Central sensitization and persistent pain: what it is and what helps

What is central sensitization?

Central sensitization is a change in how the nervous system handles pain signals. The International Association for the Study of Pain defines it as the pain-carrying nerve cells of the central nervous system becoming more responsive to their normal or subthreshold input. Translated, the pain system starts reacting more strongly than the incoming signal would account for. Woolf, whose 2011 paper is the one most often cited for the mechanism, describes it as an amplification of neural signaling within the central nervous system that produces pain hypersensitivity.

In the UK, Australia and New Zealand you will usually see it written central sensitisation, with an s. It is the same thing, and so is the shorter phrase many services use with patients, persistent pain.

Two features of the amplification matter to you more than the biology. An injury can set it going and the amplification can then outlast the injury, which is why pain carries on after the tissue has healed. And once the system is turned up, the threshold falls, so stimuli that should not hurt can hurt. Woolf describes both the drop in threshold and a widening of the area involved, in which input from uninjured tissue begins to produce pain. That describes pain somebody has already examined, so an area that has never hurt before is still a new symptom and still goes on the warning list at the end of this page.

Does this mean the pain is not real?

No, and this is worth being blunt about, because it is the question most people arrive with. Woolf's own sentence is that this does not mean the pain is not real, only that it is not being driven by a damaging stimulus. An amplified signal is a real signal, and amplification happens in a real nervous system.

Nor does it mean nobody can find anything. Health New Zealand's persistent pain page says plainly that pain is not a signal of damage to the body, and that chronic pain often reflects a problem with the pain system itself rather than damage in one part of the body. Something has been found: it is in the system that carries and interprets the signal, not in the knee or the back, and no scan of a knee or a back looks at that. That is an account of the pain you have already had examined. It is not a reason to turn down a test for something new.

The place where this goes wrong is when "your pain is central" gets heard as "stop telling me about it". That is not what it means, and the rest of this page spends as much time on what still needs checking as on what helps.

What it feels like

Descriptions vary, and no two people give the same list. The patterns that come up most often in clinic are these.

Pain that spreads beyond where it started, so a problem that began in one knee now takes in the other leg or the lower back. That belongs on this list once somebody has examined the spread. The first time your pain takes in an area that has never hurt, it goes on the same day route at the end of this page instead. One kind of new area does not wait even that long, because one knee taking in the other leg is also how pressure on the nerves at the base of the spine can start: pain, numbness, tingling or weakness in both legs, numbness or altered feeling around your genitals or bottom, or new trouble peeing or controlling your bladder or bowels is on the emergency list at the end of this page.

Pain that is out of proportion to the thing that set it off, so a short walk costs two days in the places that already hurt. Light pressure that hurts, such as a waistband, a bra strap, a seatbelt or a bedsheet.

Then the ones people are slower to mention, because they sound unlikely. Weather, noise or bright light making the pain worse with nothing physical having changed. Pain that moves around, among the places that have hurt before. Mornings worse than the day before would predict.

Along with the pain, many people report poor sleep, heavy fatigue and trouble concentrating or finding words. Those symptoms are part of the pattern the nociplastic pain criteria describe, not a separate problem you have invented, and naming them to your clinician is useful, not a distraction. What belongs there is the long-standing version of each, so fatigue that is new or has sharply worsened is a different matter, and so is weight coming off without your meaning it to, and both of those go to your doctor. Trouble finding words that comes on suddenly, or speech that turns slurred or muddled, is not the slow fog described here at all, and it is on the emergency list at the end of this page along with the other signs of a stroke. Night pain is the other one people file here: pain in one area at night that is constant, that no rest or change of position eases, and that keeps getting worse belongs on the warning list rather than on this one.

Everything above describes the pain you already have, as it was when someone last examined it. A symptom that is new to you does not join this list by resembling it. That matters most for the spreading, because spreading and moving around are both on the list, so the first time your pain takes in an area that has never hurt before it is easy to file it here and say nothing. Pain in a new place is on the warning list at the end of this page, at the same day, or straight away if the new place is both legs or anything to do with your bladder or bowels. A spread somebody has already looked at is not news, but an area that is new is.

