Tipultech logo

Chronic pain

Author: Dr Simon Moss


Chronic pain refers to any form of pain that has persisted for longer than three months-or at least appreciably longer than anticipated (Andersson, 2004& Eriksen, Ekholm, Sjogren, & Rasmussen, 2004). The pain can arise from a variety of causes, ranging from identifiable injuries or tissue damage to non-specific underpinnings. In addition, to a variety of causes, the manifestations vary extensively& the pain can be acute or dull, can be distributed widely or narrowly, and can impair functioning appreciably or mildly (Bucknall, Manias & Botti, 2001).

The reported prevalence of chronic pain varies markedly across studies, but almost always exceeds 2% of the population (Blyth, March, Brnabic, Jorm, Williamson, & Cousins, 2001& see also Breivik, H., Collett, Ventafridda, Cohen, & Gallacher, 2006). In particular, these estimates depend on the research design and location as well as definitions of chronic pain


Almost invariably, the initial origin of pain is physical in nature. Nevertheless, a variety of psychological, social, cultural, occupational, economic, and demographic characteristics impinge on the trajectory, implications, and duration of the pain (Denison, Asenlof, & Lindberg, 2004& Kendall, 1999). In general, recovery is more rapid in individuals who are younger and male as well as earning an elevated income, cohabiting with a partner, and generally healthy (e.g., Eriksen, Ekholm, Sjogren, & Rasmussen, 2004).

Education might also affect the prevalence of chronic pain. Blyth, March, Brnabic, Jorm, Williamson, and Cousins (2001) showed that education level was inversely related to chronic pain. Dionne, Von Korff, Koepsell, Deyo, Barlow, and Checkoway (2001) showed that education is related more to pain recovery or recurrence rather than development or onset. In contrast, in a longitudinal study over six years, Eriksen, Ekholm, Sjogren, and Rasmussen (2004) showed that education was inversely related to the future development of pain, but not to recovery-although, this study controlled income, which might represent colinearity.

Education might also affect functional ability in the context of pain, as shown by Roth and Geisser (2002). Specifically, education might reduce reliance on maladaptive coping and avoidance.


Chronic pain, apart from the mere discomfort, also coincides with a multitude of adversities (for reviews, see Blyth, March, Brnabic, Jorm, Williamson, & Cousins, 2001& Douglas, Graham, Anderson, & Rogerson, 2004& McGuire & Shores, 2004& Olason, 2004& Turk & Okifuji, 2002). First, chronic pain correspond to other physical difficulties, including impaired fitness, muscle deconditioning, and sleep disturbances. Second, chronic pain is associated with psychological impairment, such as affective disorders and problems with adjustment. Third, such pain compromises functioning in daily life, impinging on job performance, social interactions, family responsibilities, and quality of life in general.

Chronic pain does not affect only the individual. For example, as a consequence of their inability to fulfil all of their responsibilities, family members might also be affected (Turk & Okifuji, 2002). Similarly, chronic pain does affect the broader community. Costs associated with health care, compensation, and lost work time are exorbitant (Blyth, March, Brnabic, & Cousins, 2004& Douglas, Graham, Anderson, & Rogerson, 2004& Gatchel & Okifuji, 2006& McGuire & Shores, 2004& Turk & Okifuji, 2002).


Because many psychological and sociological factors affect the experience of pain, standard biomedical treatments, such as analgesic medications and surgical intervention, are often ineffective (Denison, Asenlof, & Lindberg, 2004& Elliott , Smith, Hannaford, Smith, & Chambers, 2002& Evers, Kraaimaat, van Riel, & de Jong, 2002& Holdcroft & Power, 2003& Kendall, 1999). As a consequence of these difficulties, treatment programs often focus on how to fulfil functional responsibilities rather than merely on how to alleviate pain. Indeed, an emphasis on pain relief can compromise functional outcomes, because individuals might withdraw from many activities as a means to preclude further pain (Blyth, March, Brnabic, Jorm, Williamson, & Cousins, 2001).

