an injury heals. Some pain doesn’t. When it lasts or keeps coming back for more than 3 months, doctors call it chronic pain [1], and it is common. In 2023, 24.3% of US adults had chronic pain [2], and a review of UK studies put the figure at between one third and one half of the population [3].
This article explains why pain can outlast the injury that started it, and which treatments have good evidence behind them.
- Pain and damage are not the same thing. Scans of people with no pain often show disc wear and bulges.
- Exercise has the strongest evidence. In chronic low back pain it reduced pain by a clinically important amount.
- Understanding pain helps. Learning how pain works mainly reduces fear of movement.
- Sleep matters. Poor sleep predicts worse pain more reliably than pain predicts poor sleep.
- NICE advises against starting most painkillers for chronic primary pain.
What chronic pain is
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” [4]. The key words are “resembling” and “potential”. Pain is your nervous system’s way of protecting you, and it can happen without fresh damage.
Chronic pain is pain that lasts or recurs for more than 3 months. Sometimes it is a symptom of another condition, such as arthritis. In other cases, such as fibromyalgia or non-specific low back pain, it is treated as a condition in its own right, called chronic primary pain [1].
Why pain can outlast the injury
Most injured tissues heal within weeks or a few months, yet pain can carry on well beyond that. One reason is that what shows up on a scan often has little to do with what you feel.
A review of 33 studies covering 3,110 people with no back pain looked at their spine scans. Disc degeneration showed up in 37% of 20-year-olds and 80% of 50-year-olds. Disc bulges showed up in 30% of 20-year-olds and 60% of 50-year-olds. The authors concluded that many of these changes are likely part of normal ageing and unrelated to pain [5].
So a scan report full of alarming words does not mean your back is damaged beyond repair. And a long run of pain does not mean the damage is getting worse. The nervous system can stay in protective mode after tissues have settled, and things like fear of movement and poor sleep can help keep it there.
Sleep deserves a special mention. A review of the research found that poor sleep reliably predicts new episodes and flare-ups of chronic pain, and that sleep problems predict pain more strongly than pain predicts sleep problems [6]. Working on sleep is part of treating pain.
What helps, according to the evidence
Exercise
Exercise is the treatment with the most research behind it. The UK’s National Institute for Health and Care Excellence (NICE) recommends a supervised group exercise programme for adults with chronic primary pain [7].
A Cochrane review of 249 trials of exercise for chronic low back pain found that exercise reduced pain by about 15 points on a 100-point scale, compared with no treatment, usual care or placebo. The reviewers rated this a clinically important difference, with moderate certainty. The improvement in day-to-day function was smaller [8].
Choose something you can keep doing, whether that is strength work, walking, cycling or swimming, and build it up gradually.
Understanding how pain works
Pain neuroscience education explains what pain is and why it persists. In a meta-analysis of 12 trials with 755 people, it had only small short-term effects on pain and disability. It did reduce fear of movement by a clinically relevant amount [9]. That matters, because fear of movement can stop people doing the exercise that helps.
Psychological therapy
NICE suggests considering cognitive behavioural therapy (CBT) or acceptance and commitment therapy (ACT) for chronic primary pain [7]. In a Cochrane review, CBT had small or very small benefits for pain, disability and distress across 59 trials [10]. The effects are modest. Psychological therapy is part of pain care because pain affects mood and behaviour, and both feed back into how much pain you feel.
Acupuncture and dry needling
For chronic primary pain, NICE says to consider a single short course of acupuncture or dry needling, delivered within strict limits on time and cost [7]. Treat it as support for an exercise plan. See our page on dry needling for how we use it.
Medicines
For chronic primary pain, NICE advises doctors not to start paracetamol, anti-inflammatories, opioids, gabapentinoids or several other drugs. It suggests that certain antidepressants may be considered instead [7]. This advice applies to chronic primary pain only. Back pain, osteoarthritis and other conditions have their own guidelines. If you already take pain medicine, don’t stop it on your own. Review it with your doctor.
What a physio does for chronic pain
At Aspire Physio Bangkok, a physiotherapist starts with a full assessment: where it hurts, what makes it better or worse, how you move, how you sleep and what you have already tried. We explain what we find in plain language, including what your scans do and don’t show.
From there we build a plan around graded exercise. That means starting at a level that doesn’t cause a big flare-up and increasing it week by week. Manual therapy or dry needling can help settle pain enough to train, but they sit alongside exercise as support. Our gym is in the same building, so the plan moves from the treatment room to the gym floor as you get stronger.
For specific problems, see our pages on back pain, neck and shoulder pain and office syndrome.
When to see a doctor first
Most long-standing pain is not dangerous, but some symptoms need medical attention. For back pain, the NHS says to get emergency help if you have pain, tingling, weakness or numbness in both legs, loss of feeling around your genitals or bottom, or new problems controlling your bladder or bowels. The same applies if the pain started after a serious accident or comes with chest pain [11]. In Thailand, call 1669 for emergency medical help.
See a doctor soon if you feel generally unwell, hot or shivery with your pain, or if severe pain starts suddenly or gets worse quickly [11].
Otherwise, book a free first consultation through our contact page or call 082-281-8009. We’re at Jasmine Building, 2nd Floor, Sukhumvit Soi 23, a short walk from Asok BTS.
Common questions
How long does pain have to last to count as chronic?
Pain is called chronic when it lasts or keeps coming back for more than 3 months. Some chronic pain follows an injury or a condition such as arthritis. Some, like non-specific low back pain, is classed as a condition in its own right.
Should I rest if I have chronic pain?
For most people, no. Guidelines recommend exercise for chronic pain, and the trials behind that advice show it reduces pain. The trick is to start at a level you can manage and build up gradually, rather than pushing through a flare-up or stopping altogether.
Will a scan show what is causing my pain?
Often it won’t. Disc wear, bulges and joint changes are very common in people with no pain at all, and they become more common with age. A scan is useful when your doctor or physio suspects something specific, such as nerve compression or a fracture.
Do painkillers help chronic pain?
For chronic primary pain, NICE advises doctors not to start paracetamol, anti-inflammatories or opioids, and to consider certain antidepressants instead. That advice is specific to chronic primary pain. If you already take pain medicine, review it with your doctor rather than stopping on your own.
References
- 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.org/10.1097/j.pain.0000000000001384
- Lucas JW, Sohi I. Chronic pain and high-impact chronic pain in U.S. adults, 2023. NCHS Data Brief, no 518. National Center for Health Statistics; 2024. doi.org/10.15620/cdc/169630
- Fayaz A, Croft P, Langford RM, Donaldson LJ, Jones GT. Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies. BMJ Open. 2016;6(6):e010364. doi.org/10.1136/bmjopen-2015-010364
- 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.org/10.1097/j.pain.0000000000001939
- Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. doi.org/10.3174/ajnr.A4173
- Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain. 2013;14(12):1539-1552. doi.org/10.1016/j.jpain.2013.08.007
- 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. 2021. www.nice.org.uk/guidance/ng193/chapter/Recommendations
- Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev. 2021;9(9):CD009790. doi.org/10.1002/14651858.CD009790.pub2
- 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. J Pain. 2019;20(10):1140.e1-1140.e22. doi.org/10.1016/j.jpain.2019.02.011
- Williams ACC, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2020;8(8):CD007407. doi.org/10.1002/14651858.CD007407.pub4
- NHS. Back pain. NHS website. www.nhs.uk/conditions/back-pain/