Sensitization, the "syndrome" label and the questionnaire are three different things

These three get used as though they were one, including by sources that should know better, and keeping them apart is the quickest way to understand where the argument in this field actually is.

The mechanism is the best supported of the three. That nociceptive pathways can become sensitized, with a lowered threshold and a widened field, is accepted. The IASP has a formal definition for it.

The label is not a diagnosis. You will see the phrase central sensitization syndrome used as though it were one, and it has no agreed definition and no place in the main diagnostic systems. The closest thing to a formal description is nociplastic pain, which the IASP defines as pain arising from altered nociception without clear evidence of tissue damage activating peripheral nociceptors, and without disease or a lesion of the sensory nervous system to explain it. Kosek and colleagues published clinical criteria and a grading system for it, and Fitzcharles and colleagues, writing about regional pain of this kind, describe the criteria as a mechanistic explanation rather than a new diagnostic category, and say they still require validation. The IASP also notes that nociplastic and nociceptive pain can be present in the same person, which matters: this is not a label that cancels out an arthritic knee or a torn tendon.

The questionnaire measures something, and what it measures is disputed. The Central Sensitization Inventory asks about a long list of symptoms and scores them out of 100.

Two meta-analyses have asked what the score actually tracks. Adams and colleagues pooled 66 studies with 13,284 people and found the inventory correlated strongly with psychological measures such as depression, anxiety, stress, catastrophizing, sleep and fear of movement, but weakly or not at all with laboratory measures of nociceptive sensitivity, including pain thresholds, temporal summation and conditioned pain modulation. Their conclusion was that the inventory tracks psychological hypervigilance more closely than it tracks any increase in how responsive the pain-carrying nerve cells are. A later meta-analysis by Neblett and colleagues, who work on the inventory itself, pooled 33 studies with 3,314 people and did find statistically significant correlations between inventory scores and all five sensory testing methods, strongest for pressure pain threshold. Both reviews are real, both are recent, and they disagree.

What that leaves you with is simple enough. A score is a summary of what you reported, useful for tracking change over a course of treatment. It is not a measurement of your nervous system, it is not a diagnosis, and a high score explains no new symptom.

Why the pain spread, and why ordinary things hurt

The two findings Woolf sets out explain most of what puzzles people. The first is a reduction in threshold, which is why a stimulus that normally would not hurt now does: the IASP calls that allodynia, and a waistband or a bedsheet is the everyday version of it. The second is a widening of the area the system responds to, so that signals from tissue that was never injured start to produce pain, which is why a problem that began in one place does not stay there. That accounts for a spread somebody has looked at. An area that has never hurt before is a new symptom whatever this section explains, and it goes on the warning list at the end of this page, at the same day, or straight away if it takes in both legs or anything to do with your bladder or bowels.

Both are described as properties of the system, not of the tissue. That is the reason a scan of the sore area can come back clean while the pain carries on, and the reason a repeat scan of the same area rarely settles anything about the pain you already have. A scan asked for because something has changed is a different question, and the answer to it is not on this page.

It is also why the usual advice to rest the painful part does so little here. There is nothing wrong with resting a flare. The trouble is that a system set to protect you reads less movement as more need for protection, and the circle gets smaller. All of that is about pain you have had for months. A part you have just injured, a joint that is hot and swollen, a joint or a part that has been operated on and is newly painful, or a leg you cannot put weight on after a fall is rested and reported rather than pushed through, and each of those is on the warning list at the end of this page.

What does the evidence actually support?

Honest answer, and it is not the answer the sites selling programs give. The mechanism is well described. The treatment evidence is modest and mostly short term.

For exercise and physical activity in chronic pain, the Cochrane overview by Geneen and colleagues found favorable effects on pain severity and physical function that were mostly small to moderate and not consistent across the reviews, with variable effects on psychological function and quality of life, and it rated the overall quality of the evidence as low. It also found that exercise has few adverse events, and that the adverse events reported were mostly increased soreness or muscle pain that subsided after a few weeks. Only a quarter of the included studies reported adverse events at all, so read that as a weak reassurance, not a strong one. What did get reported was soreness rather than injury, which is the useful part for a sensitized system.