Many treatment programs today consider a broad range of physical, social, psychological, and behavioral issues (e.g., Douglas, Graham, Anderson, & Rogerson, 2004& Holdcroft & Power, 2003). The programs include information about the sources of pain, such as gate control theory, as well as techniques to improve the psychological states of individuals, including relaxation procedures, cognitive behavioral therapy, and acceptance of commitment therapy. Furthermore, treatments, like medication and physiotherapy are discussed, together with life style. Usually, these programs are more effective than are therapies that are not multidimensional& approximately 50% of participants seem to return to a normal lifestyle (Blyth, March, Brnabic, Jorm, Williamson, & Cousins, 2001).

Psychological therapies

Cognitive behavioral therapy, in which individuals learn to challenge maladaptive thoughts, has been shown to be effective. Such therapy can curb emotional distress and functional disability-especially in social and work domains-as well as reduce utilization of healthcare and medication (Hoffman, Papas, Chatkoff, & Kerns, 2007& McCracken & Turk, 2002& Morley, Eccleston, & Williams, 1999). The main focus of these therapies is to highlight and then preclude catastrophic thinking and other maladaptive beliefs or thoughts (Turk & Rudy, 1992& Vlaeyen & Linton, 2000).

Nevertheless, the mechanisms that underpin the benefits of CBT in this context have not been established definitively (Keefe, Rumble, Scipio, Giordano, & Perri, 2004& Morley, 2004). This oversight is consequential, because some studies indicate the cognitive facet of cognitive behavioral therapy might not be integral to the alleviation of many disorders, such as anxiety and depression (Longmore & Worrell, 2007).

Several studies have also shown that acceptance and commitment therapy, as summarized by Hayes (2004), might improve functioning of individuals who experience chronic pain (see McCracken, 2005& McCracken, MacKichan, & Eccleston, 2007). Participants learn to refrain from attempting to suppress the pain. That is, they learn to accept rather than control or avoid distressing feelings. These individuals are encouraged to identify and pursue core values regardless of the pain or distress. A variety of experiential exercises, demonstrations, and metaphors are presented to inculcate these principles, including mindfulness and cognitive defusion.

Even four hours of acceptance and commitment therapy has been shown to diminish sick leave and utilization of health care in workers with pain or stress, as shown by Dahl, Wilson, and Nilsson (2004). Similarly, Wicksell, Melin, and Olsson (2007) showed that adolescents with chronic pain demonstrated better functioning after engaging in treatments that align with the principles of acceptance and commitment therapy.

The state of acceptance, in which individuals embrace rather than avoid distress, seems to underpin many of these benefits. That is, acceptance has been shown to explain improvements in functional outcomes in the context of chronic pain, even after catastrophic thinking was controlled (Vowles, McCracken, & Eccleston, 2007).

Moderators of treatment effects

The efficacy of these treatment regimes seems to vary appreciably (Evers, Kraaimaat, van Riel, & de Jong, 2002), suggesting that some factors moderate the utility of these approaches. For example, education might amplify the benefits of these treatment programs, although evidence is limited.

Measures of pain

Rowland-Morris Disability Questionnaire (RMDQ)

The RMDQ, developed by Rowland and Morris (1983), assesses the physical or functional disability that arises from pain, as gauged by the patients themselves (see also Stroud, McKnight, & Jensen, 2004). Participants specify the extent to which a series of statements, such as "I stay at home most of the time because of my pain" apply to them. This measure correlates highly with total scores on the sickness impact profile (Bergner, Bobbitt, Carter, & Gilson, 1981), a broader scale that represents physical and psychosocial impairment, with correlations exceeding .80 (e.g., Jensen, Strom, Turner, & Romano, 1992&).

