Rethinking “Chronic Pain”: Patient Perspectives on Developing an Integrated Psychology and Physical Therapy Treatment

Abstract

Chronic pain affects approximately 20% of U.S. adults and is associated with substantial psychological distress and functional impairment, underscoring the need for effective, patient-centered interventions. Evidence supports the use of cognitive-behavioral therapy (CBT) and physical therapy (PT) in chronic pain management; however, there remains limited guidance regarding how to integrate these principles within a single manualized intervention. This study describes the early-stage, formative phase of a multi-stage project to adapt an existing CBT manual for chronic pain by incorporating PT principles. Two focus groups with adults living with chronic pain were co-facilitated by a psychologist and a physical therapist, and data were analyzed using thematic analysis. Participants described frustration with communication and care coordination, dissatisfaction with the label “chronic pain,” reliance on trial-and-error treatments, loss of identity and independence, an emotionally complex relationship with pain, and identified priorities relevant to intervention adaptation. Findings were used to inform patient-centered adaptations, including incorporating pain neuroscience education, reconsidering use of the term “chronic pain,” and adding modules addressing identity, advocacy, and interprofessional collaboration. These findings provide formative, patient-informed insights to guide the early-stage refinement of integrated pain interventions and inform subsequent phases of manual development and testing.

Keywords

behavioral health pain management patient perspectives / narratives physical therapy

Introduction

Chronic pain, defined as pain persisting for 3 months or longer, affects an estimated 20% of adults in the United States, or an estimated 51.6 million individuals.¹ Among these individuals, 6.9% experience pain severe enough to substantially limit daily functioning.¹ For patients, chronic pain profoundly affects daily functioning, work, relationships, and sense of identity, with lasting consequences for quality of life. The prevalence of chronic pain continues to increase, with new cases occurring more frequently than several other major health conditions.² In the United States, chronic pain is associated with substantial economic burden, including increased healthcare utilization and lost productivity, totaling an estimated $722.8 billion annually.³

Beyond physical symptoms, individuals living with chronic pain frequently experience depression, anxiety, substance use disorders, and suicidal ideation, underscoring the condition’s biopsychosocial complexity.^4,5 Psychological factors play a critical role in the onset, maintenance, and exacerbation of pain. Depression and anxiety are linked to greater pain intensity and poorer functioning, often through mechanisms such as heightened pain catastrophizing (i.e., interpreting pain as unbearable or unending) and lower pain self-efficacy (i.e., an individual’s beliefs about their ability to successfully cope with pain and/or related negative emotions, to complete daily tasks, and to implement pain management strategies).^6,7 These maladaptive cognitive and emotional processes can amplify pain perception, reinforce avoidance behaviors, and undermine rehabilitation efforts, contributing to long-term disability independent of pain intensity.^8,9

Although coordinated care between physical therapy (PT) and psychology is recommended to address these interacting factors,¹⁰ patients with elevated psychological distress may encounter barriers to engaging multiple providers, including avoidance, hopelessness, and reduced motivation. Structural inequities further affect patient experience, as women, racial and ethnic minority groups, and individuals with lower socioeconomic status are more likely to report undertreated pain, dismissal of symptoms, and limited access to evidence-based care.^11,12 These challenges highlight the need for accessible, patient-centered interventions that integrate psychological and physical approaches.

Psychological Interventions for Chronic Pain

Psychological interventions are a central component of evidence-based chronic pain management and are increasingly recognized as essential to interdisciplinary care models.^10,13 Among these approaches, cognitive-behavioral therapy for chronic pain (CBT-CP) is the most empirically supported, with consistent evidence demonstrating improvements in pain-related interference, mood, and daily functioning across a range of pain conditions.^13,14 CBT-CP is grounded in the gate control theory of pain¹⁵ and the broader biopsychosocial model, which conceptualizes pain as a multidimensional experience shaped by physiological, cognitive, emotional, and behavioral factors. Treatment typically includes psychoeducation about pain mechanisms, cognitive strategies to address maladaptive beliefs such as catastrophizing and helplessness, behavioral activation and time-based pacing to reduce avoidance, and skills to support coping, goal setting, and engagement in meaningful activities.¹⁶ These strategies aim to increase perceived control over pain, reduce distress, and improve participation in valued life roles despite ongoing symptoms.

