The Real Causes of Chronic Pain

By: Juan Nieto

Much has changed in the paradigm of chronic pain in recent years. It seems that the message that “pain does not always mean that there is damaged tissue” is finally beginning to permeate and it no longer seems crazy to talk about contextual, environmental, psychological and social factors as the greatest predictors of chronic pain. 

We can say that the best way to manage and understand how to help a person who is in a situation of chronic or persistent low back pain is to try to understand how all the factors that influence the pain are interrelated. This is what is called the biopsychosocial model in the biomedical field. 

In this post we are going to discuss the fundamental aspects of each factor that influences this model, and how they relate to each other. 

Genetic Factors

It is important to keep in mind that isolated factors would not be the only ones that contribute to the development of chronic pain. As we have commented before, chronic pain development is generally multifactorial, and environmental, biological, psychological and social factors play an important role. 

That said, genetics can, in some cases, be a significant factor in the development of chronic pain. There is growing evidence that suggests that certain genetic variations may influence how people experience and process pain (Diatchenko, 2006). There are specific genes that may be associated with an increased risk of developing chronic pain. For example, some genetic variants have been identified in genes related to the function of neurotransmitters, such as serotonin and dopamine, that could affect the way pain signals are transmitted in the central nervous system (Nielsen, 2012). 

Additionally, genes involved in the inflammatory response may also play a role in chronic pain. Genetic variations in these genes can influence how the body handles inflammation and affect the pain response. Therefore, the interaction between genetic, environmental and psychosocial factors can determine whether a person is at increased risk of developing chronic pain and how they will respond to treatments (Nielsen, 2009). 

Pathoanatomic Factors  

Pathoanatomical factors may also significantly influence the development of chronic pain. These factors refer to pathologies or physical alterations that can contribute to the persistence or exacerbation of pain in the long term. It is important to note that, according to the available scientific evidence, only in 5%-15% of cases can a finding in a diagnostic image be directly related to the main cause of pain (Dillingham, 1995). 

For this reason, we cannot say that all pathologies of the locomotor system are susceptible to producing chronic pain; however, poor management of the acute phase of pain or the development of maladaptive beliefs or behaviors can favor the exacerbation of pain and the presence of painful symptoms beyond the normal healing period of the tissues. 

Some of the most frequent situations in which a trauma or illness is the cause of pain include: 

  • Injuries or trauma: An acute injury, such as a car accident or fall, can cause tissue damage and trigger an inflammatory response. In some cases, this can result in chronic pain due to the development of negative beliefs, poor management of the situation, persistent inflammation, or the formation of scar tissue. 
  • Degenerative diseases: Conditions such as osteoarthritis, degenerative disc diseases or rheumatic conditions such as rheumatoid arthritis can cause chronic pain. 
  • Structural factors: The presence of malformations or structural abnormalities in the body, such as spina bifida, can also be causes of chronic pain. 

Once again, pathoanatomical factors will influence the development and persistence of chronic pain, especially when they interact and feedback from other factors, such as genetic, psychological and social ones.  

Neurophysiological Factors  

Neurophysiological factors play a crucial role in chronic pain development. This refers to alterations in the nervous system that can contribute to the persistence and amplification of pain in the long term. 

This topic is immense, but as an introduction, the processes we point out below are the most common in the development of chronic pain: 

  1. Central sensitization: this is a process in which neural circuits in the central nervous system become more sensitive to painful stimuli. This may result in an increased pain response and amplification of the pain signal. 
  2. Neural plasticity: refers to the ability of the nervous system to change its structure and function in response to stimuli and experiences. In the case of chronic pain, neural plasticity can lead to long-lasting changes in the connectivity and activity of neural networks related to pain perception. 
  3. Dysregulation of pain modulation systems: The pain modulation system, which includes endogenous opioid systems and other pain inhibition mechanisms, may be altered in chronic pain. This can result in a decrease in the body’s ability to regulate and control pain, contributing to its persistence. 
  4. Changes in the transmission of pain signals: In chronic pain, there may be alterations in the transmission of pain signals along neural pathways. This may involve an increase in the excitability of sensory neurons, an increased release of pain-related neurotransmitters, and changes in the response of pain receptors in the peripheral and central nervous system. 

    Although we usually look for the explanation of pain in purely physical aspects, especially looking for the origin of pain in pathologies or changes in tissues, the reality is that psycho-social factors are those that generate a greater positive correlation with the persistence of pain. 