For explaining pain, which is where our pain neuroscience education guide goes into clinical detail, Siddall and colleagues pooled five trials with 460 people and found education plus exercise beat exercise alone in the short term, with pain about 2 points lower on a 0 to 10 scale at low certainty, and the most confidence in the reduction in fear of movement. Only a couple of trials followed anyone beyond 12 weeks.

NICE's guideline on chronic pain in the UK (NG193) advises offering a supervised group exercise program for chronic primary pain, tailored to the person's needs, preferences and abilities, and asks clinicians to discuss openly that symptoms are likely to fluctuate and flare, that a reason for the pain, or for a flare, may not be identified, that the pain may not improve or may get worse and may need ongoing management, and that quality of life can improve even if the pain does not. Those four points are a fair summary of what to expect, and two of them are about the pain you already have: the same guideline tells clinicians to offer a reassessment when symptoms change, and to re-evaluate the diagnosis if the presentation changes, so neither "a reason may not be identified" nor "the pain may get worse" is a reason to stop asking. Pain that is worse than it was is one of the changes that earns a reassessment. It is not a course you are supposed to absorb quietly because a guideline listed it among the possibilities.

The same guideline is specific about the rest of the menu, which is worth knowing before somebody sells you part of it. It says to consider acceptance and commitment therapy or cognitive behavioral therapy for pain, given by a clinician trained in it. It says to consider a single course of acupuncture or dry needling, within limits on who gives it, where, and no more than 5 hours of clinician time. It says not to offer TENS, ultrasound or interferential therapy, because there is no evidence of benefit.

On medicines, it says not to start opioids, paracetamol (acetaminophen), anti-inflammatories, gabapentinoids or benzodiazepines for chronic primary pain, while asking clinicians who find someone already on one of them to review it together rather than simply stop it: where it helps at a safe dose with few side effects, the guideline supports agreeing a plan to carry on safely. It does consider one kind of medicine for this pain, an antidepressant, after a full discussion of the benefits and harms, which in 2021 was an off-label use. Never stop or change a prescribed medicine on your own. That conversation belongs with whoever prescribed it.

What the evidence does not support is any claim to switch sensitization off, retrain a brain in a weekend, or cure persistent pain with an app. Where you meet that promise, it is a sales pitch rather than a finding.

How exercise helps when movement is what hurts

The reason to exercise a sensitized system is not that the muscles are weak, although they often are by the time someone gets here. It is that graded, predictable movement is how you find out what your body will take, instead of being told.

Two practical points come out of the research. The first is about harm: what these trials reported was soreness that settled rather than injury, with the caveat that only a quarter of them reported adverse events at all (Geneen and colleagues, 2017).

The second is about pain during the exercise itself, and whether it has to be avoided. That has been compared head to head. Smith and colleagues pooled seven trials with 385 people in 2017 and found a small short-term advantage for protocols that allowed painful exercise. The update of that review, with 16 trials, found no difference in pain or disability at any time point, wide confidence intervals, every trial at high risk of bias and the certainty of the evidence very low to low (Tran and colleagues, 2025).

What holds across both is the authors' own conclusion: pain during exercise may not need to be avoided for things to improve. So an ache is permitted. It is not the thing to aim for, and on the updated evidence nothing says pushing into pain works better. The permission covers the familiar pain of the problem you are treating and stops there: a pain that is new, in a new place, or unlike your usual pain is not a flare to work through. It does not reach a joint or a part that has been operated on either, where what counts as an acceptable ache is your surgical team's to set and not this page's. It stops the session and goes for advice on the timing the warning list at the end of this page gives it. If your own physio has told you to keep an exercise pain-free, follow that, because on the updated evidence nothing is lost by it.

