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Chronic Primary Pain

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About Chronic Pain

Overview: 

  • Chronic pain is defined as pain that is recurrent for or lasts longer than 3-months
  • Chronic musculoskeletal pain defined as continued regional pain that lasts or recurs longer than three months. Chronic MSK Pain can be subclassified into the following:
    1. Chronic Primary MSK Pain (i.e., chronic primary pain)
      1. Pain > 3 months
      2. High distress/functional deficit related to symptoms 
      3. Cannot be attributed to a secondary structural condition (i.e., structural changes [e.g. severe osteoarthritis, inflammatory spondyloarthritis], fracture, infection, serious spinal conditions [e.g. cauda equina syndrome], or visceral referral)
      4. Distinguished according to location 
      5. Not specific to any type of pain (e.g., nociceptive, neuropathic, nociplastic).
      6. Conditions that were formerly “nonspecific” are placed in this category.
    2. Chronic Secondary MSK Pain
      1. Persistent local/systemic inflammatory disease manifesting in MSK structures (e.g. inflammatory spondyloarthropathies, polymyalgia rheumatica)
      2. Local structural changes in the bones, joints, connective tissues or muscles that are attributed as the source of persistent nociception (e.g., spondylosis, severe knee OA, etc.)
      3. Diseases of the nervous system which cause MSK problems (e.g., hypertonicity from Parkinsons disease; post-stroke spasticity). 
  • Chronic pain secondary to musculoskeletal disorders is the most prevalent cause of chronic pain and is identified as “chronic secondary musculoskeletal pain”.
  • Chronic primary pain and chronic secondary pain can coexist.

Effective Management: 

  • All pain should be treated through a biopsychosocial lens. Chronic primary pain is a disorder of the entire system, in which an obvious source of peripheral nociception or central nervous system disorder is not identifiable. The pain itself is the disorder.
  • Chronic primary pain is characterized by a complex and inseparable interplay of biological, psychological and social factors. As a result, multimodal management that addresses biological, psychological or social contributors to pain is regarded as more helpful than one standalone intervention.
  • Treatment applied through the lens of the biopsychosocial framework is rooted in a strong therapeutic relationship, shared decision-making, education and acknowledgement of patient-related goals. The complexity of biological, psychological and social dimensions necessitates an individualized multimodal approach. Best practices include interdisciplinary collaboration and progression towards supported self-management.

About CCG Care Pathways

Purpose

CCG care pathways provide structured, evidence-based guidance for clinicians delivering conservative, non-operative care for common musculoskeletal conditions. They outline key steps of the clinical encounter, support safe and appropriate decision-making, and assist with referral or co-management when indicated. Pathways are designed as practical, user-friendly tools that complement, not replace, clinical judgment.

Development

Pathways are developed using the best available evidence from high-quality clinical practice guidelines when they exist, and from systematic reviews and expert consensus when guideline evidence is limited or evolving. Content is reviewed periodically to reflect emerging research and current best practices. Input from clinicians, educators, and researchers helps ensure pathways remain relevant, aligned with real-world practice, and responsive to user needs.

Principles of Conservative Care

Musculoskeletal conditions are multifactorial and often influenced by physical, psychological, social, and environmental factors. As such, there is no one-size-fits-all approach to care. Effective management should be ethical, evidence-informed, transparent, flexible, and tailored to individual needs. Shared decision-making ensures care aligns with patient goals and values. Ongoing monitoring and outcome assessment support a person-centred approach and enable timely adjustments to care plans. Care may be delivered in-person, virtually, or through hybrid models, guided by patient preference, access, and clinical judgment.

Disclaimer

CCG care pathways are intended to support, not substitute for, professional clinical decision-making or the advice of a qualified healthcare provider. Recommendations are evidence-informed and presented in simplified, accessible language to support clinical understanding and application. Terms used throughout are not intended as formal diagnostic or billing terminology, nor are pathways prescriptive, authoritative, or regulatory.

Providers are expected to apply their clinical expertise and consult authoritative sources such as regulatory standards and policies, diagnostic classification systems (e.g., ICD-10-CA), scope-of-practice documents, continuing professional education resources, and peer-reviewed literature. Pathways may not apply to every clinical scenario and should always be interpreted in the context of individual patient needs.

Chronic Primary Musculoskeletal Pain Care Pathway

1. Record Keeping

Accurate, timely, and comprehensive documentation is an essential component of high-quality, evidence-based care. Clinical records must clearly reflect patient interactions, clinical reasoning, and progress over time, and should meet all jurisdictional regulatory standards.

Providers are encouraged to use a structured note format, such as the SOAP framework, to support consistency, clarity, and continuity of care.

Subjective: Document the patient’s reported symptoms, concerns, functional changes, contextual factors (e.g., psychosocial or environmental influences), and responses to prior care.

