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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 is a knowledge translation resource of the Canadian Chiropractic Association. Its care pathways help chiropractors and other clinicians organize conservative care for musculoskeletal conditions. Each pathway outlines the main steps of the clinical encounter and supports decisions about assessment, care, monitoring, referral, co-management, and discharge. The pathways provide a structured approach to care, not a fixed prescription.

Development

Pathways draw on relevant clinical practice guidelines, systematic reviews, peer-reviewed literature, and safety or professional sources. These sources inform, but do not determine, pathway content. Their findings reflect the questions, populations, outcomes, methods, and judgments used and may not apply to every person. Condition-specific sources are identified by author or organization and year, with full citations in one reference list at the end of the pathway.

Principles of Care

Musculoskeletal conditions are shaped by physical, psychological, social, cultural, and environmental factors, so no single approach fits everyone. Good care is ethical, evidence-informed, person-centred, culturally responsive, and tailored to the patient’s goals, preferences, circumstances, and response. Shared decision-making and informed consent guide care. Education, active rehabilitation, and self-management support recovery, functioning, participation, and long-term health. Regular reassessment shows whether the plan is helping and when to continue, adapt, stop, refer, co-manage, or discharge.populations.

Pathway Flow at a Glance

The pathway follows a recurring clinical cycle: understand the person and their goals; screen for safety and referral needs; develop a working clinical profile; agree on a plan and relevant outcomes; provide care; reassess response and safety; and continue, adapt, stop, refer, co-manage, or discharge as appropriate.

Disclaimer

CCG care pathways support professional clinical judgment; they do not replace it or the advice of a qualified provider. They are not prescriptive, authoritative, or regulatory and are not intended for diagnosis or billing. Clinicians remain responsible for practicing within their competence and scope, meeting applicable legal and regulatory requirements, obtaining informed consent, recognizing emergencies, and arranging referral or co-management when needed.

Chronic Primary Musculoskeletal Pain Care Pathway

1. Record Keeping

Accurate, timely, and sufficiently detailed documentation supports safe, high-quality care. The record should reflect clinically relevant patient interactions, clinical reasoning, decisions, care provided, and progress over time. Documentation should meet the legal, regulatory, privacy, retention, and organizational requirements that apply where the clinician practices. A structured format, such as SOAP, may support consistency, clarity, and continuity and can be adapted to the encounter and practice setting.

Subjective: Record the patient’s concerns, symptoms, functioning and participation, goals, preferences, relevant history and context, and response or adverse effects from previous care.

Objective: Record relevant examination findings, outcome measures, diagnostic test results when available, and clinically important changes.

Assessment: Record the clinical interpretation of findings, working diagnosis or clinical profile, differential and safety considerations, relevant risk factors or modifiers, and the patient’s progress or response.

Plan: Record care provided or proposed, education and self-management, consent and patient decisions, changes to the plan, agreed outcomes and reassessment point, referrals or co-management, follow-up, and discharge planning.

Document at the time of the encounter or as soon as practicable. Corrections and additions should preserve the integrity of the record. Clear records support patient safety, shared decision-making, communication, continuity, and accountability.

2. Informed Consent
  • Definition: A continuing process in which a capable patient, or an authorized substitute decision-maker when required, voluntarily agrees to a proposed examination or intervention after receiving and understanding the information needed to make an informed choice.
  • Key Aspects:
    • Prior to interaction: Obtain consent before beginning an examination, procedure, or treatment, except where applicable law permits otherwise. Explain what is proposed and why. Revisit consent when the plan or material information changes.
    • Voluntarily and specific: must be voluntary and specific to the proposed care. Consider the patient’s capacity for the decision at the time it is required and follow applicable requirements for substitute decision-making when the patient lacks capacity. The patient may ask questions, refuse, place limits on, or withdraw consent.
    • Transparent process: Use honest, plain, and accessible communication. Offer interpretation or other communication support when needed and consider language, culture, health literacy, disability, and prior trauma. Written or digital information may support but does not replace discussion.
    • Patient understanding and agreement:
      • Diagnosis/prognosis: Explain relevant findings, the clinical impression or working diagnosis, important uncertainty, and the expected course in understandable language.
      • Treatment plan: Discuss the nature and purpose of proposed care, expected benefits, material risks and side effects, burdens, reasonable alternatives, the option of no intervention, and the likely consequences of accepting or declining.
      • Questions: Invite questions, explore goals and preferences, allow appropriate time for a decision, and confirm understanding, for example using teach-back.
    • Documentation: Record the consent discussion and decision, including material information provided, questions, capacity or substitute decision-maker where relevant, consent, refusal, limits or withdrawal, and any need to revisit consent. Follow documentation requirements applicable to the jurisdiction and practice setting.
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

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

  • Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
  • Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
  • Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

  • Suicide or self-harm thoughts: thoughts without immediate danger.
  • Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
  • Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

  • Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
  • Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
  • Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
  • Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

6. Yellow Flags: Factors that May Affect Recovery or Participation

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

  • Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
  • Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
  • Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
  • Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
  • Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
  • Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

  • Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
  • Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
  • Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
  • Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
  • Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.
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

Ongoing follow-up is a shared review of whether the plan remains safe, useful, acceptable and aligned with the patient’s goals. The timing of review should reflect symptoms, risk, the care being tried, goals and access rather than a fixed visit schedule.