The third point comes from how to decide when to do more. A review of exercise progression in back pain suggests that where pain behaves in a nociplastic way, with little consistent relationship to load, progressing on a planned schedule in small preset increments may suit better than waiting for the pain to give permission (Tuninetti and colleagues, 2025). Their own version of that schedule comes with guardrails, and the guardrails matter as much as the schedule: hold the amount where it is, or step back to the last amount that settled, if a flare is out of proportion or drags on, or if the movement itself starts to fall apart, and judge the session by how you are 24 to 48 hours later rather than by how it felt at the time. The authors are explicit that all of this is their reasoning rather than a trial result, and that the evidence is not yet enough to set progression standards. Even so, it fits what goes wrong in clinic: people with sensitized pain who progress by feel tend to do far too much on the good days and nothing at all on the bad ones.

How to use this program

Pick the stage that matches what you can do on an average day rather than a good one. If you are unsure, start at stage 1, and move up only when the current stage has been manageable for a week or two without setting off a flare. A stage is not a test and there is nothing in it to pass, so starting at stage 1 after years of this is a fair reading of your own history rather than a step backwards.

Every exercise page gives a typical starting dose, and with sensitized pain the right starting number is usually the lowest one on the page, or less. One set instead of three is a legitimate program. Where an exercise page gives a bigger number than the stage it sits in, the stage wins, and that applies to how often as much as to how many: several of these pages suggest once a day, most days, or a set repeated two or three times a day, written for a reader without sensitized pain, while the stages here put the stage 1 movements at once a day and the strength work on 2 or 3 days a week with a day in between. Each stage says this again where its own numbers are, because the exercise page is the one you will have open when you decide. Your physio or physical therapist will set the numbers and the steps with you, and will change them as things settle.

Set the step size in advance, before you find out how good a day you are having. A minute or two more walking, or a couple more repetitions, every week or two is a common way physios plan it. Write the plan down, then follow the plan rather than the pain. Following the plan does not mean adding to it through a worsening week: if the next morning, or the one after it, is not back to your usual level, hold the amount where it is instead of taking the next step, and go back to the last amount that settled overnight if that keeps happening. The plan governs your familiar pain and nothing else, so a symptom that is new to you stops the session and goes for advice on the timing the warning list at the end of this page gives it.

If you have high blood pressure, breathe steadily through every repetition and never hold your breath.

If you have fallen in the past year, feel unsteady on your feet, or take medicines that make you dizzy, keep a hand on a kitchen counter or a sturdy chair for the whole of the standing exercises, practice only when someone else is at home, and ask your doctor or physio about a falls check. Dizziness while you are actually doing them is not something to hold the counter through: stop, sit down, and get medical advice the same day before you practice again, which is the timing the warning list at the end of this page gives it. The standing ones here are marching on the spot, the calf raises, the sit to stands, the step ups and the standing hip abduction. For the walking, which you cannot do holding a counter, stay on ground you know and in good light to begin with, and keep using a stick or a frame if you have one.

If you live alone, that rule still stands, so plan around it rather than ignoring it. Do the standing exercises at your physio appointments or in a physio-led class rather than by yourself, keep to the seated and supported work of stages 1 and 2 when you are on your own, and ask your physio which of the standing exercises you may do alone. Keep your phone in a pocket rather than in another room, so you can reach it from the floor, and ask about an alarm you wear.

If you have had a hip or knee replacement, get the go-ahead from your surgeon or physio before you try the sit to stand exercises, marching on the spot, the calf raises, the glute bridge, standing hip abduction, step ups and bird dog. Some operations limit this kind of work for the first months, so the timing depends on your surgery. Rising from a seat bends the hip past a right angle, a high knee lift does the same, and drawing the knee in toward the elbow in bird dog bends it well past one. Many surgeons set a limit on how far the hip may bend, so find out what yours is. After a hip or knee replacement, kneeling may not be comfortable yet either, so ask before you get down onto hands and knees for bird dog. Ask the same people how far you may walk and how fast before you start the walking in stage 2.

After a knee fracture or knee surgery of any kind, including a replacement, follow your surgeon's or physio's plan for the sit to stands, the step ups and the calf raises, and start them only when they have cleared you. A bridge needs the knee bent to about 90 degrees before you lift, so if you have been given a limit on how far the knee may bend, leave the glute bridge out and ask your surgeon or physio whether the bend it needs is allowed yet.

