Let’s be honest—chronic pain can be one of the trickiest conditions to navigate in rehab. Pain is subjective, complicated, and doesn’t always play by the rules. As a referrer, you’ve likely asked yourself at some point – Is this pain something we can treat through rehab, or is it a sign that something else needs to be investigated?
It’s a fair question. And an important one.
Let’s unpack how to tell the difference—and when it’s time to hit pause and dig a little deeper.
How the Nervous System Drives Chronic Pain
When someone is experiencing pain long after the injury ‘should have’ healed, or there’s no clear structural cause, the signs often point towards a sensitised nervous system. That’s when pain becomes less about the body, and more about the brain and nerves – it’s a problem with the nervous system’s processing of pain, rather than any physical tissue damage. Consider it similar to an over-sensitive alarm system, setting off a siren when there is no threat.
Pain science education and graded movement strategies are powerful tools—when the pain presentation is more about sensitivity than structural damage. A typical ‘chronic pain’ presentation includes the following indicators:
- Pain persists beyond expected tissue healing time (3 months is the general guide)
- Pain experienced is disproportionate to physical findings (e.g. imaging doesn’t match intensity)
- Pain is diffuse or moves around the body (not clearly linked to one joint or structure)
- Symptoms change based on context, stress, or environment
- Clients demonstrate high fear of movement (kinesiophobia) and avoidance behaviours
- Client history includes PTSD, depression, or anxiety
- Client experiences flare-ups with no identifiable injury
- No red flag symptoms (see below)
These clients can absolutely benefit from a structured, graded exercise program. When chronic pain is the likely driver, graded exposure, pacing strategies, and education become key tools for improving function and quality of life.
Sometimes, Pain Is a Warning Light
There are times when pain is more than just chronic—it’s a signal that something new or more serious is going on. In these cases, exercise isn’t the answer (yet). Medical review needs to happen first.
We watch closely for what we call red flags—symptoms that suggest something more sinister might be brewing. Consider further testing or specialist referral if they are experiencing:
- New or rapidly worsening pain
- Neurological signs – sudden or progressive numbness, tingling, muscle weakness, loss of bowel/bladder control
- Night pain that disrupts sleep and doesn’t settle with position changes
- Unexplained weight loss, fatigue, or fever
- History of cancer, autoimmune disease, or inflammatory arthritis
- Pain that does not respond at all to graduated movement or desensitisation
- Pain that’s worsening fast, or just doesn’t match the injury story
In these cases, pain may be persistent, but it does not behave like a chronic pain condition. It is unrelenting, progressive, and often disconnected from the patterns we expect in mechanical or sensitised pain.
When we see these, we don’t just power through—we call it out and let you know. Getting the right investigation early can be the difference between recovery and long-term disability.
Key Comparisons: Chronic Pain Pattern vs Red Flag Indicators
Here’s a summary of how to distinguish between typical chronic pain presentations and pain that may require further medical investigation.
| Feature | Chronic Pain | Red Flag Warning |
| Pain Duration | >12 weeks, often since initial injury | New, changing, or rapidly worsening |
| Pain Location | Diffuse or vague, may move around | Specific, sharp, or linked with other concerning symptoms |
| What Makes It Worse | Stress, fatigue, too much or too little movement | Nothing helps – pain is constant or increasing |
| Neurological Symptoms | Rare or mild (e.g. tingling) | Weakness, numbness, bowel/bladder issues |
| Night Pain | May happen, but eases with movement | Severe and unrelenting |
| Other Clues | Poor sleep, fatigue, low mood | Weight loss, fever, signs of infection or tumour |
| Response to Rehab | Improves with pacing and education | No improvement or worsening despite input |
What This Means for You as a Referrer
For those working in income protection, workers’ compensation, or motor accident schemes, this distinction is critical. If your client presents with a chronic pain pattern, they are likely an excellent candidate for exercise physiology—especially when the goal is functional improvement and a return to work.
But if the story doesn’t quite fit, don’t hesitate to pause and ask whether something more needs to be ruled out. As a referring provider, your ability to act early and refer on for medical investigation can save time, money, and potential harm.
Final Thoughts
Pain is real—always. The challenge is understanding why it’s happening and which system (tissue, nervous system, or both) is driving it.
As EPs, our role is to move people toward confidence, capacity, and clarity, and raise the flag when uncertainty arises.
Our shared goal is a return to life, and a return to work—and that starts with knowing the story is right. If you’re unsure about whether a client is presenting with a chronic pain pattern or something more serious, we’re here to help.
Author: Yolanda van Vugt
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