Chronic pain

What chronic pain is

The International Association for the Study of Pain defines chronic pain as pain that lasts longer than 3 months or recurs. Since ICD-11, there have been separate diagnoses for it. In fibromyalgia or nonspecific back pain, the pain itself is considered the disease; in other forms it is the consequence of an underlying condition such as osteoarthritis or nerve damage.

The problem is common in any case. In a representative German survey from 2012 with 2,515 participants, 32.9 percent reported chronic pain. Considerably fewer, 5.4 percent, were physically and socially impaired by it, and 2.3 percent were additionally psychologically distressed. Pain and suffering from pain are therefore not the same thing, and that is precisely where treatment comes in.

How multimodal therapy works

The idea behind it: long-lasting pain is not only produced in the back or the joint, but is also amplified in the nervous system. Guarding, fear of movement, poor sleep and stress reinforce one another. A single measure rarely stands a chance against this cycle.

Multimodal therefore means: exercise and training therapy, psychological methods such as cognitive behavioural therapy, relaxation techniques, education about pain mechanisms and, where necessary, medication. What matters is that a team from several disciplines sets shared goals and coordinates regularly. The goal is often not freedom from pain, but more function and quality of life despite residual pain.

How to recognise a reputable programme

It starts with a thorough assessment of whether a treatable cause lies behind the pain. This is followed by a written plan with measurable goals, active elements that can be continued at home, and psychological co-treatment that is not meant as an insinuation that the pain is imaginary. You should be sceptical of a programme that consists mainly of passive device-based treatments, promises a quick cure or sells large packages up front.

What the studies show

Multidisciplinary rehabilitation, Cochrane analysis 2015

Kamper and colleagues evaluated 41 randomized trials with 6,858 people who had had low back pain for more than a year on average and had often already been treated without success. Compared with usual care, pain decreased by the equivalent of 0.5 points on a 10-point scale, with moderate quality of evidence. Compared with purely physical treatment, the effects were larger, but the studies were very heterogeneous.

Exercise therapy, Cochrane analysis 2021

Hayden and colleagues pooled 249 studies. Compared with no treatment, usual care or placebo, pain decreased by 15.2 points on a scale from 0 to 100. The authors had defined 15 points in advance as clinically relevant, so the effect reaches this threshold. For function, it remained below it.

Psychological therapies, Cochrane analysis 2020

Williams and colleagues analysed 75 studies with 9,401 participants. Cognitive behavioural therapy reduced pain, disability and psychological distress to a small extent compared with usual care, and the effects lasted until follow-up. Against active comparison treatments, they were very small.

Where the data stop

On average, the effects are modest. Half a point on a 10-point scale is a lot for some and barely noticeable for others, and it is hard to say in advance who will respond particularly well to a programme. In addition, almost all the large data sets come from studies on back pain; for migraine, joint pain or nerve pain the situation is thinner.

For device-based add-on procedures: TENS reduces pain during and immediately after use, as a 2022 meta-analysis of 381 studies shows. For a lasting benefit in chronic pain, however, a 2019 Cochrane overview rates the evidence as very low throughout, and whether less pain medication is needed could not be evaluated. The former German National Disease Management Guideline on low back pain advised against TENS for chronic low back pain and saw heat only as part of self-management alongside active measures. Combinations of electrical stimulation, infrared, hyperthermia and HRV measurement as a fixed package have not been tested in controlled studies.

Status, approval and legal

In Germany, interdisciplinary multimodal pain therapy is covered by statutory health insurance, usually as an inpatient service or in a day clinic. It lasts at least 7 treatment days; 1 to 4 weeks is usual. Required are an assessment by at least two disciplines, one of them psychological or psychosomatic, at least three active methods such as psychotherapy, physiotherapy or training therapy, and regular team meetings. The number of day clinics rose from 39 in 2013 to 100 in 2025. Whether the requirements are met is checked by the Medical Service at the health insurer’s request. Device-based treatments outside such a programme are usually paid out of pocket.

Safety

The basic components are low-risk. With exercise therapy, side effects are usually mild, such as muscle soreness; with TENS they were rarely reported and mostly mild. More important is what happens beforehand: new, severe or nocturnal pain, fever, weight loss, paralysis or numbness should first be assessed by a doctor before being treated as chronic pain. Painkillers, especially opioids, should be used in chronic pain only for a limited time and with a plan.

Sources

• Treede RD et al., Pain 2019 — IASP classification of chronic pain for ICD-11
• Häuser W et al., Schmerz 2013 — prevalence of chronic pain in Germany
• Kamper SJ et al., BMJ 2015 — multidisciplinary biopsychosocial rehabilitation for chronic low back pain, Cochrane analysis
• Hayden JA et al., Cochrane Database Syst Rev 2021 — exercise therapy for chronic low back pain
• Williams ACC et al., Cochrane Database Syst Rev 2020 — psychological therapies for chronic pain
• Macfarlane GJ et al., Ann Rheum Dis 2017 — EULAR recommendations on fibromyalgia
• Gibson W et al., Cochrane Database Syst Rev 2019 — TENS for chronic pain, overview of Cochrane reviews
• Johnson MI et al., BMJ Open 2022 — TENS for acute and chronic pain, meta-analysis
• Sabatowski R et al., Schmerz 2026 — interdisciplinary multimodal pain therapy in Germany
• OPS 8-918 interdisciplinary multimodal pain therapy, minimum criteria