After surgery on your spine, follow the plan from your surgical team rather than anything on this page, and get their go-ahead before the seated pelvic tilt, the glute bridge and bird dog. Protocols after a fusion or a decompression often limit bending, lifting and twisting for weeks or months, and only the team that operated can say where you are in that.

Whatever the operation was, your surgeon's and your surgical team's instructions come before this page, and nothing here replaces the post-operative review they have arranged for you.

Three of these exercises load a healing breastbone: the wall push-ups and the seated row with band in stage 2, and bird dog in stage 3. After recent heart or chest surgery, get your surgeon's or surgical team's okay before all three, because leaning your weight into your hands and pressing back off the wall loads the healing breastbone and the front of the chest. Pulling against a band pulls out across it, and in bird dog, with one arm lifted, your whole upper body weight goes through the other hand and shears across it. Only the team that wired it can clear loaded pulling. If the breastbone clicks, grinds, shifts or feels as if it is moving while you do any of them, stop, and contact your surgical team the same day.

The wall push-ups and bird dog also put your body weight through your wrists and hands. After a broken wrist, hand or forearm, or surgery on any of them such as a tendon repair, start either one only when your doctor, surgeon, physio or hand therapist says the bone or repair is ready for this, and follow their plan for how much to do.

After shoulder surgery, including a rotator cuff repair, or after a shoulder fracture or dislocation, follow your surgeon's or physio's plan for the backward shoulder rolls, the wall push-ups and the seated row with band, and do only the movements and range they have cleared. Rows with a band usually wait until later in rehab, and pressing your weight into a wall loads a healing tendon repair, so the check comes before either rather than after. After neck surgery or a broken collarbone, check with your surgeon or physio before the shoulder rolls. After a broken or dislocated elbow, or elbow surgery such as a tendon repair, start the wall push-ups only when your surgeon or physio has cleared you.

If you are pregnant and past the first three months, check with your physio before exercising flat on your back. If you have nobody to ask, do the breathing and the body scan sitting upright or propped instead of flat, which works just as well, and leave the glute bridge until you can ask.

The exercise program

The exercises below carry their own stop signs and precautions. Open the line under an exercise and read them before you try it.

What to do this week, and on a flare day

Four things, and they are all small.

Pick your starting amount by asking what you could manage on your worst day this month and still repeat tomorrow. Start there even if the number looks absurd. The cost of starting too low is a slow start, and the cost of starting too high is a week lost.

Choose one thing to measure and a morning check. A one-line note each day of what you did and how the next two mornings went will tell you more about your own pattern in a month than any wearable, and two mornings rather than one is deliberate: 24 to 48 hours is the window the progression research uses, and plenty of people describe the cost of a session landing on the second day rather than the first. Pick a repeatable check, such as getting out of a chair or the first hundred steps of the day, and use the same one every time.

Write your flare plan now, while you are well. A flare plan is a smaller version of your program: the breathing, the body scan and one gentle movement. Write it out and keep it somewhere you will find it. The breathing and the body scan can be done lying down, and both work just as well sitting upright or propped, which is the version to use if lying flat on your back makes you more short of breath, or if you are pregnant past the first three months and have not asked your physio about lying flat. On a flare day the aim is to keep the number of sessions and cut the size of them, so that the habit survives the week.

Set your pain rule with the next two mornings in mind. Some ache during and after the exercises is usually acceptable if it is back to your usual level by the next morning, or the one after it, and is not climbing from week to week. The pain monitoring model guide sets out how physios put numbers on that, and for sensitized pain many of them start with a lower ceiling than the usual one: if yours has given you a tighter rule than this page, use hers, and if you have no physio to ask, take the lower ceiling as yours rather than the usual one, because the trial evidence says you give up nothing by it. The rule applies to the familiar pain of the problem you are treating and to nothing else. New pain, pain somewhere new, or anything on the warning list at the end of this page is not an acceptable ache, and it is not a flare. Nor does it apply to a joint or a part that has been operated on, where what counts as an acceptable ache is your surgical team's to set and not this page's.

