Reframing Chronicity in Research and Care: A Patient-Informed Framework of Pain Adaptation

Abstract

Chronic pain is a complex and heterogeneous condition shaped by interactions among biological processes, psychological responses, behaviors, environmental contexts, cultural and structural constraints. Yet many prevailing models remain static, insufficiently capturing how patient experiences evolve over time, particularly during the transition from acute to chronic pain. This conceptual paper advances a patient-informed conceptual framework developed through qualitative research conducted within a National Institutes of Health–funded study on patient preferences and appropriateness of care. The Chronic Adaptive Resilience & Endurance (CARE) Framework of Pain situates pain along an acute to chronic continuum and identifies a critical experiential shift from cure-seeking to coping-oriented goals. It also conceptualizes chronic pain as an adaptive process characterized by feedback loops between pain and everyday life that encompasses cognitive, emotional, behavioral, and environmental domains. Distinct from traditional biopsychosocial models, this framework highlights patient assessments, treatment preferences, individual capacity for treatment seeking and disease management, medical mistrust due to prior healthcare experiences, and economic resources as crucial influences that shape recovery trajectories and treatment engagement. By reframing chronicity as a reorganization of goals rather than a simple temporal threshold, the CARE Framework seeks to describe the patient experience of chronicity in greater depth. Finally, this framework expands on prior literature that describe a shift in focus from pain reduction to functional improvement as a marker of treatment success.

Introduction

Pain is one of the most prevalent and costly health conditions worldwide and a leading cause of disability.^1–4 While acute pain is often conceptualized as a transient symptom with a clear pathophysiological cause and expected resolution, chronic pain represents a fundamentally different phenomenon – one that persists or recurs and becomes embedded in daily life. Over the past several decades, research has increasingly emphasized biopsychosocial models of pain, recognizing that pain is shaped not only by biological processes but also by cognitive, emotional, behavioral, cultural and social factors.^5–7

Despite this progress, many prevailing frameworks remain limited in their ability to reflect how patients understand and navigate their pain experience over time.⁸ In particular, there is a need for models that explicitly capture (1) the transition from acute to chronic pain, (2) the shifting goals and meanings associated with pain persistence, and (3) the real-world constraints that shape coping and treatment engagement.

This manuscript describes a conceptual framework of patient experiences with chronic pain that was developed through a combination of literature review and exploratory qualitative interviews conducted as part of a RAND-led, NIH-funded study examining patient preferences and appropriateness of care for chronic musculoskeletal pain.⁹ The purpose of this manuscript is to situate that framework within the broader pain literature and to demonstrate its coherence with existing empirical and theoretical work.

Conceptual Framework Development and Purpose

Origins of the Framework

The framework presented here was developed within the RAND Center for Excellence in Research on Complementary and Alternative Medicine as part of a broader effort to refine appropriateness methodology for chronic pain care by incorporating patient preferences, patient-reported outcomes, and costs.^10,11 The qualitative study included 40 adults with chronic neck or low back pain recruited from chiropractic practices participating in the RAND Center of Excellence in Research on Complementary and Integrative Health. Semi-structured interviews explored participants’ experiences living with chronic pain, treatment histories, satisfaction with care, coping strategies, and perceptions of meaningful recovery. Detailed descriptions of participant recruitment, sampling, interview procedures, analytic methods, and primary qualitative findings have been published previously.^9,10,12 During analysis, several recurring concepts emerged that were not fully represented within existing conceptual models, including patients’ descriptions of a transition from seeking a cure toward managing an enduring condition, the central role of treatment preferences, and the influence of contextual constraints such as available resources and healthcare experiences. These interview-derived observations were considered alongside existing theoretical and empirical literature on chronic pain adaptation and were iteratively synthesized into the conceptual framework presented here. This conceptual framework informed the development of a national patient experience and preferences survey of over 2000 patients with chronic low back and neck pain which showed that only 32% of chronic pain patients sought a permanent cure for their pain, while most patients aimed to reduce their pain temporarily or prevent their pain from getting worse.^11–13

Role of Conceptual Frameworks in Pain Research

Conceptual frameworks serve to articulate how a phenomenon operates, identify key components, describe relationships among those components, and make underlying assumptions explicit. They also help frame the research questions and objectives. In the context of chronic pain, frameworks are particularly valuable for clarifying how diverse domains (eg, biological, psychological, social) interact, and for identifying where patient experiences may influence care seeking behavior or diverge from clinician or researcher assumptions.^14,15