    Social and Contextual Factors   

    Some of these social or contextual factors are often quite unintuitive and often remain “invisible.” Below you can find three examples of situations that can lead to chronic pain and that are normally not considered by patients or health professionals: 

    1. Family and social relationships: Close relationships can have a significant impact on chronic pain. Good emotional support from family and friends can help manage pain and improve emotional well-being. On the other hand, if relationships are conflictive or lack support, this can increase stress and worsen pain. 
    2. Medical advice: When a doctor, as an authority figure and supposedly an expert on the subject, overemphasizes the possible negative side effects of a physical activity, this can generate insecurity, fear and anxiety in the patient. These negative expectations can have a real impact on the patient’s experience, causing symptoms or an aggravated perception of existing symptoms. Of course, this negative effect is not intentional on the part of the physician and likely arises from legitimate concern for patient safety. However, the way this information is communicated can influence the patient’s perception and response. 
    3. Emotional compensation: A person can maintain their chronic pain situation due to the emotional attention they receive from their close circle. This relates to the concept of “secondary gain,” and refers to the benefits or rewards that the person may receive because of their chronic pain situation. In some cases, the emotional attention and compassion received from family, friends or caregivers can create a sense of support and make the person feel heard, understood and emotionally cared for, which can be comforting and satisfying. There could be a situation where people find a sense of identity in their role as a “sick person” or “person with chronic pain.” This can create a dynamic in which chronic pain is perpetuated to maintain attention, care, and emotional connection with your immediate environment. 

    Psychological Factors  

    The interaction between the mind and the body is complex and influences the perception, intensity and duration of pain. Situations such as chronic stress, anxiety, depression and especially negative beliefs about pain can amplify the sensation of discomfort and make it difficult to resolve. 

    For example, the personality type of patients is a determining factor in the prognosis in a situation of chronic pain. We can subclassify two types of patients based on their attitude towards the disease: active copers or “confronters” and passive copers or “avoidants.” 

    Active copers tend to confront pain directly. They are more willing to recognize and confront it, typically seeking more active coping strategies such as seeking medical information, participating in therapies, or learning strategies to help them manage their pain. A proactive approach can help them feel more control over their pain and take steps to mitigate its impact. 

    There is other “overly active” copers who tend to ignore symptoms and refuse to modify their behaviors when pain occurs. We refer to patients who live their lives under the motto “no pain, no gain.” This type of personality tends to make symptoms chronic, not for psychological reasons, but rather by continuously excessively stressing tissues without allowing the necessary rest and recovery. 

    However, avoidant patients, also known as passive copers, tend to avoid making decisions necessary to manage their pain. Very often they stop doing activities that they think could trigger their pain and the only medical treatment that interests them is one that passively eliminates the symptoms. By avoiding actively facing pain and not making changes to their beliefs, habits, and behaviors, they are more likely to prolong their experience of pain and experience greater difficulty managing it. 

    There are other factors that we know are key in the development of chronic pain. The most studied due to their clinical relevance are the following: 

    • Kinesiophobia: the feeling of fear and avoidance of movement or physical activity due to the fear that it may cause pain or worsen an injury. 
    • Catastrophizing: a pessimistic mental state in which the worst is anticipated in relation to pain or injuries. People who experience catastrophizing may magnify pain, feel a lack of control, and believe that their injury is irreversible. 
    • Self-efficacy: the confidence that certain people have in their ability to successfully undertake a task or objective. It is a key factor in pain management, as it influences the perception of control and the adoption of effective strategies to cope with it. 
    • Hypervigilance: a state of excessive and constant alertness towards bodily sensations, especially pain. Hypervigilant people are more attentive and sensitive to pain signals, which can amplify the painful sensation. 

    Chronic pain is a complex health problem that involves an interaction of contextual, biological, psychological and social factors. Throughout this article, we have briefly presented some of these factors and how each of them can contribute to the development and maintenance of chronic pain. 


    We hope that, if you have come this far, you are more aware that psychological factors and emotions, thoughts and beliefs or behaviors can influence the intensity and perception of pain. Additionally, social factors, such as social support, family environment, and cultural experiences, can influence how chronic pain is experienced and managed. 

    It is important to recognize that chronic pain cannot be addressed alone but requires a multidisciplinary approach that considers all these interrelated factors. Health professionals and patients themselves must consider not only the biological and physical aspects of pain, but also the psychological and social factors that influence the patient’s experience. 

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    About the Author: 

    As a trained physiotherapist, Juan Nieto professionally identifies as a practitioner, student, and teacher of movement. His main goal is to help individuals regain their agency, alleviate their fears, and enjoy the freedom of movement in their lives. 

    He has founded and is involved in several companies related to movement and health. He is the founder of NEPO Movement Studio in Madrid, the creator of “Movimiento Desencadenado” podcast, the co-founder of, and the Spanish representative for Polestar Pilates. 

    Follow Juan on Instagram and read more about Polestar España 

    Watch Juan on the Pilates Hour here and stay tuned for more episodes 

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