Chronic pain biopsychosocial model: chronic pain (>3 months) involves complex interactions between nociceptive (peripheral tissue), nociplastic (altered central nervous system processing - central sensitization), and neuropathic mechanisms. Common conditions - chronic low back pain, fibromyalgia, complex regional pain syndrome (CRPS), chronic widespread pain, postsurgical pain, post-whiplash, chronic pelvic pain, neuropathic pain. Disability is shaped by - 1) biological factors (tissue, neuroplasticity, central sensitization, sleep, deconditioning); 2) psychological factors (catastrophizing, fear-avoidance, depression, anxiety, PTSD); 3) social factors (employment, family, healthcare interactions, compensation/litigation). Yellow flags (psychosocial risk factors) and red flags (serious pathology) are screened at intake.
Patient selection and program structure: indications - chronic non-cancer pain with significant functional disability after standard care, fear-avoidance behaviors, opioid dependence/misuse, multiple unsuccessful interventions, return-to-work failure. Contraindications - acute pathology requiring surgery/medical treatment, severe untreated psychiatric illness (active psychosis, severe suicidal ideation), active substance use disorder requiring detox, cognitive impairment limiting participation. Pre-program evaluation - physical examination, functional capacity evaluation, psychological assessment (BDI-II, PHQ-9, PCS, TSK, FABQ, PSEQ), pain measures (NRS, BPI, MPQ), substance use screen, medication review. Programs vary - intensive outpatient (4-6 hours/day, 3-5 days/week, 3-6 weeks, 60-150 hours total), inpatient/residential (2-4 weeks), interdisciplinary individual program.
Program components and outcomes: 1) Physical therapy - graded aerobic exercise, resistance training, flexibility, postural correction, motor control, graded exposure to feared movements; 2) Occupational therapy - activity pacing, energy conservation, ergonomics, return-to-work planning, work conditioning; 3) Psychology - CBT (cognitive restructuring, behavioral activation), ACT (acceptance, values-based action, defusion), mindfulness-based stress reduction (MBSR), pain neuroscience education (Explain Pain), graded exposure for kinesiophobia; 4) Medical management - rational pharmacotherapy, opioid weaning protocols (taper 10% per week), sleep hygiene, comorbidity treatment; 5) Vocational - employer liaison, work hardening, accommodations; 6) Family education and involvement; 7) Group therapy and peer support. Outcomes (Cochrane reviews) - moderate effect on pain reduction (SMD 0.3-0.5), large effect on disability (SMD 0.6-0.8), depression, return-to-work (40-70%), opioid reduction, healthcare utilization. Long-term benefits maintained at 12 months in majority.