Although CBT-CP improves psychological well-being and quality of life, its effects on physical functioning are often modest, and gains may diminish over time.¹⁷ One explanation is that traditional CBT protocols primarily target cognitive and emotional processes without directly addressing fear of movement, physical deconditioning, or graded re-engagement in activity.^18,19 Although CBT-CP incorporates time-based pacing to disrupt the maladaptive boom-and-bust cycle of overactivity followed by pain-related inactivity, these strategies primarily help patients regulate overexertion rather than increase baseline physical activity. Consequently, CBT may reduce fluctuations in activity but may be insufficient to promote the gradual physical conditioning needed to improve daily functioning, leaving some patients with better coping skills yet persistent functional limitations. Integrating PT principles into CBT offers an opportunity to address these gaps by pairing cognitive and behavioral strategies with structured guidance for safe movement, conditioning, and functional goal attainment. Such integration has the potential to enhance both psychological and physical functioning.

Physical Therapy and Pain Neuroscience Education

PT interventions are another evidence-based component of chronic pain treatment.¹⁰ In addition to exercise-based rehabilitation, contemporary PT interventions increasingly incorporate pain neuroscience education (PNE), which helps patients understand pain as a protective nervous system response rather than a direct indicator of tissue damage.²⁰ PNE can reduce fear of movement, support safe re-engagement in activity, and improve confidence in managing pain.²¹ Meta-analytic evidence indicates that PNE, particularly when combined with exercise, is associated with reductions in pain intensity and disability, as well as improved understanding of pain mechanisms that contribute to the persistence of pain.^22,23

Although PT-based interventions also address cognitive and emotional processes such as fear-avoidance and catastrophizing, they typically do so through education and movement-based exposure rather than explicit cognitive or behavioral skills training. These approaches often assume that increased understanding of pain will naturally lead to sustained behavior change. In contrast, CBT provides structured strategies to help patients identify and modify maladaptive thoughts and behaviors but generally lacks the neurophysiological education and experiential movement components emphasized in PT. From a patient experience standpoint, each approach may address important but incomplete aspects of living with chronic pain.

Rationale for Integration

Integrating psychological and PT principles aligns with longstanding recommendations for interdisciplinary, biopsychosocial approaches to chronic pain management. Interdisciplinary programs have demonstrated superior outcomes compared to single-modality treatments^24,25; however, these models are often resource-intensive and limited to specialized settings. For many patients, access to coordinated interdisciplinary care remains constrained by cost, geography, and system-level barriers.

Developing a manualized, integrated intervention that can be delivered by behavioral health providers has the potential to expand access to evidence-based pain care while addressing gaps in treatment. Embedding PT principles, such as pain neuroscience education and functional movement goals, within a psychological framework may better reflect patients’ lived experiences of pain and their priorities related to function and independence. To date, however, no published manual integrates PT and psychological strategies into an intervention deliverable by behavioral health providers, highlighting a critical gap in accessible chronic pain care.

Additionally, although there has been a growing shift toward patient-centered and co-designed approaches in healthcare, patient perspectives are not consistently incorporated during early stages of intervention development, which may limit alignment with real-world needs.^26-28 As a result, many existing treatments remain largely clinician-driven, with limited integration of patient input during the design process. Incorporating patient perspectives may strengthen intervention relevance and alignment with patients’ lived experiences.

The Current Study

The current study addresses this gap by adapting an evidence-based psychological treatment manual, Cognitive Behavioral Therapy for Chronic Pain,¹⁶ to incorporate PT principles into an integrated intervention deliverable by psychologists and other behavioral health providers. Guided by the National Institutes of Health (NIH) recommendations for adapting manualized interventions,²⁹ the adaptation process follows a multistage, iterative design. Specifically, this framework outlines nine steps: (1) selecting a base manual; (2) conducting focus groups with the target population; (3) making initial manual revisions; (4) piloting the revised intervention; (5) conducting facilitator focus groups; (6) obtaining expert review; (7) incorporating staff and expert feedback; (8) conducting an initial open trial; and (9) evaluating the intervention through a randomized controlled trial. The current study represents an early phase of this process, corresponding to Step 2, in which focus groups with adults living with chronic pain are used to gather patient-centered feedback and identify priorities for integration. Findings from this phase will inform subsequent manual refinement, pilot testing, and later efficacy evaluation through randomized controlled methods. By centering patient perspectives early in intervention development, this project aims to advance more accessible, interdisciplinary approaches to chronic pain care that improve both functioning and patient experience.

Method

Participants

Two focus groups were conducted with adults living with chronic pain as part of the initial phase of adapting an integrated chronic pain treatment manual. A total of 14 participants took part across two groups (8 in the first group and 6 in the second). Participants were recruited through community flyers and referrals from a PT clinic in the southeastern United States. Recruitment through a PT clinic was intentional, as individuals with chronic pain frequently seek rehabilitative services and could offer relevant insight into PT components suitable for integration into a psychological intervention.

