Chronic Pain: Symptoms, Causes, Diagnosis and Treatment

Chronic pain is pain that persists or repeatedly returns for more than three months. It may continue because of an ongoing disease or injury, persist after surgery or trauma, involve nerve damage, or sometimes occur without one single identifiable structural cause.

Persistent pain can affect:

• Sleep
• Movement
• Work
• Exercise
• Mood
• Relationships
• Independence
• Quality of life

Importantly, a normal MRI or blood test does not mean that pain is imaginary. Pain cannot always be explained by one scan or structural abnormality.

At Painacea, the first question is not simply “Which painkiller should we prescribe?” or “Which procedure should we perform?”

The first question is:

What type of pain is this, what may be generating it, and what is the most appropriate treatment?

What Does Chronic Pain Feel Like?

Chronic pain may be constant or come and go.

It can feel:

• Aching
• Burning
• Shooting
• Stabbing
• Throbbing
• Electric
• Deep or pressure-like

Depending on the condition, there may also be:

• Tingling
• Numbness
• Increased sensitivity
• Stiffness
• Weakness
• Reduced movement
• Fatigue
• Disturbed sleep

Two people with the same diagnosis may experience pain very differently.

Pain is influenced by biological factors as well as sleep, activity, mood, stress and social circumstances. This does not mean that the pain is “all in the mind.” IASP describes chronic pain as multifactorial, with biological, psychological and social factors contributing to the pain experience.

What Causes Chronic Pain?

Chronic pain can arise from many different conditions.

Common examples include:

Musculoskeletal and Joint Pain

• Osteoarthritis
• Persistent knee pain
• Shoulder pain
• Facet-joint pain
• Sacroiliac-joint pain

Spine-Related Pain

• Chronic lower-back pain
• Neck pain
• Disc-related pain
• Sciatica
• Spinal stenosis
• Persistent pain after spine surgery

Neuropathic Pain

Pain caused by a lesion or disease affecting the somatosensory nervous system may produce burning, electric, shooting or abnormal sensations.

Examples include:

• Diabetic neuropathy
• Peripheral neuropathy
• Post-herpetic neuralgia
• Trigeminal neuralgia
• Nerve injury

Persistent Pain After Surgery or Injury

Pain may sometimes continue for months after an operation or trauma, including pain with neuropathic features.

Cancer-Related Pain

Pain may result from the cancer itself or from cancer treatment. Cancer pain requires diagnosis-specific assessment and treatment.

Visceral and Other Chronic Pain

Persistent pain may also occur with conditions affecting internal organs, headaches, pelvic pain and other disorders.

Chronic Primary vs Secondary Pain

Chronic pain can broadly be classified as primary, secondary, or a combination of both.

Chronic Primary Pain

Chronic primary pain is persistent pain associated with significant distress or interference with daily life that is not better explained by another chronic pain diagnosis.

Fibromyalgia and some chronic widespread-pain conditions may fall within this group.

Chronic Secondary Pain

Chronic secondary pain occurs in association with another identifiable condition, such as:

• Osteoarthritis
• Neurological disease
• Cancer
• Surgery or trauma
• Internal-organ disease
• Musculoskeletal disease

The distinction matters because the treatment of chronic primary pain is not automatically appropriate for every other chronic pain condition. NICE specifically separates assessment of all chronic pain from its recommendations for managing chronic primary pain.

How Is Chronic Pain Diagnosed?

There is no single test for chronic pain.

A pain assessment may look at:

• Where the pain occurs
• How and when it began
• What the pain feels like
• Whether it travels
• What makes it better or worse
• Previous injuries or operations
• Previous treatments and their effects
• Medication use
• Sleep
• Neurological symptoms
• Effect on work and daily activities

The examination depends on the condition and may include:

• Movement
• Muscle strength
• Sensation
• Reflexes
• Joint examination
• Nerve examination
• Walking and functional assessment

Investigations may include:

• X-rays
• MRI or CT
• Blood tests
• Ultrasound
• Nerve-conduction or EMG testing

These are ordered when they are likely to help answer a specific clinical question.