  • Review symptoms and safety: ask what has changed in symptoms, functioning and daily activities; review adverse effects; and check for new or worsening Red Flags and relevant Orange or Yellow Flag concerns. Arrange earlier or urgent assessment when the findings require it.
  • Review outcomes: repeat the small set chosen at baseline and use the same measures when possible. These may include the Patient-Specific Functional Scale, WHODAS 2.0, quality of life using the patient’s own rating or a measure such as WHOQOL-BREF, symptom impact, participation and the patient’s own assessment of change. Interpret measures with the patient and alongside what has changed in daily life rather than relying on a score alone.
  • Review goals, preferences and consent: ask whether care remains acceptable, feasible and worthwhile; revisit goals and priorities; and confirm consent when the plan or circumstances change.
  • Adapt care: continue what is useful and acceptable, and change, pause or stop what is not. If progress is not sufficient from the patient’s perspective, review the clinical impression, the fit and amount of care, barriers to participation, other health or social factors and whether other expertise is needed.
  • Support self-management and participation: review the strategies the patient is using, including physical activity or exercise, symptom management, pacing and participation in work, school, caregiving, recreation or community life. Ask what is helping and which barriers can be addressed.
  • Referral and co-management: arrange emergency assessment for Red Flags requiring urgent care. Consider referral or co-management when findings or needs are beyond the clinician’s role, the patient’s condition is worsening, progress remains insufficient after the plan has been reviewed, or the patient requests another opinion.
  • Plan the next step: agree whether to continue, change the interval between visits, move toward more self-directed care, or apply the Criteria for Discharge section.
12. Criteria for Discharge

Discharge is a shared decision about ending or transferring a course of care. It does not require complete symptom resolution, a normal outcome score or a fixed number of visits.

  • When discharge may be appropriate: consider discharge when the patient’s goals have been met to a degree they consider satisfactory; the patient feels able to manage with less or no clinician involvement; the patient chooses to end care; continued care is not providing enough benefit to justify its burden, cost or time; or care is being transferred to another provider.
  • Reassess before discharge: review symptoms, functioning, participation, selected outcomes, goals, adverse effects, confidence and preferences. Check for new or worsening Red Flags and any Orange or Yellow Flag concerns that still require action. If the condition is worsening or a safety concern remains, arrange the required assessment or referral rather than routine discharge.
  • When progress has slowed: review the clinical impression, response to care, goals, barriers and access, other health or social factors, and other reasonable options before deciding with the patient whether to continue, change or end care.
  • Plan after discharge: agree on self-management, physical activity or exercise, symptom management, pacing and participation in work, school, caregiving, recreation or community life. Explain which changes should prompt earlier or urgent assessment and when and where to seek care.
  • Future access to care: explain how the patient can return if symptoms recur, functioning declines, or goals or demands change. Any planned future review or supportive care should have an agreed purpose, expected benefit and review point.
  • Referral or transfer: explain the reason, share a relevant summary with the patient’s consent, and clarify who will address outstanding concerns when possible. Avoid an unintended gap in care when safety or ongoing needs remain.
  • If the patient ends care or does not return: respect the patient’s right to stop. Record what is known and unknown about the outcome, advice or referral offered, attempts to communicate when clinically warranted, and any unresolved safety concern. Follow applicable record keeping and communication requirements.
  • Documentation: record the reason care ended, the patient’s status and selected outcomes, goals and preferences, unresolved concerns, advice and self-management plan, referral or transfer details, and how to seek care again if needed.

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. 
  3. Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. London: National Institute for Health and Care Excellence (NICE); 2021 Apr 7. (NICE Guideline, No. 193.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK569960/
  4. Fitzcharles, M. A., Cohen, S. P., Clauw, D. J., Littlejohn, G., Usui, C., & Häuser, W. (2021). Nociplastic pain: towards an understanding of prevalent pain conditions. Lancet (London, England), 397(10289), 2098–2110.
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  6. Kaplan, C. M., Kelleher, E., Irani, A., Schrepf, A., Clauw, D. J., & Harte, S. E. (2024). Deciphering nociplastic pain: clinical features, risk factors and potential mechanisms. Nature reviews. Neurology, 20(6), 347–363
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  9. Bussières, A., Hancock, M. J., Elklit, A., Ferreira, M. L., Ferreira, P. H., Stone, L. S., Wideman, T. H., Boruff, J. T., Al Zoubi, F., Chaudhry, F., Tolentino, R., & Hartvigsen, J. (2023). Adverse childhood experience is associated with an increased risk of reporting chronic pain in adulthood: a stystematic review and meta-analysis. European journal of psychotraumatology, 14(2), 2284025. https://doi.org/10.1080/20008066.2023.2284025