Eligibility criteria included being 18 years or older, English-speaking, and having experienced chronic pain for at least three months. Participants ranged in age from 25 to 75 years (M = 49.0). Most participants identified as female (71.4%), and the majority identified as White (78.6%), with two participants identifying as Black or African American (14.3%) and one participant not reporting race (7.1%). All participants identified as non-Hispanic or Latino. All participants were college graduates, and half had completed postgraduate degrees. Half of the sample was employed full time, 7.1% part time, and 42.8% were not currently employed.

Participants reported living with chronic pain for an average of 9.4 years (range = 1 to 20 years) and described extensive prior engagement with health care services. All participants reported prior physical therapy, and many reported additional treatments, including medical interventions (79%), prescription medications (57%), chiropractic care (57%), surgery (36%), and psychotherapy (14%). Full demographic characteristics are presented in Table 1.

Table 1.

Participant Characteristics

Characteristic	% (n) or M (range)
Age (years)	M = 49.0 (25–75)
Sex and Gender Identity
Female	71.4% (n = 10)
Male	28.6% (n = 4)
Race
White	78.6% (n = 11)
Black or African American	14.3% (n = 2)
Other/Not reported	7.1% (n = 1)
Ethnicity
Not Hispanic or Latino	100% (n = 14)
Education
College graduate	100% (n = 14)
Postgraduate degree	50% (n = 7)
Employment Status
Full-time	50.0% (n = 7)
Part-time	7.1% (n = 1)
Not employed	42.8% (n = 6)
Average Duration of Pain (years)	M = 9.4 (1–20)
Treatments Tried
Physical Therapy	100% (n = 14)
Medical interventions	79% (n = 11)
Medications	57% (n = 8)
Chiropractic care	57% (n = 8)
Surgery	36% (n = 5)
Psychotherapy	14% (n = 2)

Note. Percentages represent the proportion of participants endorsing each category (N = 14).

Procedure

Each focus group lasted approximately 90 minutes and was co-facilitated by a licensed psychologist and a licensed physical therapist to ensure representation of both psychological and physical perspectives on pain. A semi-structured discussion guide was used to explore participants’ experiences living with chronic pain, communication with health care providers, perspectives on CBT and PT approaches, and recommendations for integrating both disciplines into a single manualized intervention. Focus groups were conducted via secure videoconference, audio-recorded with participant consent, and transcribed verbatim. Topics and core questions are summarized in Table 2. All procedures were approved by the university’s Institutional Review Board and written informed consent was obtained from all participants.

Table 2.

Focus Group Questions

Topic	Core questions
I. General Experience with Chronic Pain	Strategies used to manage pain
I. General Experience with Chronic Pain	Impact of pain on relationships, routines, and work
II. Communication about Pain	Helpful vs. unhelpful language used to describe pain
	Perceptions of the term “chronic pain”
	Coordination and communication among healthcare providers
III. Psychology and Chronic Pain	Most and least helpful CBT-related topics
IV. Physical Therapy and Chronic Pain	Most and least helpful PT topics
V. Creation of an Integrated Manual	Desired features of an integrated treatment program
V. Creation of an Integrated Manual	Ways to integrate psychological and PT concepts

Data Analysis

Data were analyzed using thematic analysis following Braun and Clarke’s six-phase framework.^30,31 This inductive approach allowed themes to emerge from participants’ narratives without imposing preexisting theoretical assumptions. Two trained coders independently reviewed and coded all transcripts. Codes were compared and refined through iterative discussion to enhance clarity and analytic depth. Intercoder agreement was high (κ = .90), and all discrepancies were resolved by consensus. Conceptually related codes were grouped into themes, which were reviewed and refined to ensure internal coherence and distinctiveness across themes. Deidentified transcripts are available upon request.

Results

Eight major themes were identified: (1) frustration with communication and care coordination, (2) dissatisfaction with the label “chronic pain,” (3) reliance on trial-and-error treatment strategies, (4) loss of identity and independence, (5) an emotionally complex relationship with pain, (6) feedback on CBT content, (7) feedback on PT content, and (8) recommendations for an integrated manual. Each theme is described below with illustrative quotations.

