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1 Royal Berkshire NHS Foundation PRACTICE POINTER
Trust, Reading, UK

2 Live Well With Pain Team, UK Chronic pain: definitions and diagnosis
3 Oxford University Hospitals NHS
Youngjoo Kang, 1 Louise Trewern, 2 John Jackman, 3 David McCartney, 5 Anushka Soni6
Foundation Trust, Nuffield
Department of Orthopaedics,
What you need to know three months 10 17, which has been incorporated into
Rheumatology and Musculoskeletal the classification system implemented in 2019 in
Sciences, Oxford, UK
• Acknowledging chronic pain as a diagnosis in its own ICD-11. This approach, which subdivides chronic pain
5 Medical Sciences Division, University right can help clinicians and patients move on from into chronic primary pain and chronic secondary pain
of Oxford, Oxford a mindset of searching for a diagnosis to discussing syndromes, has been developed to improve the ease
long term management strategies and accuracy of data recording.7 10 According to
6 Nuffield Department of Clinical
Neurosciences/Nuffield Department
• Consider non-pain features such as poor sleep, low ICD-11, chronic primary pain conditions include a
of Orthopaedics, Rheumatology and mood, and reduced physical activity: these can be collection of syndromes such as fibromyalgia and
Musculoskeletal Sciences, University both a cause and a consequence of chronic primary chronic migraine, which are considered health
of Oxford pain
conditions in their own right. In contrast, the pain in
* Joint senior authors • Consultations where patients feel believed, listened chronic secondary pain conditions initially manifests
to, and validated can enable a therapeutic as the result of another condition—eg, rheumatoid
Correspondence to Anushka Soni
relationship that forms the basis for subsequent arthritis or inflammatory bowel disease—but
anushka.soni@ndorms.ox.ac.uk
management strategies, including supported
Cite this as: BMJ 2023;381:e076036 diagnosing chronic secondary pain marks the stage
self-management.
http://dx.doi.org/10.1136/bmj-2023-076036 when the pain requires treatment in its own right.
Published: 27 June 2023 Although it can be challenging to disentangle chronic
Pain related diseases are the leading cause of primary pain from chronic secondary pain (and they
disability and disease burden worldwide.1 2 Chronic can coexist), this general shift towards
pain affects between a third and half of the acknowledging chronic pain in its own right can help
population globally,3 -5 and high impact chronic clinicians and patients move on from a mindset of
pain—defined as pain experienced on most days or searching for a diagnosis to discussing long term
every day in the previous three months that causes management strategies.19 Here, we will focus on

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restriction in at least one activity—has been found to chronic primary pain (particularly chronic
affect 4.8% of the US adult population.6 Furthermore, widespread and musculoskeletal pain), although
chronic pain is a common reason for accessing many of the concepts may also apply to chronic
healthcare, with 22-50% of GP consultations being secondary pain and much of the literature to date
related to pain.7 Patients often report a delay in does not yet distinguish between these two
diagnosis,8 with a longer and more difficult journey subcategories of chronic pain.
to diagnosis being associated with reduced
satisfaction with subsequent treatment.9 When to suspect chronic primary pain
A lack of diagnostic biomarkers and universally Based on the literature and guidance from the UK in
effective treatment options for chronic pain often managing musculoskeletal pain, box 1 describes
result in frustration for both patients and factors that may help alert the clinician to an
clinicians.7 10 Consultations can sometimes focus on underlying chronic primary pain condition.11 20 21 The
how to treat pain, without first naming the diagnosis distribution of pain can help to distinguish chronic
of chronic pain. Creating space in the consultation primary pain from other causes. Although patients
for this can help patients to feel heard, reduce often focus on the most prominent local or regional
frustration, and refocus on supported areas of pain at any one time, it is important to screen
self-management strategies rather than the clinician for pain elsewhere in the body, as widespread pain
striving to fix the problem. This article offers an is a feature suggestive of chronic primary pain.11 20 21
approach to identifying and discussing chronic pain
with patients, drawing on formal guidance from the Box 1: Factors suggestive of chronic primary pain11 20 21
UK,11 -14 patient voices, and our clinical experience.
• Pain related factors
What is chronic pain? ‐ Widespread pain (although only regional pain may
According to the International Association for the be reported)
Study of Pain (IASP), chronic pain is defined as “pain ‐ Pain longevity
that persists or recurs for longer than three ‐ Ineffective treatments so far
months.”7 10 15 This distinguishes chronic pain (as
‐ Already diagnosed with a chronic primary pain
that persisting beyond normal tissue healing time)
condition
from physiological, acute pain.16 As this timeframe
can be difficult to quantify, and a clear trigger or • Non-pain related factors
injury is absent in many cases, a somewhat arbitrary ‐ Poor refreshment from sleep
cut-off period of three to six months was originally
‐ Hypersensitivity to visual, auditory, and tactile
adopted by IASP in 1994.18 The most recent definition
stimuli
supported by IASP uses a cut-off time of more than