Sometimes diagnosis requires more than a scan

A scan may show several abnormalities without clearly identifying which one is actually causing pain.

For selected patients, an image-guided diagnostic MIPSI may help determine whether a particular joint, nerve or other structure is acting as the pain generator.

How Is Chronic Pain Treated?

There is no single treatment for all chronic pain.

Treatment should depend on:

• Diagnosis
• Pain mechanism
• Severity
• Previous treatment
• Medical conditions
• Functional limitations
• Patient goals

Painacea follows a:

Diagnosis First → Targeted Treatment Next

approach.

1. Physical Activity and Rehabilitation

Depending on the condition, rehabilitation may include:

• Physiotherapy
• Strengthening
• Mobility exercises
• Progressive activity
• Functional rehabilitation
• Work or ergonomic modification

For chronic primary pain, NICE recommends exercise and encourages continued physical activity tailored to the individual’s needs and abilities.

Exercise remains important in many chronic pain conditions, but the programme should be adapted to the diagnosis rather than being identical for every patient.

2. Medicines—When They Have a Defined Role

Medication can be useful, but treatment should depend on the type of pain.

Medicines used for:

• Nerve pain
• Osteoarthritis
• Cancer pain
• Inflammatory pain
• Chronic primary pain

are not necessarily the same.

The goal should not be to repeatedly increase painkillers without reassessing why pain continues.

For chronic primary pain specifically, NICE advises against initiating opioids because evidence of benefit is lacking and there are risks including dependence.

Patients already taking opioids or other prescribed medicines should not suddenly stop or alter them without medical advice.

3. Psychological and Behavioural Pain Care

For some chronic pain conditions, treatment may include approaches such as:

• Cognitive behavioural therapy for pain
• Acceptance and commitment therapy
• Pain-management programmes
• Sleep and coping strategies

NICE recommends considering CBT for pain or ACT as part of management for chronic primary pain.

These treatments do not imply that the pain is psychological or imaginary.

They address the effects chronic pain can have on function, distress, sleep and daily life.

When Can MIPSI Help Chronic Pain?

MIPSI stands for Minimally Invasive Pain and Spine Interventions.

The Indian Society for the Study of Pain recognises MIPSI as a structured framework of image-guided diagnostic and therapeutic interventions performed by appropriately trained pain physicians. It includes procedures involving joints, nerve roots, peripheral nerves, the epidural space, radiofrequency systems, vertebral augmentation, intradiscal procedures and advanced neuromodulation.

MIPSI is not required simply because pain has lasted for three months.

It becomes relevant when:

• A specific pain generator has been identified or strongly suspected
• Conservative treatment has not provided adequate improvement
• Pain prevents meaningful rehabilitation
• A targeted intervention is likely to offer a reasonable clinical benefit
• Repeated systemic medication is not the best next step

Depending on the diagnosis, MIPSI may include:

Diagnostic Nerve or Joint Blocks

Used selectively to help confirm whether a particular structure is producing pain.

Epidural and Selective Nerve-Root Procedures

May be considered for selected nerve-root and radicular pain conditions.

Radiofrequency Ablation

Radiofrequency ablation may provide longer-duration reduction of pain signals from selected nerves, including appropriately diagnosed facet-joint or other specific pain conditions.

Cryoablation / Cryoneurolysis

Cryoablation may be considered for selected focal peripheral-nerve pain conditions where the target and indication are appropriate.

Vertebroplasty and Kyphoplasty

May be considered for selected painful vertebral compression fractures.

Epidural Adhesiolysis and Advanced Spine Interventions

May have a role in selected persistent spinal or post-surgical pain conditions.

Spine Endoscopy

Selected disc or nerve-compression conditions may be suitable for minimally invasive endoscopic treatment.

Neuromodulation

For carefully selected refractory neuropathic pain, treatment may include:

• Spinal cord stimulation
• Dorsal root ganglion stimulation
• Peripheral nerve stimulation

The ISSP includes implantable neuromodulation and advanced interventional techniques within its MIPSI framework and emphasises appropriate patient selection and pre-procedure evaluation.