Several influential frameworks have shaped contemporary pain research and care. The biopsychosocial model established the foundational insight that pain emerges from interacting biological, psychological, and social processes rather than from tissue pathology alone.^5–7 More recently, mechanistic models have sought to clarify neurophysiological contributors to pain persistence, including central sensitization, altered nociceptive processing, and nociplastic mechanisms.^16,17 Other frameworks have emphasized fear-avoidance processes, pain catastrophizing, and other cognitive-behavioral pathways implicated in disability.^18,19 Acceptance-based models, particularly Acceptance and Commitment Therapy (ACT), have similarly emphasized psychological flexibility, acceptance of experiences that cannot be readily changed, engagement in valued activities, and reorientation from symptom elimination toward meaningful functioning despite persistent pain.^20,21 Further, newer work has also highlighted the importance of attention to the socioecological factors that increase risk for experiencing pain, misdiagnosis, and treatment delays among specific marginalized groups.²² Collectively, these models have advanced our understanding of underlying mechanisms and informed targeted interventions.

Although many of these existing frameworks (eg, fear-avoidance, illness representations, acceptance) are primarily organized around pathophysiology or specific psychological processes and often operate at a population or mechanism level.^5,6,18 They may less explicitly model how patients’ goals and expectations shift across time, particularly during the transition from acute to chronic pain. In addition, while CARE shares conceptual overlap with frameworks include ACT and the biopsychosocial model of pain, the CARE Framework is intended to complement rather than replace these approaches by organizing established constructs within a dynamic model of the patient’s experience across the acute-to-chronic pain continuum. Its primary contribution is not the introduction of entirely new constructs, but the integration of treatment orientation, patient preferences, individual capacity, contextual resources, and everyday life within a single framework that emphasizes how these relationships evolve over time and influence engagement with care.

The Acute–Chronic Pain Continuum

Acute Pain: Focus on Explanation and Cure

In the acute phase, pain is typically experienced as a discrete event that signals injury or pathology. Patients and clinicians tend to approach acute pain with an expectation of resolution, emphasizing diagnosis, identification of cause, and curative treatment. Care-seeking during this phase often involves searching for explanations through imaging, diagnostic testing, and specialist consultation (Figure 1). Acute pain care is dominated by biomedical reasoning and short-term outcomes, with relatively little attention to long-term functional or psychosocial consequences. For many individuals, this approach is sufficient, and pain resolves without lasting impact.

Figure 1.

CARE (Chronic Adaptive Resilience and Endurance) Framework of Pain. The CARE Framework conceptualizes pain across an acute-to-chronic continuum. During acute pain, care seeking is primarily oriented toward identifying the cause of pain and achieving symptom resolution. When pain persists or recurs, treatment goals may increasingly incorporate coping, pain management, prevention of exacerbations, and maintenance of function. Chronic pain is represented as a dynamic process in which pain and everyday life reciprocally influence one another through interacting cognitive, emotional, behavioral, and environmental domains. Treatment preferences, individual capacity, and economic resources influence engagement with care and pain management across this process. The circular arrows represent reciprocal interactions among domains rather than a fixed or unidirectional sequence. The dotted line represents the conceptual transition from acute to chronic, persistent, or recurrent pain rather than a discrete temporal threshold.

Pain Persistence and the Acute–to–Chronic Transition

For a subset of patients, pain becomes intractable and extends beyond the expected healing timeframe. The CARE Framework identifies this period as a critical transition period of time in which uncertainty and increasing disruption to daily life may motivate patients to continue seeking explanations and cures, even as repeated treatments fail to resolve symptoms. For some, treatment seeking may be delayed due to stigma associated with the pain, expectations of continued pain with specific activities, shame or guilt about the experience of pain, and cultural mistrust of medical providers due to prior healthcare experiences. As such, an experience that was once acute may become chronic.

The transition from acute to chronic pain is often operationalized in research and clinical guidelines using a duration-based threshold, most commonly as pain persisting for three months or longer.^23,24 This convention reflects typical timelines for tissue healing and provides a standardized definition that facilitates epidemiologic study and clinical communication. However, accumulating evidence suggests that the processes underlying pain persistence evolve gradually and heterogeneously across individuals, rather than undergoing a discrete transformation at a specific timepoint in the course of healing.^25,26 Peripheral and central sensitization, psychological adaptation, and behavioral changes may emerge earlier or later than three months, and some individuals with pain beyond this threshold may recover, while others develop persistent symptoms well before it. In addition, recent longitudinal efforts, including the Acute to Chronic Pain Signatures program (A2CPS), reflect growing recognition that the acute-to-chronic transition is a heterogeneous process shaped by interacting biological and psychosocial factors.^25,26

Moreover, clinically, we see that a patient’s understanding of chronicity often diverges from strictly duration-based definitions. Rather than emphasizing elapsed time, our prior qualitative work showed that individuals frequently describe chronic pain in terms of perceived permanence, recurrence, unpredictability, or the need for ongoing management.²⁷ In this way, pain chronicity may represent not only a temporal marker but also a qualitative shift in treatment expectations and goals. Recognizing both the utility and limitations of a duration-based definition of chronic pain may allow for a more nuanced understanding of the acute-to-chronic transition and it may also change the clinical focus in treatment.