Tampa Scale for Kinesphobia (TSK),

The TSK, constructed by Kori and Miller (1991), assesses fear of pain or injury-the converse of acceptance-as a consequence of physical movement. Participants evaluate the extent to which they agree or disagree with 17 statements, such as "I am afraid that I might injure myself if I exercise". High positive correlations with related measures, such as the pain catastrophizing scale and the fear avoidance beliefs questionnaire, established the validity of this scale (Woby, Roach, Urmston, & Watson, 2005). Internal consistency also approached .8 and treatment did reduce overall levels of fear(Woby, Roach, Urmston, & Watson, 2005).

Pain Related Self-Statements Scale (PRSS)

The PRSS, developed by Flor (1993), examines the capacity of participants to cope with pain. Specifically, participants specify the frequency with which they engage in specific thoughts when they experience severe pain. Nine items reflect adaptive coping, such as "If I stay calm and relaxed, things will get better. The other nine items reflect catastrophising, such as "No matter what I do my pain does not change." Flor, Behle, and Birbaumer (1993) reported elevated levels of test-retest reliability over a week and well as alpha coefficients that approximate .85 for both subscales. In addition, these scales are correlated as expected with the multidimensional health locus of control scale, the pain related control scale, and other associated measures.


Adams, J. H., & Williams, A. C. (2003). What affects return to work for graduates of a pain management program with chronic upper limb pain? Journal of Occupational Rehabilitation, 13, 91-106.

Anderson, H. I. (2004). The course of non-malignant chronic pain: A 12-year follow-up of a cohort from the general population. European Journal of Pain, 8, 47-53.

Australian Qualifications Framework Advisory Board. (2007). Australian Qualification Framework: Implementation handbook (4th ed.). Victoria, Australia: Author.

Bergner, M., Bobbitt, R. A., Carter, W. B., & Gilson, B. S. (1981). The Sickness Impact Profile: Development and final revision of a health status measure. Medical Care, 29, 787-805

Blyth, F. M., March, L. M., Brnabic, A. J. M., & Cousins, M. J. (2004). Chronic pain and frequent use of health care. Pain, 111, 51-58.

Blyth, F. M., March, L. M., Brnabic, A. J. M., Jorm, L. R., Williamson, M., & Cousins, M. J. (2001). Chronic pain in Australia: A prevalence study. Pain, 89, 127-134.

Breivik, H., Collett, B., Ventafridda, V., Cohen, R., & Gallacher, D. (2006). Survey of pain in Europe: Prevalence, impact on daily life, and treatment. European Journal of Pain, 10, 287-333.

Bucknall, T., Manias, E., & Botti, M. (2001). Acute pain management: Implications of scientific evidence for nursing practice in the postoperative context. International Journal of Nursing Practice, 7, 266-273.

Dahl, J., Wilson, K. G., & Nilsson, A. (2004). Acceptance and commitment therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: A preliminary randomized trial. Behavior Therapy, 35, 785-802.

Denison, E., Asenlof, P., & Lindberg, P. (2004). Self-efficacy, fear avoidance, and pain intensity as predictors of disability in subacute and chronic musculoskeletal pain patients in primary health care. Pain, 111, 245-252.

Dionne, C. E., Von Korff, M., Koepsell, T. D., Deyo, R. A., Barlow, W. E., & Checkoway, H. (2001). Formal education and back pain: a review. Journal of Epidemiology and Community Health, 55, 455-468.

Douglas, W., Graham, C., Anderson, D., & Rogerson, K. (2004). Managing chronic pain through cognitive change and multidisciplinary treatment program. Australian Psychologist, 39, 201-207.

Elliott, A. M., Smith, B. H., Hannaford, P. C., Smith, W. C., & Chambers, W. A. (2002). The course of chronic pain in the community: Results of a 4-year follow-up study. Pain, 99, 299-307.

Eriksen, J., Ekholm, O., Sjogren, P., & Rasmussen, N. K. (2004). Development of and recovery from long-term pain. A 6-year follow-up study of a cross-section of the adult Danish population. Pain, 108, 154-162.