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‐ Intrusive fatigue
What is the best way to discuss chronic primary pain with
‐ patients?
Poor concentration and poor short term memory
Patients often report having to defend their experience of severe
• Medical history
pain, and cite active listening by clinicians as a key success factor
‐ Numerous comorbid illnesses and allergies in building a good patient-clinician partnership.8 27 29 30 Effective
• Consultation related factors
communication strategies help people with chronic primary pain
feel listened to, validated, supported, and empowered as they
‐ Feeling of being overwhelmed (patient, clinician, or both) develop strategies to help to improve their quality of life, often
despite the ongoing pain. Feeling believed, being listened to, and
Several non-pain features—such as poor sleep, mood disturbance, the validation of a person’s experience are key features of effective
low levels of physical activity, memory disturbance, and communication. This is highlighted by the National Institute for
fatigue—can often occur as a consequence of living with chronic Health and Care Excellence (NICE) guidelines on chronic pain,
pain.2 11 12 14 20 21 A bidirectional relation can be seen between poor which recommend fostering a collaborative and supportive
sleep and chronic pain, whereby sleep disturbance causes chronic relationship with the person with chronic pain.12 The combination
pain and poor sleep increases the intensity and duration of chronic of multiple symptoms and a limited consultation time can be
pain.22 -24 Depression, anxiety, and negative beliefs about pain are challenging for both clinicians and patients.9 Over time, longer
also related to developing chronic pain, as well as worse outcomes consultations and follow-up with the same clinician may help
from chronic pain.25 26 Many people also experience an erosion of overcome these problems, to enable an improved therapeutic
identity and experience problems in maintaining work, relationship.
relationships, and social activities.27 28 Ask about these aspects to People living with chronic pain value a specific diagnosis alongside
understand the burden of symptoms as well as to identify potential an explanation of the cause of the pain.12 The latter can cause
areas to focus on when making shared decisions about management. clinicians to feel undue pressure, as much remains unknown about
Co-existing hypersensitivity to non-pain stimuli, such as sound, the mechanisms and specific causes. However, patients tend to be
light, temperature change, or touch are also suggestive of chronic understanding about the difficulty in treating chronic pain and the
primary pain rather than a local or regional structural lack of certainty involved.12Box 3 gives some suggested concepts,
abnormality.11 20 21 In our experience, patients can feel validated drawn from our experience, to consider when discussing the
when clinicians are able to group and offer a single diagnostic label diagnosis of chronic primary pain.