Objective: Record measurable or observable findings, including physical examination results, relevant diagnostic tests, functional assessments, and any clinically significant changes.

Assessment: Provide the clinical interpretation of findings, including diagnostic impressions or updates, identification of key risk factors or modifiers, and evaluation of the patient’s status or progression.

Plan: Outline the management strategy, including treatments delivered, modifications made, patient education and self-management recommendations, referrals, co-management decisions, and planned follow-up.

Documentation should be completed contemporaneously and maintained in accordance with regulatory requirements for privacy, security, and record retention. High-quality records support patient safety, facilitate interprofessional communication, enable shared decision-making, and promote continuity and accountability in care.

2. Informed Consent
  • Definition: A process where the patient voluntarily agrees to proposed healthcare interventions after receiving adequate information on the nature, benefits, risks, and alternatives.
  • Key Aspects:
    • Prior to interaction: Obtain consent before any diagnostic testing or treatment. Ensure the patient understands the planned examinations, treatments, expected outcomes, and is given the opportunity to ask questions.
    • Voluntarily and specific: Consent must be given willingly, without coercion, and pertain to the specific condition and proposed treatment. The patient should also understand that they can withdraw consent at any time. 
    • Transparent process: Consent must be obtained honestly, with a clear explanation of the condition and proposed interventions. Consent is not a one-time event, and involves ongoing discussions with the patient.
    • Patient understanding and agreement:
      • Diagnosis/prognosis: Explain findings clearly, using understandable language and visuals if needed.
      • Treatment plan: Outline recommended treatments and how they align with patient goals. Discuss benefits, risks, and alternatives.
      • Questions: Encourage questions and confirm understanding (e.g., “teach-back”).
    • Documentation: Record the consent process, including information provided, patient questions, and explicit consent given.
3. Health History
  • History is directed toward understanding a patient’s experience and gathering information to direct a shared understanding of the experience by identifying a correspondence between the patient’s presentation and a secondary pain disorder, primary pain, or a mixed presentation.
  • Apply person-centered narrative assessment to identify factors contributing to their pain experience and how it affects the person’s life. Ask the person to describe:
    • how chronic pain affects their life and that of those around them
    • how aspects of their lifestyle, activities of daily living, work and sleep may affect their pain
    • their physical and psychological wellbeing
    • current or previous physical or emotional traumatic events
    • current or history of substance misuse
    • difficulties with housing, employment or other social concerns
  • Apply cultural awareness and trauma-informed care principles to learn about the patient as an individual, and to consider how these might influence their symptoms and choice of care
  • Assess the person’s health literacy, including:
    • their views on living well
    • their pain management skills
    • their understanding of what causes their pain
    • their expectations for treatment
    • their understanding of possible treatments and past history of treatment

4. Red Flags : Differential Diagnosis Requiring Medical Referral

ACTION: Refer to appropriate medical provider:

  • Malignancy: Severe, progressive localized or radiating pain radiating; worse at night, not relieved by rest; history of cancer, constitutional symptoms (e.g., fatigue, weight loss), localized tenderness, potential neurological deficits
  • Infection: Night sweats, fever, history of recent infection, immunocompromised state, immune suppressing medication, general malaise
  • Inflammatory conditions (e.g., ankylosing spondylitis): LBP potentially radiating to buttocks/thighs, improves with activity, worse at night, morning stiffness > 1-hour, systemic symptoms (e.g., fatigue, weight loss, fever), reduced spinal mobility, positive Schober’s test, joint tenderness, inflammatory signs (e.g., uveitis, psoriasis).
  • Fracture: Sudden, localized pain/tenderness following minor trauma or spontaneous in individuals with osteoporosis, corticosteroid use, female sex, older age (>60), history of spinal fracture/cancer
  • ​Referred pain from abdominal/pelvic visceral conditions (e.g., aortic aneurysm, endometriosis, kidney stones, pancreatitis): Abdominal pain, GI or urinary symptoms, systemic signs (e.g., fever, weight loss), abdominal/pelvic tenderness, palpable mass, specific findings (e.g., Murphy’s sign for kidney stones, Cullen’s sign for pancreatitis).

5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.

ACTION: Refer for immediate care (emergency department, medical/mental health provider):

  • Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.   
  • Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.
  • Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.

ACTION: Refer to appropriate medical/mental health provider:

  • Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).

ACTION: Co-management by non-medical/mental health providers:

  • Triage: Ensure primary management by medical/psychiatric providers.
  • Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.
  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation without implying a diagnosis. Tools include:
    • PHQ-9 (depressive symptoms)
    • GAD-7 (anxiety symptoms)
    • FABQ (fear related to physical activity/work) 
    • PCS (catastrophic thoughts) 
    • ORT (opioid risk)
6. Yellow Flags: Psychosocial Factors that May Delay Recovery

Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.