Evers, A. W. M., Kraaimaat, F. W., van Riel, P. L. C. M., & de Jong, A. J. L. (2002). Tailored cognitive-behavioral therapy in early rheumatoid arthritis for patients at risk: A randomized controlled trial. Pain, 100, 141-153.

Fishbain, D. A., Cole, B., Cutler, R. B., Lewis, J., Rosomoff, H. L., & Fosomoff, R. S. (2003). Is pain fatiguing? A structured evidence-based review. Pain Medicine, 4, 51-62

Flor, H., Behle, D., & Birbaumer, N. (1993). Assessment of pain-related cognitions in chronic pain patients. Behaviour Research and Therapy, 31, 63-73.

French, D., France, C., Vigneau, F., French, J., & Evans, T. (2007). Fear of movement/(re)injury in chronic pain: A psychometric assessment of the original English version of the Tampa scale for kinesiophobia (TSK). Pain, 127, 42-51.

Gatchel, R. J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. Journal of Pain, 7, 779-793.

Hayes, S. C. (2004). Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behavior Therapy, 35, 639-665.

Hoffman, B. M., Papas, R. K., Chatkoff, D. K., & Kerns, R. D. (2007). Meta-analysis of psychological interventions for chronic low back pain. Health Psychology, 26, 1-9.

Holdcroft, A., & Power, I. (2003). Management of pain. British Medical Journal, 326, 635 - 639.

Jensen, M. P., Karoly, P., & Braver, S. (1986). The measurement of clinical pain intensity: A comparison of six methods. Pain, 27, 117-126.

Jensen, M., Strom, S., Turner, J., & Romano, J. (1992). Validity of the Sickness Impact Profile Roland scale as a measure of dysfunction in chronic pain patients. Pain, 50, 157-162.

John, M. T., Miglioretti, D. L., LeResche, L., Von Korff, M., & Critchlow, C. (2003). Widespread pain as a risk factor for dysfunctional temporomandibular disorder pain. Pain, 102, 257-263.

Keefe, F. J., Rumble, M. E., Scipio, C. D., Giordano, L. A., & Perri, L. C. M. (2004). Psychological aspects of persistent pain: Current state of the science. Journal of Pain, 5, 195-211.

Kendall, N. A. (1999). Psychosocial approaches to the prevention of chronic pain: The low back paradigm. Best Practice & Research in Clinical Rheumatology, 13, 545-554.

Kurtze, N., & Svebak, S. (2001). Fatigue and patterns of pain in fibromyalgia: Correlations with anxiety, depression and co-morbidity in a female county sample. British Journal of Medical Psychology, 74, 523-537

Longmore, R. J., & Worrell, M. (2007). Do we need to challenge thoughts in cognitive behavior therapy? Clinical Psychology Review, 27, 173-187.

McCracken, L. M., & Turk, D. C. (2002). Behavioral and cognitive-behavioral treatment for chronic pain: Outcome, predictors of outcome, and treatment process. Spine, 27, 2564-2573.

McCracken, L. M., & Vowles, K. E. (2006). Acceptance of chronic pain. Current Pain and Headache Reports, 10, 90-94.

McCracken, L. M., Vowles, K. E., & Eccleston, C. (2004). Acceptance of chronic pain: Component analysis and a revised assessment method. Pain, 107, 159-166.

McCracken, L. M., Vowles, K. E., & Eccleston, C. (2005). Acceptance-based treatment for persons with complex, long-standing chronic pain: A preliminary analysis of treatment outcome in comparison to a waiting phase. Behaviour Research and Therapy, 43, 1335-1346.

McCracken, L. M., & Yang, S. (2006). The role of values in a contextual cognitive-behavioral approach to chronic pain. Pain, 123, 137-145

McGuire, B., & Shores, E. (2004). The Pain Patient Profile: Data from an Australian chronic pain sample. Australian Psychologist, 39, 97-100.