Sleep, pacing and the things that turn the volume up

Sleep is worth more attention than it usually gets. Finan and colleagues reviewed the sleep and pain research and reported that in studies tracking people over short intervals, poor sleep was a stronger and more reliable predictor of next-day pain than pain was of that night's sleep. The direction of that is not settled, and they say so. It is still a reason to treat sleep as part of the treatment rather than as a symptom to put up with, and to raise it at your next appointment, because a sensitized system that is short of sleep is harder to settle.

Pacing is the other half. The pattern that costs people the most is the one everybody recognizes once it is named: a good day gets filled, and the next three are gone. Pacing means finding the amount you can manage on a bad day, doing roughly that on good days too, and increasing it in steps you decided in advance. It is dull by design.

Stress, a busy week and a bad night all turn the volume up, and NICE asks clinicians to explore how parts of life such as sleep and stressful events affect chronic pain. Knowing that is useful for planning around your own pattern. It is not a reason to attribute a new symptom to a bad week. A hard week can raise the pain you already have. It does not produce a new pain in a new place, new weakness, a fever or weight you did not mean to lose.

Can central sensitization be reversed?

The mechanism is reversible in principle. Woolf's description is of a prolonged but reversible increase in excitability, which is why clinicians talk about calming a sensitive system instead of fixing a broken part.

In practice, be careful with the word cure. The exercise evidence gives small to moderate, inconsistent gains in pain and function at low quality (Geneen and colleagues, 2017), and the education evidence gives short-term gains with little long-term data (Siddall and colleagues, 2022). The honest version is that most people can expect to do more than they do now, with less fear and fewer lost weeks, while still having some pain. NICE makes the same point from the clinical side, asking clinicians to be open that pain may not improve and that quality of life can improve even if it does not. What the same guideline does not do is treat that as the end of the matter, because it also asks for a reassessment when symptoms change.

Judged by what you can do, that is a result worth working for. Judged only by the pain score, it will feel like failure in week three, which is why the things worth writing down are the recovery time after a busy day, the gap between flares, and the number of days you managed the program. Keep noting the pain score as well, for its direction rather than its height. A level that climbs steadily week after week, instead of going up and down, is on the warning list at the end of this page, and it earns an appointment rather than more patience.

What still needs checking

This is the half of the page nobody else writes, and it exists because the explanation on this page is itself a reason some people stop reporting things.

Start with what the label covers. Sensitization is an explanation for pain that has already been examined. It says nothing about a symptom that has appeared since. Nothing on this page, and nothing your clinician said, means that the next new thing is also the nervous system.

A normal scan is not a permanent pass either. It described one area at one moment, and most of what matters on the warning list at the end of this page would not show on it anyway. If something has changed since you were last assessed, the question is not whether your old scan was clear.

If one of the painful parts has been operated on, that part has its own list of things that can go wrong, and this page explains none of them. A replacement can loosen, wear or become infected years after it went in. A repair or a reconstruction can come apart. The bone around an implant can crack in a fall you walked away from, and OrthoInfo says those fractures can happen at any point after the operation and that pain, swelling and not being able to put weight through the leg are the usual symptoms. Every one of those starts as pain, and pain is the thing this page has just told you not to read as damage.

So the rule for an operated part is narrower than the rule for the rest of you. New pain there, pain that had settled and has come back, pain building month by month, or a movement you could do before and suddenly cannot, goes to your surgical team rather than into your flare plan, each on the timing the warning list at the end of this page gives it. A normal temperature is not an all clear either: OrthoInfo's page on infection after a joint replacement says fever is no longer considered a sign of an infection after a joint replacement, and that the signs can be as little as mild redness and swelling. Nobody has applied this page's explanation to your implant, and nothing here was written with it in mind.

The hardest exit to close is the one built out of being disbelieved. Plenty of people reading this have been dismissed before and expect to be again, and deciding not to bother is a reasonable response to that history. It is also the thing most likely to cost you. The label is a reason to be re-examined when something changes, not a reason to be turned away, and the sentence that works at the desk is a plain one: this is different from my usual pain, it started on this date, and this is what has changed.

NICE tells clinicians to offer a reassessment if a person turns up with a change in symptoms, including a flare, and when that happens to review the plan and to consider investigating and managing any new symptoms, so you are asking for something the guideline already expects. It also tells them to recognize that a first diagnosis of chronic primary pain can change with time, and to re-evaluate it if the presentation changes. Nothing in it treats the label as final.