Factors:

  • Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.
  • Social: Lack of family/social support, limited connections.
  • Socioeconomic: Employment status, financial stress, litigation/compensation.
  • Environmental/cultural: Social inequality, unsafe/unsupportive environments.
  • Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).
  • Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.

ACTION: Co-management by non-medical/mental health providers: 

  • Education & self-care: Provide resources for (e.g., stress management, coping strategies, graded activity).  
  • Monitor & coordinate: Regularly assess psychosocial challenges; refer to medical/mental health provider if persistent.
  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation (aligned with Orange Flag guidance), without implying a diagnosis. Tools include:
    • PHQ-9 (depressive symptoms)
    • GAD-7 (anxiety symptoms)
    • FABQ (fear related to physical activity/work) 
    • PCS (catastrophic thoughts) 
    • ORT (opioid risk)

7. Physical Examination
  • Assessment is directed toward identifying a correspondence between the patient’s presentation and a somatic or psychological disorder that can account for their presentation (chronic secondary pain).
  • Chronic Primary pain may be considered when there is no clear underlying cause for their symptoms/ pain-experience, or the impact is disproportionate to any observable injury or disease, or they are experiencing significant distress or disability. 

8. Diagnosic Criteria for Chronic Primary Musculoskeletal Pain
  • Pain in one or more areas of any body system (e.g. MSK, GI) or any body site (e.g. extremity, axial, abdominal, urogenital). It may be local, regional or widespread.
  • Pain persisting or recurring for longer than three months
  • Associated with significant emotional distress (e.g. anxiety, anger, frustration, depressed mood) or significant functional disability (e.g. interfered ADLs, limited social roles) or both
  • Symptoms not otherwise better accounted for by another chronic pain condition
  • Diagnoses of chronic primary pain may be further sub-typed. Although all subtypes have common features, each subtype has unique characteristics, allowing for enhanced understanding of natural history and prognosis, and individualized plans to optimize management.
  • Specifiers (psychological factors, social factors, pain intensity) help to guide treatment, and to evaluate outcomes over time.
  • Reevaluate the diagnosis if the presentation changes over time.

Note:

  • Here, the conditions that were formerly named “nonspecific” musculoskeletal pain are classified as “chronic primary” conditions.
  • Examples of diagnoses in SOAP notes (e.g., Chronic primary low back pain vs chronic low back pain secondary to degenerative spondylosis; chronic primary shoulder girdle pain vs chronic shoulder pain secondary to glenohumeral OA; chronic primary left knee pain vs chronic left knee pain secondary to tricompartmental OA). 
  • Chronic primary musculoskeletal pain syndromes are distinguished according to location: upper (chronic primary cervical pain), middle (chronic primary thoracic pain), lower back (chronic primary low-back pain), and limbs (chronic primary limb pain). 
  • Patients may present with spontaneous or evoked pain in the affected region, accompanied by regional allodynia and/or hyperalgesia that exist outside of a known dermatomal/peripheral nerve distribution. 

9. Treatment Considerations for Chronic Primary Pain

Approach to Treatment

The treatments outlined in this section reflect core domains of care consistently identified across high-quality clinical practice guidelines and established clinical practices. These include interventions shown to improve patient-important outcomes such as pain, function, and quality of life. Management plans should be tailored to the individual’s needs, goals, and preferences, taking into account clinical presentation, response to care, and contextual factors.

Not all domains need to be included in every care plan or at every stage of recovery. Clinicians are expected to apply professional judgment in selecting the most relevant components based on the clinical context.

This pathway is not prescriptive, nor does it list every possible intervention. Readers are encouraged to consult individual guidelines for specific treatment protocols, dosage, and condition-specific considerations.

While a range of other interventions may be in use, such as passive physical modalities, these have mixed or limited evidence of clinical benefit and are therefore not recommended for routine use. If applied, such therapies should be used as adjuncts to the core, evidence-based components of care, and not as standalone treatment.