In addition, empirical studies have shown that psychological factors such as fear-avoidance, catastrophizing, and low self-efficacy often emerge or intensify during this transition and are associated with pain persistence and disability.^18,28 This framework highlights that this transition is not merely temporal but experiential: patients may begin to recognize that pain could become persistent while continuing to pursue treatments aimed at symptom reduction. Rather than conceptualizing chronicity solely in terms of duration, the transition to chronic pain may be accompanied by a change in the interactions between biological processes, cognition, emotion, and treatment behavior. Further, one’s understanding of their own identity can shift as they integrate what it means to move through the world as a person who lives with chronic pain.²⁹ As patients begin incorporating coping-oriented goals alongside continued efforts to seek symptom relief, their expectations, goals, and treatment priorities are also reorganized in response to persistent symptoms.

A Cognitive Shift: From Cure to Coping

A central feature of the framework is a cognitive shift in which patients come to understand that their pain may not be eliminated and instead must be managed. This shift marks a reorientation of goals: patients move from cure-seeking to coping, prevention of flares/exacerbations, and maintenance of function.

The broader literature on chronic illness adaptation supports the importance of this shift.^30,31 Acceptance, reappraisal, and goal adjustment have been linked to improved functioning and quality of life across chronic conditions, including chronic pain.^32–34 This shift in orientation has important implications for how treatment success is defined and measured. In the acute phase, patients and clinicians often prioritize pain elimination as the primary outcome. However, once pain is understood as ongoing or recurrent, goals frequently expand to include maintenance of function, prevention of exacerbations, and preservation of valued life roles. Many clinical guidelines already emphasize improvements in function and quality of life rather than complete pain relief as a realistic and meaningful outcome.^35–37 The present framework provides a conceptual explanation for this shift: treatment priorities evolve alongside patients’ changing relationship to their pain. Measurement strategies that align with a patient’s current orientation (ie, cure-seeking or coping-focused) may therefore better capture clinically meaningful changes in symptoms. Importantly, this cognitive shift does not occur uniformly or linearly; it is likely that patients will oscillate between cure-seeking and coping orientations over time.

Pain and Everyday Life: A Reciprocal Relationship

The framework emphasizes that everyday life is affected by pain, and pain is affected by everyday life. Rather than viewing pain as an isolated symptom, the framework situates pain within the context of daily activities, roles, relationships, and environments. Ecological and longitudinal research supports this bidirectional relationship.^38,39 Daily stressors, work demands, sleep disruption, and social interactions influence pain intensity, while pain constrains participation in valued activities.^40–43 Further, everyday life is shaped by sociohistorical context. As such, the enduring effects of effects cultural bias in marginalized communities may also impact the experience of chronic pain. Chronic pain trajectories are therefore best understood as cyclical and recursive.

The reciprocal relationship between pain and everyday life suggests that chronic pain is best conceptualized not as a static condition but as a dynamic system characterized by feedback loops. Pain intensity, emotional responses, behaviors, and environmental demands fluctuate over time, often in ways that are obscured by population-level averages. While traditional research has focused on between-person comparisons, emerging work in behavioral science and digital health emphasizes the importance of within-person variability, person-specific dynamics, and sociocultural factors.^44,45 From this perspective, chronic pain trajectories reflect evolving patterns of adaptation that may differ substantially across individuals, even when diagnostic categories appear similar.

Recent work in systems science has identified how multi-level socioecological factors can interact over time. Small changes in one domain (eg, sleep disruption, increased stress, financial strain) may amplify or attenuate challenges in other domains. The transition from acute to chronic pain can therefore be understood as a reorganization of a patient’s pain management system rather than merely the passage of time.