Theme 1: Frustration With Communication and Care Coordination

Participants frequently described frustration with fragmented care and dismissive or invalidating encounters with health care professionals. These experiences included unclear or conflicting diagnoses, poor communication across providers, and treatment plans that failed to account for contextual or psychosocial factors. Participants often felt responsible for coordinating their own care and translating information between providers, which contributed to confusion and mistrust. Several participants also expressed dissatisfaction with standardized pain assessment tools, such as numerical rating scales, which they felt oversimplified their experiences and limited meaningful communication. Representative quotations include:

● “The state that we are in now where it's so difficult to coordinate is unbelievable. I've been given patient coordinators, and I've had them just laugh and be like, ‘I can't help you’.”

● “The idea of communicating about it sometimes just seems ridiculous. How much does it hurt? I don't know. If you could measure it, it might be the same as yesterday, except today it's ten times worse.”

Theme 2: Dissatisfaction With the Label “Chronic Pain”

Many participants reacted negatively to the term chronic pain, describing it as stigmatizing, emotionally discouraging, or implying permanence. They viewed the label as overly general and insufficient to capture the fluctuating and individualized nature of their experiences. Several participants expressed that the term shaped how they viewed themselves and their prognosis, sometimes fostering a sense of hopelessness or disconnection from recovery. Others emphasized the need for language that reflects management and adaptation rather than inevitability. Representative quotations include:

● “Chronic pain is a very general term. It doesn’t account for the type of pain. Is it nerve pain? Is it muscle skeletal pain? Is it a stabbing? Tingling? Is it throbbing? It overgeneralizes it to the point where it's hard to really get a true understanding of what that is.”

● “I don't like the term chronic pain, because it kind of feels like it's never going to stop. It's never ending. It comes and goes, but you're stuck with it. I don't have an alternative that I like. But another word would be nice.”

Theme 3: Reliance on Trial-And-Error Treatment Strategies

Participants described navigating an ongoing, nonlinear process of experimenting with multiple treatments, including both medical and self-directed approaches, with inconsistent results. They detailed rotating through providers, medications, and therapies, often feeling exhausted by the emotional toll of this repeated “trial-and-error” cycle. Representative quotations include:

● “In addition to things like tens units, decompression, and massage, I’ve tried all those types of things that have helped to relieve the pressure and pain on an interim basis, but not anything that's long-lasting.”

● “I have tried many different strategies, including ibuprofen, ice, physical therapy, chiropractic, massage, yoga, meditation, breathwork, all kinds of things to try to manage. It's been sometimes helpful and sometimes not.”

Theme 4: Loss of Identity and Independence

Participants conveyed a profound disruption of self-concept tied to the limitations imposed by chronic pain. They described grief over lost roles (e.g., worker, athlete, caregiver), diminished self-worth, and strain in relationships. This loss of autonomy and role identity was central to the emotional experience of chronic pain and often intertwined with feelings of isolation and frustration. Representative quotations include:

● “Pain has massively limited my ability to socialize. I see my friends go out on hikes and things that I used to love to do, and I can't do most of those things. I can still garden sometimes, but it's really changed who I am as a person as well as my personality.”

● “It's changed not who I am, but what I love to do, which makes me who I am I guess. I was a health and fitness teacher and still love being active, except for I can’t be active. I feel like I can’t overstate how catastrophically chronic pain has changed my outlook and my existence.”

Theme 5: An Emotionally Complex Relationship With Pain

Participants expressed a wide range of emotions toward their pain. While many described frustration, sadness, and anger, others acknowledged acceptance, personal growth, or a reframed relationship with pain. This emotional complexity illustrates that adaptation to chronic pain is not a linear process but an ongoing negotiation between distress and acceptance. For many, adjustment involved meaning-making and redefining their relationship with pain rather than focusing solely on symptom reduction. Representative quotations include:

● “When my chronic pain started like 20 plus years ago… I decided that it was now or never because I didn't know what the future was going to be like. It kind of kicked me into pursuing a Ph.D. It took me into a different career path, which was really cool. So that was positive.”

● “I would still like to not hurt, but I’ve accepted that as the cards I’m dealt. I’m not going to cry. I’m just going to have these strategies to try to get through it… I really resent that I have it and I hate it.”

Theme 6: Feedback on CBT Content

Participants generally valued cognitive and behavioral strategies such as time-based pacing and sleep hygiene but expressed mixed reactions to mindfulness and relaxation exercises, including diaphragmatic breathing and progressive muscle relaxation. They emphasized the importance of flexibility, personalization, and a clearer understanding of how these techniques relate to the body’s pain mechanisms. Several participants noted that traditional explanations, such as the gate control theory of pain, felt insufficient or overly simplistic in capturing the complexity of their lived pain experience. Representative quotations include:

● “The time-based pacing is helpful because I’m always bad about the boom-and-bust cycle of chronic illness - when I feel okay, I try to do everything at once.”

