Pain management in rehabilitation: A call for integrated, patient-centred approaches

Abu Talha Bin Fokhrul is a specialty doctor in rehabilitation medicine in Northamptonshire

Pain is a prevalent concern in rehabilitation medicine and a major determinant of a patient’s functional outcome. Yet, in everyday clinical practice, pain often receives inadequate attention compared to the overt functional and physical goals of rehabilitation. This imbalance is counterproductive as unmanaged or poorly managed pain can hinder engagement in therapy, exacerbate psychological distress and ultimately delay recovery.^1,2

Understanding pain as a biopsychosocial phenomenon

Modern pain science emphasises the biopsychosocial model, recognising that pain is not merely a nociceptive signal but a complex experience influenced by physical, psychological and social factors.³ NICE Clinical Knowledge Summaries (CKS) on chronic pain underscore the importance of considering co-morbid anxiety, depression and psychosocial stressors when assessing and managing pain.⁴

In real-world rehabilitation settings, patients often present with a history of chronic musculoskeletal pain, post-stroke central pain or complex regional pain syndromes, each compounded by emotional and social elements. For example, a patient recovering from a spinal cord injury may experience neuropathic pain, social withdrawal and anxiety about their future independence. Addressing only the physical symptoms without recognising these intersecting factors leads to suboptimal outcomes.³

A shift away from opioid-centric approaches

Both NICE NG193 (“Chronic pain [primary and secondary] in over 16s”) and NHS England guidelines have decisively moved away from opioid-centric approaches, especially for non-cancer chronic pain.^5,6 These guidelines cite limited long-term efficacy of opioids and significant risks including dependence, overdose and tolerance.⁶

In rehabilitation settings, patients frequently arrive on high-dose opioids, prescribed in primary care with diminishing benefit and mounting side effects such as sedation, cognitive impairment and constipation.⁶ Imagine a patient in his early 60s* with post-stroke shoulder pain and longstanding back pain who has been taking oxycodone and pregabalin for many years. After a multidisciplinary medication review, he is weaned off opioids and engaged in a tailored program combining physiotherapy, cognitive-behavioural strategies and structured pain education. Over weeks, he reports better mood, improved sleep and increased engagement in therapy—clear gains not achieved during the months he has relied on medication alone.*

The role of non-pharmacological interventions

NICE and NHS guidelines now prioritize non-pharmacological approaches for pain management.^5,6 These include:

• Cognitive Behavioral Therapy (CBT): Helps patients reframe their relationship with pain, reduce catastrophizing thoughts and build adaptive coping mechanisms.
• Graded Physical Activity: Regular movement tailored to the individual, progressively increasing intensity without provoking flares.
• Education and Self-Management: Teaching patients about pain physiology (e.g. neuroplasticity, central sensitization) to reduce fear and increase self-efficacy.^3,4

Realistically, the implementation of these approaches requires time and structure which can be challenging in busy rehabilitation units. However, embedding them into ward routines is not only feasible but impactful. For instance, delivering weekly “pain education groups” facilitated by a psychologist and physiotherapist has proven effective in my ward in demystifying pain for patients and caregivers.

Integrating pain management into rehabilitation: What this looks like

Pain should not be treated as an adjunct issue but woven into the fabric of rehabilitation planning.

Key elements include:

• Multidisciplinary Teamworking: Integration of physiotherapists, occupational therapists, psychologists, pharmacists, nurses and physicians to form a shared pain management framework. For example, during multidisciplinary meetings in our unit, pain is a standing agenda item, ensuring it is proactively addressed rather than retrospectively managed.²
• Individualized Care Plans: A standardized approach does not work for pain. Each patient’s experience is unique. Consider a young patient recovering from traumatic brain injury who has low pain tolerance due to sensory hypersensitivity and PTSD. Their plan would differ significantly from that of an elderly patient with osteoarthritis and cognitive impairment.
• Early Assessment: Where I work we have introduced a structured pain assessment within 48 hours of admission using validated tools (e.g. the Brief Pain Inventory, VAS/NRS and the PainDETECT questionnaire for neuropathic features). This has improved our ability to stratify risk and tailor interventions.^1,4

Challenges in Real-Life Implementation

There are barriers: lack of staff training in modern pain principles, time constraints and legacy practices that favour medication over conversation.³ However, change is achievable with institutional support. In many trusts, introducing trained ‘pain champions’—senior therapists with additional training in pain neuroscience—has shown promise in improving pain documentation, promoting interdisciplinary coordination and reducing over-reliance on opioids.⁶ Such models could be adapted locally to enhance an integrated approach.

Another common issue is the fragmentation between acute and rehabilitation services. Patients often arrive at our unit with pain poorly controlled and no coherent strategy. Greater coordination is needed, starting from discharge planning in acute care, ideally with shared care pathways.²

Conclusion

Clinical leadership and health policy must support a shift towards integrated pain management. NHS England’s Core20PLUS5 and Long Term Plan prioritize personalized care which includes comprehensive pain strategies ^[7,8]. Commissioners and service planners should mandate inclusion of pain management competencies in staff training and allocate funding for psychology and advanced practitioner roles in rehabilitation units.

Quality improvement audits across NHS rehabilitation services have consistently shown that structured documentation and staff training significantly improve pain management practices. For example, targeted interventions such as MDT teaching, revised templates and regular reminders can raise documented pain plan completion from under 50% to over 80% within a few months.^2,4

Effective pain management is not a luxury; it is fundamental to rehabilitation. The body cannot heal while in constant distress. When patients are heard, educated and empowered, they move from being passive recipients of care to active agents in their recovery.

Rehabilitation teams must embrace the reality that pain is not just a symptom to be medicated but a signal that requires understanding, partnership and strategic intervention. With clear policies, interprofessional collaboration and patient involvement, we can transform pain management into an enabler of rehabilitation rather than a barrier.

*Author’s note: This is a fictional scenario based on the author’s clinical experience and does not refer to any specific individual living or deceased.

Deputy Editor’s note– see also

• https://bjgplife.com/fibromyalgia-and-chronic-pain-are-we-asking-about-psychological-trauma-or-traumatic-events/
• https://bjgplife.com/fibromyalgia-and-chronic-pain-are-we-asking-about-psychological-trauma-or-traumatic-events/

References

1. NICE Clinical Knowledge Summaries: Chronic Pain. https://cks.nice.org.uk/topics/chronic-pain/ [accessed 26/6/2025]
2. British Pain Society (2013). Pain Management Programmes for adults: An evidence-based review. https://www.britishpainsociety.org [accessed 26/6/2025]
3. McCracken LM, Morley S. The psychological flexibility model: a basis for integration and progress in psychological approaches to chronic pain management. J Pain. 2014;15(3):221–34.
4. NICE Guideline [NG193] (2021). Chronic pain in over 16s: assessment and management. https://www.nice.org.uk/guidance/g193 [accessed 26/6/2025]
5. Faculty of Pain Medicine, RCoA. Opioids Aware. https://www.fpm.ac.uk/opioids-aware [accessed 26/6/2025]
6. NHS England. Core20PLUS5: An approach to reducing health inequalities. https://www.england.nhs.uk/about/equality/equality-hub/core20plus5/ [accessed 26/6/2025]
7. NHS England Long Term Plan. https://www.longtermplan.nhs.uk [accessed 26/6/2025]
8. International Association for the Study of Pain (IASP). Pain terms and definitions. https://www.iasp-pain.org [accessed 26/6/2025]

Featured image by Adrian Swancar on Unsplash