Domains of Chronic Pain Experience

Cognitive processes (eg, beliefs, attitudes, expectations, self-efficacy) play a central role in the experience of chronic pain. Negative illness representations (eg, beliefs about pain controllability and prognosis) are associated with greater disability, while higher self-efficacy predicts better functional outcomes.^46–49 Emotional responses such as fear, anxiety, frustration, and depression frequently co-occur with chronic pain and interact with cognitive appraisals to amplify the pain experience.^50,51

Behavioral responses encompass self-care practices, activity regulation, and help-seeking behaviors. Patients with chronic pain often engage in ongoing experimentation with strategies such as activity pacing, exercise, rest, complementary and integrative health, and medical care.^52,53 Informal caregivers and social networks (including online spaces) may also provide additional support and community while patients begin to manage life with a chronic illness.

Physical activity represents a particularly illustrative example of the bidirectional relationships embedded within the chronic pain experience. On one hand, pain frequently limits physical activity participation due to discomfort, fear of exacerbation, or prior negative experiences. Reduced movement may initially feel protective, particularly in the context of acute injury, however, prolonged inactivity can contribute to deconditioning, reduced strength and endurance, altered movement patterns, social withdrawal, and increased disability – factors that may amplify pain and functional limitation.^54–57 In this way, pain and physical activity often develop a feedback loop that can be challenging for patients to break.

Fear-avoidance models have demonstrated that pain-related fear and catastrophizing can lead to activity avoidance, hypervigilance, and increased disability.^18,19,58 To combat this, contemporary rehabilitative therapies increasingly emphasize graded exposure and pacing as strategies to disrupt maladaptive cycles. From a systems perspective, this bidirectional relationship underscores why simplistic prescriptions to “just exercise” are often insufficient and why activity engagement must be aligned with patients’ evolving goals and orientations toward their pain.

Finally, environmental factors including home, work, and social contexts shape opportunities and constraints for pain management. Workplace demands, social support, and physical environments may present barriers to feasibly implementing coping strategies and managing pain throughout the day. The framework explicitly recognizes these contextual influences as integral, rather than peripheral, to the chronic pain experience.

Preferences, Capacity, and Resources

Distinct from many biopsychosocial models, this framework emphasizes patient preferences, capacity for treatment seeking and disease management, and financial and social resources as major influences on all domains of the chronic pain experience. Whether we consider it or not, patient preferences already shape engagement with treatments and coping strategies (ie, patients are more likely to attempt therapies that they already feel optimistic about). In addition, factors such as historic exclusion and marginalization, economic constraints, insurance coverage, and transportation often limit access to multidisciplinary care and self-management resources. Recognizing these factors is essential for understanding real-world variation in pain outcomes and for designing equitable interventions.

These considerations intersect directly with implementation science – even when interventions demonstrate efficacy under controlled conditions, their uptake, sustainability, and impact in real-world settings depend on alignment with patient capacity, preferences, and contextual constraints.^59–61 Multiple implementation frameworks including the Consolidated Framework for Implementation Research (CFIR); Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM); Exploration, Preparation, Implementation, Sustainment (EPIS); and Expert Recommendations for Implementing Change (ERIC) already emphasize variables including treatment scalability, intervention adaptability, and stakeholder engagement. The present framework complements this perspective by clarifying how patient orientation toward cure or coping, functional priorities, and resource limitations influence treatment engagement and persistence over time.

From a systems perspective, implementation should not be considered a downstream phase separate from intervention design, but part of the same adaptive process. Treatments are enacted within complex social and economic environments, and their effectiveness emerges through interaction with those environments. Recognizing chronic pain as embedded within daily life underscores the importance of designing interventions that are scalable and responsive to variability across patients and settings. Translational intervention development frameworks such as the Multiphase Optimization Strategy (MOST) and the Discover–Design–Build–Test (DDBT) model conceptualize behavioral interventions as systems that must be iteratively refined for efficiency and alignment with stakeholder needs.⁶² These approaches parallel the principles of user-/human-centered design which emphasize a deep understanding of user experience, the need for iterative prototyping, and evaluation within the real-world.⁶³

The central role of patient preferences also has important implications for clinical trial design and interpretation. Traditional randomized controlled trials often assume equipoise at the population level and may treat treatment allocation as independent of patient expectations. However, in the context of chronic pain, a domain where patients frequently hold strong beliefs about specific therapies, preferences are not an inert variable that pain researchers should ignore – instead, the CARE Framework suggests that treatment preferences may function as active contributors to treatment engagement and should be considered when designing and evaluating future interventions.^64–66

Preference-based and partially randomized trial designs offer one approach to address this complexity. In such models, participants who have strong treatment preferences may receive their chosen intervention which leverages the expectancy effects of participating in a treatment that patients may already be favorable towards.^67–69 Preference-based designs have been proposed as one approach to improve recruitment and adherence in settings where patients hold strong treatment preferences, although their utility within chronic pain interventions requires further evaluation.^70–73 Incorporating preference-based methodologies aligns with the present framework’s emphasis on patient-centered care and recognizes that treatment outcomes emerge from interactions among biological mechanisms, expectations, and behavior. More broadly, explicitly measuring and modeling patient expectations and goals may enhance understanding of heterogeneity in treatment response and advance more precise, person-aligned approaches to chronic pain care.