● “The pain gate stuff never made sense to me. Sometimes meditation or breathing makes me feel like I’m suffocating. I get mad when people come out of the gate and say to ‘just breathe’- like with the diaphragm breathing thing.”

Theme 7: Feedback on PT Content

Participants generally valued PT for its comprehensive and holistic approach to health, which often incorporated elements such as nutrition education alongside physical components like manual therapy. They especially appreciated when therapists provided pain neuroscience education that clarified why particular exercises or movements were recommended, helping them understand the purpose behind tasks that might otherwise seem counterintuitive or unhelpful. Finally, participants emphasized the value of setting individualized, functional goals tailored to their personal priorities (e.g., being able to garden or engage in meaningful daily activities), noting that these personalized objectives enhanced both motivation and perceived relevance of treatment. Representative quotations include:

● “I did like the neuroscience education. I'm very big about telling me why I’m doing this. I immediately will go to lift 45 pounds with no problem, so why is my PT telling me to lift these 5-pound dumbbells? Like what is this doing?”

● “I think the biggest thing is that the physical therapist listens to where the person’s coming from, because the person might be a gardener, you know, and it’s important to get the person to be able to do what they love to do.”

Theme 8: Recommendations for an Integrated Manual

Participants expressed enthusiasm for a unified, interdisciplinary manual that bridges psychological and physical therapy approaches. Feedback centered on how to combine and adapt content for accessibility, flexibility, and patient relevance. Participants recommended modules on communication skills, advocacy, identity reconstruction, and interprofessional collaboration as well as not using the label “chronic pain”. Representative quotations include:

● “I think there needs to be education on how to coordinate with your healthcare providers. Something like, okay, you’re sick. Here’s what to expect, and here’s how you delegate because it is not an easy thing to have to deal with, like five specialists and insurance and all of this. It’s so many tiny little steps that feel like insider knowledge that you have to do, and so there needs to be some kind of a guide on how to deal with coordination.”

● “Once you’ve been labeled with chronic pain, does that mean now I’m going to have pain forever? Maybe we need to be mindful of the language and how that manual, what it’s literally called because that can influence that person’s perspective on what the goal is. I think that’s important.”

Discussion

This qualitative study examined the lived experiences of adults with chronic pain to inform the early-stage adaptation of an integrated manual that combines cognitive-behavioral and physical therapy approaches. Participants’ reflections highlighted emotional, social, and systemic barriers to care and offered important insights for developing a more accessible and patient-centered interdisciplinary treatment.

Participants described chronic pain as not only a physical condition but also a challenge to communication, trust, and identity. Many expressed frustration with fragmented care and poor communication among healthcare providers, often feeling responsible for coordinating treatment themselves. These experiences mirror well-documented shortcomings of conventional pain care, where patients frequently navigate multiple providers without a unified treatment plan.²⁵ Participants emphasized the importance of collaboration and common language among providers, suggesting that integrated treatment approaches should include guidance on communication, support patient self-advocacy, and promote greater coordination across disciplines to improve patient-provider interactions.

More broadly, these findings reflect systems-level challenges within chronic pain care, including fragmented communication and difficulty navigating complex healthcare systems. Participants’ desire to feel heard and meaningfully involved in treatment decisions aligns closely with patient-centered care and shared decision-making frameworks, which emphasize validation and inclusion of patient perspectives in healthcare planning.²⁸ From an intervention development perspective, these findings suggest that integrated pain interventions should extend beyond symptom management to also support communication, care navigation, and patient self-advocacy, all of which may help strengthen trust in the healthcare system.

The adapted intervention may include modules focused on communication with healthcare providers, including questions to ask, strategies for discussing symptoms, and approaches to improving alignment across providers. We also anticipate including a care coordination toolkit to help patients share information across providers, maintain a personal care summary or treatment log, and better understand how different treatments fit together. Additional components may address patient advocacy skills, such as preparing for appointments, asking for referrals or second opinions, and navigating situations in which concerns are dismissed. Modules may also explore trust and expectations within healthcare relationships by helping patients understand why providers may differ in their recommendations, clarify the roles of different disciplines (e.g., physical therapists, psychologists, physicians), and rebuild trust following negative care experiences. Together, these components directly reflect key aspects of the patient experience identified in this study and highlight opportunities to strengthen patient-provider interactions within an integrated model of care.