Morley, S. (2004). Editorial: Process and change in cognitive behaviour therapy for chronic pain. Pain, 109, 205-206

Morley, S., Eccleston, C., & Williams, A. C. (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain, 80(1-2), 1-13.

Nicassio, P. M., Moxham, E. G., Schuman, C. E., & Gevirtz, R. N. (2002). The contribution of pain, reported sleep quality, and depressive symptoms to fatigue in fibromyalgia. Pain, 100, 271-279.

Nicholas, M. K., Asghari, A., & Blyth, F. M. (2008a). What do the numbers mean? Normative data in chronic pain measures. Pain, 134, 158 - 173.

Olason, M. (2004). Outcome of an interdisciplinary pain management program in a rehabilitation clinic. Work, 22, 9-15.

Roth, R. S., & Geisser, M. E. (2002). Educational achievement and chronic pain disability: Mediating role of pain-related cognitions. The Clinical Journal of Pain, 18, 286-296.

Rustoen, T., Wahl, A. K., Hanestad, B. R., Lerdal, A., Paul, S., & Miaskowski, C. (2004). Prevalence and characteristics of chronic pain in the general Norwegian population. European Journal of Pain, 8, 555-565.

Stone, A. A., Broderick, J. E., Porter, L. S., & Kaell, A. T. (1997). The experience of rheumatoid arthritis pain and fatigue: Examining momentary reports and correlates over one week. Arthritis Care & Research, 10, 185-193.

Stroud, M., McKnight, P., & Jensen, M. (2004). Assessment of self-reported physical activity in patients with chronic pain: Development of an abbreviated Roland-Morris Disability Scale. The Journal of Pain, 5, 257-263.

Turk, D., & Okifuji, A. (2002). Psychological factors in chronic pain: Evolution and revolution. Journal of Consulting & Clinical Psychology, 740, 687-690.

Turk, D. C., & Rudy, T. E. (1992). Cognitive factors and persistent pain: A glimpse into Pandora's box. Cognitive Therapy and Research, 16, 99-112.

Vlaeyen, J. W. S., & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain, 85, 317-332.

Vowles, K. E., Gross, R. T., & Sorrell, J. T. (2004). Predicting work status following interdisciplinary treatment for chronic pain. European Journal of Pain, 8, 351-358.

Vowles, K. E., & McCracken, L. M. (2008). Acceptance and values-based action in chronic pain: A study of treatment effectiveness and process. Journal of Consulting and Clinical Psychology, 76, 397-407.

Vowles, K. E., McCracken, L. M., & Eccleston, C. (2007). Processes of behavior change in interdisciplinary treatment of chronic pain: Contributions of pain intensity, catastrophizing, and acceptance. European Journal of Pain, 11, 779-787.

Vowles, K. E., McCracken, L. M., & Eccleston, C. (in press). Patient functioning and catastrophizing in chronic pain: The mediating effects of acceptance. Health Psychology, 27, S136-S143.

Vowles, K. E., McNeil, D. W., Gross, R. T., McDaniel, M., Mouse, A., Bates, M., et al. (2007). Effects of pain acceptance and pain control strategies on physical impairment in individuals with chronic low back pain. Behavior Therapy, 38, 412-425.

Wicksell, R. K., Melin, L., & Olsson, G. L. (2007). Exposure and acceptance in the rehabilitation of adolescents with idiopathic chronic pain: A pilot study. European Journal of Pain, 11, 267-274.

Woby, S., Roach, N., Urmston, M., & Watson, P. (2005). Psychometric properties of the TSK-11: A shortened version of the Tampa Scale of Kinesiophobia. Pain, 117, 137-144.

Zautra, A., Smith, B., Affleck, G., & Tennen, H. (2001). Examinations of chronic pain and affect relationships: Applications of a dynamic model of affect. Journal of Consulting and Clinical Psychology, 69, 786-795

Academic Scholar?
Join our team of writers.
Write a new opinion article,
a new Psyhclopedia article review
or update a current article.
Get recognition for it.

Last Update: 6/21/2016