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for a vast range of debilitating and seemingly unrelated sensations.
Box 3: Considerations for shared decision making discussions about
The presence of a several comorbid illnesses or allergies may also chronic primary pain
be suggestive of a chronic primary pain condition.21 Furthermore, • Validate the patient’s pain. Stress that normal results of investigations
an existing diagnosis of one chronic primary condition may also
do not mean there is not a problem.
suggest an increased chance of developing another.21
• Reinforce a positive diagnosis of chronic primary pain and discuss
What is the role of investigations in chronic primary pain? management strategies.
In practice, investigations to identify or exclude potential coexisting • Discuss how pain is a complex sensation and many factors can affect
conditions may be required, depending on clinical suspicion. The the sensitivity of the early warning alert system. Several parts of the
brain, including those involved in learning, memory, mood, sleep,
combination and timing of tests required will be patient specific
context, movement, and sensation, work together to try to accurately
and may evolve over time. However, clear communication of test predict danger signals, and this is why other factors, such as stress,
results is important to consider in all cases, particularly when a can trigger worsening of symptoms.
patient receives normal results from an investigation.12 Doctors may • Explain that no medication or procedure is likely to resolve the
feel reassured because normal results mean the patient has no problem.
underlying pathology; however, patients can feel frustrated and
• Although the mechanisms are not fully understood and pain cannot
dismissed as the normal result doesn’t match their experience of
always be explained, learning more about the pain can be helpful for
pain. Box 2 gives some practical steps, drawn from our experience,
some patients.
to help minimise this risk.

Box 2: Practical tips for discussing the diagnosis of chronic primary pain Prospective population cohort studies conducted in the UK,31 US,32
What is the cause of my pain?
Norway,33 and the Netherlands34 suggest chronic pain tends to
persist or fluctuate, rather than resolve. Explaining the difference
Explain that, while our usual understanding of pain is as a response to
the damage of tissues, it can be more helpful to think of pain as an early in the prognosis of chronic pain (compared with acute pain) helps
warning alert system. It makes us aware of potential danger, but doesn’t to ensure that patients have realistic expectations about future pain
necessarily wait for tissue injury to occur. levels. In our experience, it can also be helpful to highlight that
In chronic primary pain, the tissues may be normal but the pain processes experiencing a better quality of life does not always depend on pain
are not working properly. For this reason, investigations may be normal levels reducing in severity and that it often requires the use of
but this doesn’t mean there is not a problem. strategies to improve wellbeing, despite the pain.
An example, such as phantom limb pain in a patient who has had an
amputation, may be helpful. Education into practice

• How often do you assess non-pain symptoms in patients presenting

with chronic pain?
• How do you explain chronic primary pain to patients?

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BMJ: first published as 10.1136/bmj-2023-076036 on 27 June 2023. Downloaded from http://www.bmj.com/ on 20 April 2024 at Manipal Academy of Higher Education. Protected by
How patients were involved in the creation of this article How this article was created
Louise Trewern (chronic pain patient advocate, immediate past vice-chair A literature search was conducted across Ovid Medline, PubMed,
of the British Pain Society Patient Voice Group, executive committee of Cochrane Collaboration, and NICE for chronic pain clinical guidelines
the Physiotherapy Pain Association, chair of Get-Involved—Evolving and systematic reviews. The most recent guidelines and systematic
Through Patient Experience Committee at Torbay Hospital Pain Service, reviews were selected to draft the initial outline, collating the most recent
lead lived experience trainer, Live Well With Pain Team) is a co-author of evidence. Finally, the clinical experience of senior authors was added
this article and provided key input from a patient perspective. Expert alongside patient perspectives.
patient representatives from the Patient Voice and the Footsteps Festival
Expert Patient Team provided feedback on the article content overall and
provided specific advice regarding the role of communication skills.

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copyright.

Royal Berkshire Hospital Library Services for their help with literature searches. We also acknowledge
Contributorship and the guarantor: YK, JJ, LT, DM, and AS conceived the article and are guarantors. All Kiyan Irani for his help with the figures.
authors wrote and reviewed the article, created the boxes, and helped with the figures. LT was the
contact for patient involvement. Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial
companies. The authors declare the following other interests: none.
We thank the patient representatives of the British Pain Society Patient Voice and the Footsteps Festival
Expert Patient Team for their contribution, in particular Niki Jones, Jim Blake, Rachel Bonnington, and Provenance and peer review: commissioned; externally peer reviewed.
Mark Farmer. Many thanks to Victoria Harrison and the Library and Knowledge Specialist Team at the

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