A striking finding was participants’ negative reactions to the term chronic pain. Many described the label as stigmatizing or emotionally discouraging because it implied permanence. Although participants preferred language that reflected flexibility and management, they did not identify a preferred alternative term. Participants’ reactions also suggested concern that the label oversimplifies a complex and highly variable experience, contributing to feelings of misunderstanding or invisibility. This finding aligns with broader literature suggesting that diagnostic labels can shape self-concept and interactions with healthcare systems, with both positive and negative psychological effects reported across health conditions.^32,33 These results suggest that the language used within pain interventions may shape how patients understand their condition, engage in treatment, and feel validated by healthcare providers.

These findings have important implications for intervention development. Specifically, they highlight the importance of using language that patients experience as accurate and empowering, while recognizing that no single label will resonate positively with all individuals. Incorporating more precise diagnostic descriptors, such as nociceptive, neuropathic, and nociplastic pain, may be beneficial, as accurate classification has been associated with improved patient engagement and hope.³⁴ Revising treatment materials to incorporate more validating conceptualizations of pain may help promote engagement and reduce hopelessness, particularly given evidence that diagnostic labels can shape self-concept and clinical outcomes.³⁵ For example, the intervention may include guidance on how to describe pain in ways that are more effectively understood by providers and explore alternatives to the term chronic pain when it is experienced as invalidating.

The emotional impact of pain also emerged as a central theme. Participants described grief, loss of identity, and reduced self-worth as pain disrupted their ability to participate in meaningful roles and activities. Loss of identity and social strain are commonly reported among individuals with chronic pain, with many patients describing feelings of burden and disconnection from others.^36,37 At the same time, participants’ narratives also reflected resilience and personal growth. This duality underscores the need for treatments that address meaning-making and rebuilding a sense of identity, rather than focusing solely on symptom reduction. Acceptance- and values-based components may therefore complement traditional CBT techniques by helping individuals redefine self-concept, strengthen social connections, and reconnect with valued life domains despite ongoing pain.

Participants also described navigating an exhausting and fragmented system of care, often cycling through a “trial-and-error” process with inconsistent treatment outcomes. These experiences appeared to reflect not only frustration, but also the emotional burden of ongoing uncertainty and repeated adjustment to changing recommendations. Continually evaluating whether treatments are working may place additional cognitive and emotional strain on individuals coping with persistent pain. This may help explain participants’ preference for clearer treatment rationales and more coordinated models of care.

Participants offered nuanced feedback regarding CBT and PT content. Although they identified helpful components within both treatments, many felt that neither approach alone fully addressed the complexity of their experiences. Participants appeared to value interventions that felt both credible and personally relevant. Mixed responses to certain CBT strategies, such as relaxation exercises or simplified pain explanations, suggest that interventions perceived as overly generic or disconnected from patients’ lived experiences could feel invalidating. These findings support incorporating more nuanced psychoeducation regarding the mechanisms underlying pain and pain management. Participants valued CBT strategies such as time-based pacing and sleep hygiene, while expressing appreciation for PT components including pain neuroscience education and its emphasis on movement, nutrition, and individualized functional goals. Together, these perspectives point to the need for a unified approach that links psychological and physical mechanisms within a cohesive model of care. Embedding pain neuroscience education within CBT sessions, for instance, could clarify how cognition, emotion, and movement interact to influence pain and functioning.

Importantly, the contribution of this study lies not solely in demonstrating the value of integrating CBT and PT, an approach already supported in the literature,¹⁰ but in advancing how such integration can be implemented through a patient-informed, manualized intervention. Specifically, this study provides a foundation for developing an intervention that embeds PT principles within a CBT framework deliverable by behavioral health providers. By incorporating patient perspectives at the earliest stage of intervention design, this work moves beyond existing models by aligning treatment structure and content with patients’ lived experiences and preferences. Consequently, the aims of this initiative are consistent with the tenets of patient-centered care that prioritize patient engagement and empowerment, care coordination, and clear communication.³⁸ By centering patient voices, this integrated treatment aims to provide both practical tools for pain management and a more validating treatment experience.

Limitations

Several limitations warrant consideration. The sample was small (N = 14), relatively homogeneous, and recruited from a PT clinic in the southeastern United States, which may limit the transferability of findings. Participants were highly educated, with all holding college degrees and approximately half possessing postgraduate training, and the sample was predominantly White. These characteristics may not reflect the broader population of individuals with chronic pain, particularly those with lower health literacy, more limited access to care, or more diverse cultural backgrounds.