Red flags are not a perfect filter, and the people who wrote the main framework on them say so: Finucane and colleagues record that good evidence for the diagnostic accuracy of most red flags is absent. The point of the list at the end of this page is not that it catches everything. It is that none of it is explained by a sensitive nervous system.

Reporting a change is not the same as asking for a cure. It is how the small number of things that need treating actually get found, and most of them are easier to treat early, so the reason to go is the same whether or not anyone can do much about your usual pain.

So, the short version. A flare of your familiar pain settles over days and is managed with your flare plan. A new symptom gets examined. If you are not sure which one you have, that uncertainty is itself the reason to ask.

Persistent pain services in Australia and New Zealand

If you are in Australia or New Zealand, the phrase to use with your clinician is persistent pain, because it is what the services are called.

In Australia, healthdirect says a doctor can refer you to a pain management program, run at a pain clinic, and that most major public hospitals have one. In New Zealand, Health New Zealand says that if your pain is complex your healthcare provider may refer you to pain management services. In both countries the usual way in is a referral rather than booking yourself in, so the appointment to make is with your GP or physio, with a request for referral as the thing you are asking for. Healthdirect adds that these programs run privately in Australia as well as in public hospitals.

In the USA, Canada and the UK the same kind of service usually goes by another name, such as a pain clinic, a pain management program or a pain rehabilitation program. Your doctor or physical therapist can tell you what runs locally and what getting in takes, and it is a fair question to ask at an ordinary appointment. What is worth knowing before you ask is the shape of these programs: they treat with exercise, education and pacing taught over a course of weeks, rather than with a procedure, which is also why they are usually run as a group.

When to see a physio or doctor

See a physio if every attempt at exercise sets off a flare, if you do not know where to start, or if pain is stopping you doing everyday things. A program that gets adjusted by someone who can see you works better than a program you abandon in week two, and NICE recommends supervised group exercise for chronic primary pain, so it is worth asking whether a physio-led class or a pain program runs near you.

See your doctor if your pain has changed, if your mood is low or you are struggling to cope, or if sleep has become the main problem. Low mood and anxiety are common alongside persistent pain and are treatable in their own right. Common is not a reason to wait: thoughts of suicide or of harming yourself are on the warning list below, and they need help the same day.

Anything on the warning list below has its own timing, from an emergency call to an appointment in a few days. Pain in one place at night that nothing eases, a new pain after a fall, and anything with weakness, numbness, fever or unplanned weight loss are the ones people most often sit on, and they are the ones not to sit on. If night pain is your main problem and you want to think it through first, our page on knee pain at night works through what makes night pain ordinary and what makes it worth a call, and the same reasoning applies to other joints.

For physiotherapists

Three points for anyone using this page with a patient.

Separate the mechanism from the label and the questionnaire out loud, because patients arrive with all three merged. The honest account of the Central Sensitization Inventory, disagreement included, lands better than a score presented as a result, and the two meta-analyses in the references take opposite views of what the instrument measures.

Where irritability is high and load and pain are poorly related, consider time-contingent progression in small preset increments. That is what Tuninetti and colleagues propose, and they label it as reasoning rather than as a trial finding.

Screen before you reassure, every time. The explanation on this page lowers the threshold at which a patient decides a new symptom is not worth mentioning, which makes the reassessment conversation part of the treatment rather than an afterthought. Our red flags guide covers the screening side, and the pain neuroscience education guide covers delivery, including why reassurance given before a screen is the wrong way round.

Common questions

References

1. International Association for the Study of Pain. IASP terminology: central sensitization, nociplastic pain, hyperalgesia, allodynia. https://www.iasp-pain.org/resources/terminology/
2. Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2-S15. doi:10.1016/j.pain.2010.09.030 Full text: https://pmc.ncbi.nlm.nih.gov/articles/PMC3268359/
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Written and checked by the PocketPhysio editorial team. Last updated 2026-11-02.

This page is general education, not a diagnosis or a personal treatment plan. See a physiotherapist or doctor for advice about your own situation.