  1. Advice and education (NICE 2021)
    • Provision should be appropriate to the person’s preferences at all stages of care. Be sensitive not to invalidate the person’s experience. Include information that:
      • symptoms fluctuate
      • a biomedical causative reason may not be found
      • the pain may not improve, may get worse, or may need ongoing management
      • quality of life may improve even if pain does not.
    • Advice and education should facilitate management decision making.
  2. Care planning (NICE 2021)
    • Foster a collaborative and supportive relationship with the person with chronic pain.
    • Should be patient centered, and employ shared decision making that considers the person’s:
      • Priorities, abilities and goals. 
      • Consider outcomes from initial and subsequent PSFS or other assessments.
      • Consider what they are already doing that’s helpful.
      • Incorporate their preferred approach to balancing treatment for multiple conditions.
  3. Exercise (NICE 2021)
    • Supervised exercise.
    • Encouragement to remain physically active.
  4. Psychosocial and psychological support (NICE 2021)
    • Consider inclusion of CBT, delivered by a trained healthcare professional.
  5. Acupuncture (NICE 2021)
    • Consider a trial of acupuncture limited to 5 hours of treatment in total, delivered by a trained healthcare professional.
  6. Medication (NICE 2021)
    • Consult a medical professional. Medical professionals may consider antidepressants for people 18 years of age or older to manage pain, sleep, or psychological distress even in the absence of clinical depression.
  7. Assurance
    • Making sense of pain: pain education, managing pain in the present
    • Reshaping pain as part of one’s identity but not their entire identity
    • Goal setting: clear, purposeful goals that matter to life situation
    • Shift from patient-to-person: prioritizing activities that express who the person is and what matters to them
    • Flexible persistence: staying committed to goals while adjusting how they are achieved
    • Value meaningful activities (even modified)
    • Building active and passive coping strategies (across the BPS spectrum): movement, meditation, reframing, manual therapy, medications, etc.
    • Life beyond pain: shift to living a purposeful life with acceptance, optimism and control

10. Risk and Prognostic Factors

(Kaplan et al. 2024)

  • Risk factors: Genetic predisposition to nociplastic conditions, female sex, increasing age, early life factors (e.g. low birth weight), sedentary, obesity, sleep disturbances, physical trauma, emotional trauma, psychological factors. 
  • Negative Prognostic Factors: High pain severity at baseline, Severity of interference at baseline, pain lasting longer than 2 years, not living with a partner, not currently employed, comorbid depressive episode longer than 2 years, depression severity at baseline, comorbid anxiety disorder, catastrophizing.

11. Ongoing Follow-up
  • Monitor progress: Reassess symptoms, functional status, and patient-reported outcomes at appropriate intervals. Confirm that care remains aligned with the patient’s goals, values, and expectations.
  • Adjust treatment plan: Continuously realign the management plan based on evolving goals, treatment response, clinical findings, and professional judgment. Modify interventions, dosage, frequency, or focus as needed to support meaningful improvement.
  • Support self-management: Reinforce the patient’s understanding of home strategies, activity recommendations, and behavioural approaches. Encourage adherence and address barriers that may affect progress.
  • Recognize plateaus or change in status: Identify when the patient is improving, stable, or worsening. Reassess for contributing factors such as comorbidities, psychosocial influences, or new functional limitations.
  • Referral and co-management: Consider referral or co-management with an appropriate provider when there is limited or no significant improvement within an expected timeframe (for example 6 to 8 weeks), when new or concerning findings emerge, or when additional expertise is required to support optimal care.
  • Documentation: Record follow-up assessments, changes to the plan, patient feedback, reassessment of goals, and any referral or co-management decisions.
12. Criteria for Discharge
  • Discharge criteria: Establish clear criteria for concluding active care. These may include achieving the patient’s initial goals, demonstrating meaningful improvement in symptoms or function, reaching a plateau in progress, or transitioning to self-management as the primary approach. Consider patient preferences, functional demands, and clinical judgment when determining readiness for discharge.
  • Clinical reassessment: Prior to discharge, complete a focused reassessment to confirm stability of symptoms, functional status, and the patient’s confidence in managing their condition. Address any remaining concerns and ensure no new issues require further evaluation.
  • Post-discharge planning: Discuss ongoing self-management strategies, including activity recommendations, home exercises, behavioural or lifestyle modifications, and symptom monitoring. Provide guidance on when to return for follow-up, when to seek additional care, and what indicators should prompt medical evaluation.
  • Future care needs: Clarify options for episodic care, preventive visits, or re-engagement with the provider if symptoms recur or functional demands change. Encourage ongoing communication if new concerns arise.
  • Documentation: Record the rationale for discharge, the patient’s status at the time of discharge, self-management recommendations provided, and the agreed-upon follow-up plan

References

  1. Nicholas, M., Vlaeyen, J. W. S., Rief, W., Barke, A., Aziz, Q., Benoliel, R., Cohen, M., Evers, S., Giamberardino, M. A., Goebel, A., Korwisi, B., Perrot, S., Svensson, P., Wang, S. J., Treede, R. D., & IASP Taskforce for the Classification of Chronic Pain (2019). The IASP classification of chronic pain for ICD-11: chronic primary pain. Pain, 160(1), 28–37.
  2. Perrot, S., Cohen, M., Barke, A., Korwisi, B., Rief, W., Treede, R. D., & IASP Taskforce for the Classification of Chronic Pain (2019). The IASP classification of chronic pain for ICD-11: chronic secondary musculoskeletal pain. Pain, 160(1), 77–82. 
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