Recruitment through a PT clinic may have also introduced bias, as participants were likely already engaged in or receptive to movement-based treatment approaches and interdisciplinary care. As a result, findings may overrepresent individuals with more favorable attitudes toward physical and behavioral health interventions, potentially limiting applicability to patients who are less engaged in treatment or who hold different beliefs about pain management. The limited socioeconomic and racial diversity further constrains the range of perspectives captured, particularly given well-documented disparities in pain assessment, treatment access, and patient-provider interactions among marginalized populations.¹¹ Together, these sample characteristics suggest that the findings should be interpreted with caution and may not generalize to more diverse or underserved populations.

Future research should prioritize recruiting larger and more diverse samples across clinical and community settings, including individuals with varying levels of education, health literacy, and access to care. Additionally, examining how cultural, economic, and structural factors influence engagement with integrated physical and psychological interventions will be critical for improving the generalizability and equity of chronic pain treatment approaches.

Conclusions

This qualitative study highlights the importance of centering patient perspectives in the development of interventions. Participants described chronic pain as a multidimensional experience shaped by communication barriers, identity disruption, emotional complexity, and fragmented care. Their feedback underscored limitations of standalone psychological or physical therapy approaches and emphasized the need for cohesive, interdisciplinary models that address both physical and psychosocial contributors to pain.

Findings informed patient-centered adaptations to an existing CBT manual, including incorporation of pain neuroscience education, reconsideration of the term chronic pain, and inclusion of modules addressing identity, advocacy, and interprofessional communication. By grounding intervention development in lived experience, this project advances efforts to create accessible, biopsychosocial treatments for chronic pain. Subsequent phases will focus on refining the manual and evaluating clinical outcomes, with the goal of informing future efforts to improve both functional outcomes and patient experience in chronic pain care.

Footnotes

ORCID iD

Mary Beth McCullough

Ethical Considerations

This study was reviewed and approved by Mercer University’s institutional review board.

Consent to Participate

Written informed consent was obtained from all participants prior to study participation.

Consent for Publication

All data were deidentified, and participants provided consent for publication of deidentified data as part of the informed consent process.

Author Contributions

McCullough led the study concept and design, data collection, data analysis, and manuscript drafting. Orton and Kemp contributed to study design, data analysis, interpretation of findings, and critical revision of the manuscript. Yang contributed to data analysis, interpretation of findings, and critical manuscript revision. All authors approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data supporting the findings of this study are available from the corresponding author upon request.*

References

Rikard

Strahan

Schmit

Guy

Jr . Chronic pain among adults—United States, 2019-2021. MMWR Morb Mortal Wkly Rep. 2023;72(15):379-385.

Nahin

Feinberg

Kapos

Terman

. Estimated rates of incident and persistent chronic pain among US adults, 2019-2020. JAMA Netw Open. 2023;6(5):e2313563.

Guy

GPJ

Miller

Legha

, et al. Economic costs of chronic pain—United States, 2021. Med Care. 2025;63(9):679-685.

Zis

Daskalaki

Bountouni

Sykioti

Varrassi

Paladini

. Depression and chronic pain in the elderly: links and management challenges. Clin Interv Aging. 2017;12:709-720.

Ditre

Zale

LaRowe

. A reciprocal model of pain and substance use: transdiagnostic considerations, clinical implications, and future directions. Annu Rev Clin Psychol. 2019;15:503-528.

Montag

Salomons

Wilson

Duggan

Bisson

. Examining the roles of depression, pain catastrophizing, and self-efficacy in quality-of-life changes following chronic pain treatment. Can J Pain. 2023;7(1):2156330.

Shimada

Doorenbos

Goldstein

. A systematic review of pain catastrophizing and chronic musculoskeletal pain. Pain Manag Nurs. 2025;27(1):e72-e84. doi:10.1016/j.pmn.2025.00242. Published online.

Asmundson

GJG

Parkerson

D’Ambrosio

. Fear, anxiety, avoidance, and chronic pain. In: Ressler

Pine

Rothbaum

, eds. Anxiety Disorders. doi:10.1093/med/9780199395125.003.0016. Oxford University Press; 2015.

Hruschak

Cochran

. Psychosocial predictors in the transition from acute to chronic pain: a systematic review. Psychol Health Med. 2018;23(10):1151-1167.

10.

American Psychological Association . Clinical Practice Guideline for the Psychological Treatment of Chronic Musculoskeletal Pain in Adults. 2019. https://www.apa.org/practice/guidelines/nonpharmacological-treatment-chronic-musculoskeletal-pain.pdf. Accessed 5 November 2025.

11.

Anderson

Green

Payne

. Racial and ethnic disparities in pain: causes and consequences of unequal care. J Pain. 2009;10(12):1187-1204.