Does Chronic Pain Mean You Need a Procedure?

No.

Some patients need rehabilitation.

Some need medication.

Some require psychological pain-management support.

Some have an identifiable anatomical pain generator that may benefit from MIPSI.

Some need surgery or another specialist.

And many require a combination.

Painacea’s approach is therefore neither:

“Just learn to live with the pain”

nor:

“Every chronic pain needs an intervention.”

The objective is to determine which treatment level is appropriate for the individual patient.

How Can You Manage Chronic Pain Day to Day?

Depending on your condition, helpful strategies may include:

• Remaining physically active within safe limits
• Following an individual exercise programme
• Breaking demanding activities into manageable stages
• Avoiding repeated cycles of excessive activity followed by prolonged inactivity
• Maintaining a regular sleep routine
• Setting realistic functional goals
• Using heat or cold safely when appropriate
• Maintaining general health and nutrition

Self-management complements medical care. It does not mean that a patient should be expected to manage disabling pain alone.

When Should You See a Pain Specialist?

Consider specialist assessment when:

• Pain persists or repeatedly returns for more than three months
• Pain significantly affects sleep, work, mobility or quality of life
• The diagnosis remains unclear
• Medicines provide inadequate or only temporary relief
• You are repeatedly taking painkillers without a clear long-term plan
• Burning, tingling, numbness or other nerve symptoms are present
• Pain continues after surgery
• Rehabilitation is limited by pain
• A targeted intervention is being considered
• You have been advised surgery and want to understand whether other appropriate options exist

A pain-specialist consultation should begin with assessment and diagnosis—not with the assumption that a procedure is required.

When Should You Seek Urgent Medical Attention?

Do not automatically attribute new symptoms to an existing chronic pain condition.

Seek urgent medical care for symptoms such as:

• Sudden severe chest pain
• Severe breathing difficulty
• New or rapidly worsening weakness
• New major loss of sensation
• New confusion
• Severe pain following major trauma

For back pain, urgent assessment is particularly important if there is:

• New bladder or bowel dysfunction
• Difficulty passing urine
• Numbness around the groin or saddle area
• Rapidly worsening leg weakness

What Is the Goal of Chronic Pain Treatment?

The goal is not always complete elimination of pain.

Depending on the condition, successful treatment may mean:

• Less pain
• Better mobility
• Improved sleep
• Reduced reliance on medication
• Improved ability to exercise
• Return to work
• Greater independence
• Better participation in family and social life
• Improved quality of life

ISSP’s MIPSI framework similarly emphasises functional restoration—including mobility, independence, work capacity and quality of life—rather than pain scores alone.

Painacea’s Approach to Chronic Pain

Painacea is neither medicine-only nor procedure-first.

Our approach is:

Understand the pain → identify the mechanism and possible pain generator → choose the least invasive appropriate treatment → use MIPSI when indicated → use advanced interventions or surgical referral when required.

A patient may therefore leave the first consultation with:

• Education and self-management advice
• Rehabilitation
• Medication for a defined purpose
• Further investigation
• Diagnostic MIPSI
• Therapeutic MIPSI
• Radiofrequency or cryoablation
• Advanced spine intervention
• Neuromodulation evaluation
• Referral to another specialist

Treatment follows diagnosis not the other way around.

A consultation does not mean that an injection or procedure will automatically be recommended.

References

1. International Association for the Study of Pain. Definitions of Chronic Pain Syndromes. Definitions and ICD-11 classification of chronic primary and secondary pain.
2. 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, NG193. Guidance on assessment, exercise, psychological approaches and treatment recommendations for chronic primary pain.
3. National Institute for Health and Care Excellence. Suspected neurological conditions: recognition and referral, NG127. Guidance on recognising neurological symptoms requiring urgent assessment.
4. 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.
5. Indian Society for the Study of Pain — What is MIPSI? Understanding Minimally Invasive Pain and Spine Interventions in Modern Pain Medicine. – https://issp-pain.org/2026/05/21/what-is-mipsi-minimally-invasive-pain-spine-interventions/