Guide
Chronic pain and inflammation: what an integrative assessment can and cannot do
Integrative care for chronic pain works best as an addition to the NICE NG193 pathway, not a replacement. A longer assessment can find treatable contributors that short appointments miss, but no honest clinic promises to take the pain away, and inflammation is usually the wrong word for what is happening.
Who this guide is for
If you have hurt for more than three months, you have been through the pain clinic or are waiting for one, and the offer so far has been medication you do not want to take or exercise you cannot manage, this is written for you.
I am a hospital doctor who also runs a private functional medicine practice in Twickenham and Richmond, and online. I am not a pain specialist and this guide is not going to pretend otherwise. What I can do is a long assessment that looks for things which are treatable and often missed, and be straight with you about how much difference that is likely to make.
I have a commercial interest in you booking. The section on what the evidence supports is the one to read first.
What NICE actually says, and why people are angry about it
NICE NG193, published in 2021, governs chronic pain in the UK and it is worth knowing what it says, because a great deal of private marketing is built on people's frustration with it.
It divides chronic pain into two kinds. Chronic secondary pain is pain caused by an underlying condition - osteoarthritis, rheumatoid arthritis, endometriosis, nerve injury. Chronic primary pain is pain that persists beyond three months with no other diagnosis that accounts for it. Fibromyalgia and chronic widespread pain sit here.
For chronic primary pain, NICE recommends not starting paracetamol, non-steroidal anti-inflammatories, opioids, benzodiazepines or gabapentinoids, because the evidence shows little benefit and real harm over time. What it recommends considering instead is supervised exercise, cognitive behavioural therapy or acceptance and commitment therapy, acupuncture within defined limits, and certain antidepressants.
People find this infuriating, and I understand why. Being told that the drugs do not work, when you are in pain, sounds like being told the pain is not real. It is not what the guideline says. It says those drugs do not help enough, for long enough, to justify what they do to you.
About the word inflammation
This needs saying plainly, because 'chronic inflammation' is the phrase private clinics lean on hardest and it is frequently the wrong description of what is happening.
In chronic secondary pain from an inflammatory disease - rheumatoid arthritis, an active flare of inflammatory bowel disease - there is measurable inflammation, and treating it helps. That is real.
In chronic primary pain, inflammatory markers are usually normal. The mechanism is better understood as changes in how the nervous system processes pain signals: the volume control is turned up, and it stays up. That is not imaginary and it is not psychological in the dismissive sense. It is a real, physical change in a real, physical system. But it is not inflammation, and treating it as though it were - with anti-inflammatory supplements, elimination diets and inflammation panels - aims at the wrong target.
So when someone offers to find and treat your chronic inflammation, a fair question is: which marker, measured how, and what happens if it is normal?
Contributors that are treatable and often missed
This is where a long appointment earns its place. None of these cures chronic pain. Each of them makes pain worse when present, and each is addressable.
| Contributor | Why it matters | What I do |
|---|---|---|
| Poor or disordered sleep | The relationship with pain runs both ways, and poor sleep reliably lowers pain threshold. It is the single most productive thing to address. | Detailed sleep history, screening for sleep apnoea, referral for a sleep study where indicated. |
| Vitamin D deficiency | Common, and associated with musculoskeletal pain. The trial evidence for supplementation relieving pain is weak, but correcting a genuine deficiency is worth doing anyway. | Measure it. Treat it if low. Do not promise it will fix the pain. |
| Iron deficiency and anaemia | Drives fatigue, which drives deconditioning, which drives pain. | Full iron studies, not just haemoglobin. |
| Thyroid disease | Hypothyroidism causes muscle pain and fatigue and is missed regularly. | Thyroid function, properly interpreted. |
| Undiagnosed inflammatory or structural disease | Some chronic primary pain turns out to be chronic secondary pain that nobody has diagnosed. Endometriosis is the commonest example and averages years to diagnosis. | A careful history. Referral back into the NHS where the picture fits. |
| Mood, and being disbelieved | Depression and anxiety worsen pain and are worsened by it. Years of not being believed does its own damage. | Asked about directly, treated as a consequence rather than an explanation. |
| Deconditioning | Understandable and self-reinforcing. Activity avoidance shrinks the range of things that can be done without a flare. | Graded, paced activity planning - not a prescription to exercise more. |
| Medication side effects | Some of the fatigue and fog attributed to pain belongs to the drugs used to treat it. | Full medication review, with letters to the prescriber. |
What the evidence supports
Honestly, and in rough order of how well it holds up.
- Supervised exercise and paced activity. The strongest evidence of anything in chronic primary pain, and NICE recommends it. The difficulty is that it has to be genuinely graded, because doing too much too soon produces a flare and puts people off for a year.
- Psychological therapy - CBT or ACT. Also NICE-recommended. This is not being told the pain is in your head. It is treatment aimed at the nervous system pathway that is actually involved.
- Acupuncture. NICE recommends considering it for chronic primary pain, within specific limits on course length and cost. The effect is modest and the evidence is contested, but it is in the guideline, which is more than most things offered privately can say.
- Certain antidepressants, including duloxetine and amitriptyline, which NICE says can be considered for chronic primary pain regardless of whether you are depressed. They work on pain pathways, not only on mood.
- Sleep treatment. Not specific to pain guidelines, but consistently useful in practice.
- Correcting real deficiencies. Modest, and worth doing.
What I would not claim: that supplements, elimination diets or intravenous infusions treat chronic pain. The evidence is not there, and I do not offer intravenous nutrient therapy for pain or fatigue.
Tests I will tell you not to buy
Private inflammation panels
Broad panels of inflammatory markers and cytokines, sold as a way to find hidden inflammation. In chronic primary pain they are usually normal, and when a single value comes back mildly out of range it generates a supplement plan rather than a diagnosis. CRP and ESR are worth measuring, are available on the NHS, and answer the question that actually matters: is there an inflammatory disease here that has been missed.
IgG food sensitivity panels
Sold for pain on the theory that food is driving inflammation. IgG antibodies to food reflect what you eat. The main result of acting on them is a narrower diet.
Hair mineral analysis, applied kinesiology, bioresonance
No evidence base for chronic pain.
A realistic aim
I cannot promise to take your pain away, and I would be suspicious of anyone who does. What is realistic is a reduction in the things making it worse, more predictable days, a wider range of activity without a flare, and occasionally a diagnosis nobody had made.
Some people get a good deal from that. Some get very little, and I would rather say so at the outset than after three appointments. If you have already had a thorough workup, your sleep is good, your bloods are normal and you are doing paced activity and psychological therapy, there is honestly not much I can add.
What it costs, and the trade-offs
My fees are set out in full on the fees page. Testing is separate.
| In favour | Against |
|---|---|
| Two hours to go through a history that short appointments cannot cover | You pay for it. NHS pain services are free, if slow |
| Contributors found and treated that nobody had checked | None of them is a cure, and the effect is often modest |
| Sleep, mood, diet and deconditioning addressed together | A pain consultant or pain psychologist knows more about pain than I do |
| Occasionally a missed diagnosis, which changes everything | Most of the time there is not one |
| No waiting list | The treatments with the best evidence - exercise programmes, CBT, ACT - are largely NHS services you may still need |
If you are waiting for an NHS pain management programme, take the place when it comes. Those programmes deliver the interventions with the strongest evidence, and nothing I offer replaces them.
About the writer
I am Dr Andrew Greenland, GMC 4419909. I qualified in London in 1997, I am a Fellow of the Royal College of Emergency Medicine, and I still work at consultant level in an NHS hospital in west London alongside my private practice. I am a certified functional medicine practitioner.
I see patients in Twickenham and Richmond in Greater London, and online across the UK. I write to patients' GPs with their consent, and I see every patient myself.
Common questions
How effective are integrative clinics for long-term chronic pain management?
Modestly, and as an addition rather than a replacement. The interventions with the best evidence in chronic primary pain - supervised graded exercise, CBT or ACT, and certain antidepressants - are mostly NHS services. What a long private assessment adds is finding treatable contributors that short appointments miss: sleep disorder, deficiency, thyroid disease, medication side effects, and occasionally a missed diagnosis. Anyone claiming an integrative approach resolves chronic pain is overstating it.
Is fibromyalgia real?
Yes. It is a recognised diagnosis and it describes a real change in how the nervous system processes pain. It is classified as chronic primary pain, which means it is not caused by another condition rather than that it is not caused by anything. Being told your tests are normal is not the same as being told nothing is wrong.
Will you stop my painkillers?
Not abruptly, and not unilaterally. Stopping opioids or gabapentinoids suddenly is dangerous. NICE advises against starting them for chronic primary pain, which is a different question from what to do when someone is already established on them. If a reduction makes sense, it is planned slowly and with whoever prescribes them.
Can you treat my chronic inflammation?
It depends whether you have any. In inflammatory disease there is measurable inflammation and treating it helps. In chronic primary pain the markers are usually normal, and the mechanism is a change in pain processing rather than inflammation. I would want to measure before treating, and if the markers are normal I will say so rather than sell you an anti-inflammatory programme.
Do I need a diagnosis before I come?
No, and a good number of people I see do not have one. But if your history suggests an inflammatory, structural or gynaecological cause that has not been investigated, my job is to get you into the right NHS pathway, not to keep you in private care.
Sources
- NICE NG193. Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain.
- Nijs J et al. Nociplastic pain criteria: a proposal for their application in clinical practice. Lancet Rheumatol 2021.
- Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain 2013.
- Geneen LJ et al. Physical activity and exercise for chronic pain in adults: overview of Cochrane Reviews. Cochrane Database Syst Rev 2017.
Written and reviewed by Dr Andrew Greenland, MBBS, MRCSEd, FRCEM, FMCP-M, a practising hospital doctor and certified functional medicine practitioner. Registered with the General Medical Council, number 4419909(verify). This guide is general information and not a substitute for individual medical advice.
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