12.

Green

Anderson

Baker

, et al. The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Med. 2003;4(3):277-294.

13.

Ehde

Dillworth

Turner

. Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. Am Psychol. 2014;69(2):153-166.

14.

Williams

ACDC

Fisher

Hearn

Eccleston

. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2020;8:CD007407.

15.

Melzack

Wall

. Pain mechanisms: a new theory. Science. 1965;150(3699):971-979.

16.

Otis

. Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach. Oxford University Press; 2007.

17.

Morley

Williams

Eccleston

. Examining the evidence about psychological treatments for chronic pain: time for a paradigm shift? Pain. 2013;154(10):1929-1931.

18.

Turk

Wilson

. Psychological principles and practice in pain management: bridging the gap between research and clinical application. J Pain. 2010;11(2):135-141.

19.

Edwards

Dworkin

Sullivan

Turk

Wasan

. The role of psychosocial processes in the development and maintenance of chronic pain. J Pain. 2016;17(9 suppl):T70-T92.

20.

Moseley

Butler

. Explain Pain Supercharged: The Clinician’s Manual. Noigroup Publications; 2017.

21.

Louw

Zimney

Puentedura

Diener

. The efficacy of pain neuroscience education on musculoskeletal pain: a systematic review. Physiother Theory Pract. 2016;32(5):332-355.

22.

Malfliet

Kregel

Meeus

, et al. Effect of pain neuroscience education combined with exercise therapy on chronic spinal pain: a systematic review and meta-analysis. JAMA Neurol. 2018;75(7):808-817.

23.

Watson

Ryan

Cooper

, et al. Pain neuroscience education for adults with chronic musculoskeletal pain: a mixed-methods systematic review and meta-analysis. J Pain. 2019;20(10):1140.e1-1140.e22.

24.

Gatchel

Peng

Peters

Fuchs

Turk

. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007;133(4):581-624.

25.

Nicholas

Asghari

Corbett

, et al.

Is adherence to multidisciplinary chronic pain management programs associated with improved outcomes?

Pain. 2019;160(5):1045-1055.

26.

Yardley

Morrison

Bradbury

Muller

. The person-based approach to intervention development: application to digital health-related behavior change interventions. J Med Internet Res. 2015;17(1):e30. doi:10.2196/jmir.4055.

27.

Forsythe

Carman

Szydlowski

, et al. Patient engagement in research: early findings from the Patient-Centered Outcomes Research Institute. Health Aff (Millwood). 2019;38(3):359-367. doi:10.1377/hlthaff.2018.05067.

28.

Epstein

Street

Jr . The values and value of patient-centered care. Ann Fam Med. 2011;9(2):100-103. doi:10.1370/afm.1239.

29.

Goldstein

Kemp

Leff

Lochman

. Guidelines for adapting manualized interventions for new target populations: a step-wise approach using anger management as a model. Clin Psychol (New York). 2012;19(4):385-401.

30.

Braun

Clarke

. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101.

31.

Braun

Clarke

. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qual Res Psychol. 2021;18(3):328-352.

32.

Sims

Michaleff

Glasziou

Thomas

. Consequences of a diagnostic label: a systematic scoping review and thematic framework. Front Public Health. 2021;9:725877.

33.

Thoits

. Disentangling mental illness labeling effects from treatment effects on well-being. Soc Ment Health. 2021;11(3):183-200. doi:10.1177/2156869320972368.

34.

Nijs

Lahousse

Kapreli

, et al. Nociplastic pain criteria or recognition of central sensitization? Pain phenotyping in the past, present and future. J Clin Med. 2021;10(15):3203.

35.

Ahuvia

Link

. The mental illness self-labeling model: a conceptual model for studying the effects of mental-illness self-labeling on clinical outcomes. Clin Psychol Sci. 2025;13(6):1031-1050. doi:10.1177/21677026241308317.

36.

Voorhees

. “I was literally just not myself”: how chronic pain changes multiple frames of identity. Health Commun. 2023;38(9):1641-1653. doi:10.1080/10410236.2022.2025702.

37.

Kowal

Wilson

McWilliams

Péloquin

Duong

. Self-perceived burden in chronic pain: relevance, prevalence, and predictors. Pain. 2012;153(8):1735-1741. doi:10.1016/j.pain.2012.05.009.

38.

Grover

Fitzpatrick

Azim

, et al. Defining and implementing patient-centered care: an umbrella review. Patient Educ Couns. 2022;105(7):1675-1688. doi:10.1016/j.pec.2021.11.004.