Discussion

The framework presented here is grounded in patient narratives, therefore, it offers a practical consideration for designing interventions that are aligned with lived experience. Many pain interventions are developed primarily around hypothesized mechanisms of action (eg, reducing inflammation, improving cognition, increasing physical activity). While mechanism-driven approaches are valuable, they may overlook how patients understand and experience their condition, what outcomes they consider meaningful, and what constraints limit engagement.

This acute-to-chronic continuum suggests that interventions may need to be tailored not only to symptom severity but also to patient orientation regarding cure or coping. Patients who remain strongly cure-oriented may require different educational, motivational, or behavioral strategies than those who have shifted toward long-term pain management. Similarly, attention to the importance of designing scalable, accessible interventions that acknowledge real-world constraints is likely a crucial component for ensuring that interventions are effective when deployed across healthcare systems.

While the CARE Framework has several strengths, including its integration of how various factors (including sociohistorical context, patient preferences, and resources) impact the continuum of acute to chronic pain, some limitations must be noted. The CARE Framework was developed using data from participants who had already engaged in treatment or had previously sought treatment for their chronic neck and low back pain. Some forms of pain, such as pelvic pain and sexual pain, are socially understood as expected and normalized, despite the fact that treatment and tools for management are available.⁷⁴ Given this, pain that was once acute becomes chronic, and a patients’ primary self-management strategy can become avoidance or pushing through the pain in an attempt to achieve a desired outcome rather than seeking treatment. As such, individuals whose pain may have shifted from acute to chronic without accessing treatment may not be fully represented by this framework. Future research should be conducted from a perspective that focuses on how enduring systems of power impact the acute to chronic pain continuum for more stigmatized forms of pain and for those with marginalized identities.

Despite this limitation, the CARE Framework may have implications for efforts to advance precision medicine in the field of chronic pain management. Recognizing substantial heterogeneity in pain trajectories has prompted calls for phenotyping and stratified care,^75,76 and differences in expectations, coping orientation, and available resources may shape treatment response as meaningfully as differences in sensory processing or neurophysiology. Incorporating these domains into phenotyping efforts may enhance the field’s ability to match patients with interventions that align with both their symptom profiles and their lived realities.

The CARE Framework also generates several hypotheses that can be evaluated prospectively. For example, it is possible that patients whose treatment goals are aligned with their current orientation toward pain (eg, cure-seeking versus coping-focused) may demonstrate greater treatment engagement and adherence than patients whose interventions are poorly aligned with these goals. In addition, it may be that individual capacity, available resources, and contextual constraints moderate the effectiveness of pain interventions by influencing patients’ ability to implement self-management strategies. Finally, shifts in treatment orientation occur dynamically over time and may predict changes in outcome priorities, including the relative importance of pain reduction versus functional improvement. Future longitudinal studies are needed to evaluate these and other propositions generated by the CARE Framework.

Conclusion

Chronic pain is commonly defined by duration, yet patients often experience it as a reorganization of expectations, goals, and everyday life. The CARE Framework proposes that the transition to chronic pain is characterized not only by persistent symptoms but also by evolving treatment orientations, contextual constraints, and changing definitions of meaningful recovery. By organizing these concepts within a patient-centered conceptual model, the framework offers one approach for understanding how individuals adapt to persistent pain over time. In addition, The CARE Framework is intended as a hypothesis-generating conceptual framework rather than a validated explanatory model. Future prospective research should evaluate its proposed relationships across diverse pain conditions, patient populations, healthcare systems, cultural settings, and stages of illness. If supported through empirical investigation, the framework may provide a useful foundation for designing patient-centered interventions, informing implementation strategies, and guiding future research on chronic pain adaptation.

Funding Statement

The authors of this publication are supported by grants from the National Institutes of Neurological Disorders and Stroke (PI – Wexler: K12NS130673) and the National Center for Complementary and Integrative Health (PI – Maiers, Coulter: U24AT012549) of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Use of Artificial Intelligence

Artificial intelligence was used for editing the manuscript to improve conceptual clarity.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest.