---
id: wiki-2026-0508-chronic-pain-management
title: Chronic Pain Management Protocols
category: 10_Wiki/Topics
status: verified
canonical_id: self
aliases: [chronic pain, central sensitization, biopsychosocial, GMI, pain neuroscience education, opioid alternative]
duplicate_of: none
source_trust_level: B
confidence_score: 0.85
verification_status: conceptual
tags: [pain, chronic-pain, biopsychosocial, neuroplasticity, gmi, cbt, exercise, mindfulness, opioid-crisis]
raw_sources: []
last_reinforced: 2026-05-10
github_commit: pending
tech_stack:
  language: medical / behavioral
  applicable_to: [Healthcare, Productivity, Wellness, Cognitive Workers]
---

# Chronic Pain Management Protocols

## 📌 한 줄 통찰
> **"매 pain = 매 brain interpretation"**. 매 tissue 의 heal 후 도 매 brain 의 alarm system 의 stuck. 매 modern: 매 biopsychosocial + 매 neuroplasticity rewire. 매 opioid 의 trap 의 alternative.

## 📖 핵심

### 매 mechanism

#### Acute → Chronic transition
- 매 3 month 이상 의 pain.
- 매 tissue heal 후 도 의 persist.
- 매 nervous system 의 sensitize.

#### Central Sensitization
- 매 spinal cord 의 hyperexcitable.
- 매 light touch 의 매 severe pain.
- 매 NMDA receptor 의 upregulate.

#### Cortical reorganization
- 매 somatosensory cortex 의 remap.
- 매 phantom limb pain 의 example.

#### Biopsychosocial model (Engel 1977)
- **Bio**: tissue / neural.
- **Psycho**: anxiety / depression / catastrophizing.
- **Social**: support / context / culture.

→ 매 3 의 mutually reinforce.

### 매 modern protocol

#### 1. Pain Neuroscience Education (PNE)
- 매 patient 의 pain 의 understand.
- 매 fear-avoidance 의 reduce.
- 매 Lorimer Moseley 의 pioneer.

#### 2. Graded Motor Imagery (GMI)
- 매 stage 1: laterality recognition.
- 매 stage 2: 매 imagined movement.
- 매 stage 3: 매 mirror therapy.
- 매 phantom limb / CRPS 의 effective.

#### 3. Graded exercise / exposure
- 매 baseline 의 set.
- 매 매 week 의 small ↑.
- 매 fear-avoidance 의 break.

#### 4. CBT (Cognitive Behavioral Therapy)
- 매 catastrophizing 의 reframe.
- 매 acceptance.
- 매 ACT (Acceptance and Commitment Therapy).

#### 5. Mindfulness / MBSR
- 매 Jon Kabat-Zinn.
- 매 attention 의 shift.
- 매 default mode network 의 modulate.

#### 6. Movement-based
- 매 Tai Chi, 매 Qi Gong, 매 Yoga.
- 매 systematic review 의 evidence.

#### 7. Multimodal (gold standard)
- 매 PT + 매 psychology + 매 medical.
- 매 specialist team.

### 매 medication (last resort / adjunct)
- **NSAIDs**: 매 acute / inflammatory.
- **Acetaminophen**: 매 mild.
- **Anticonvulsants** (gabapentin, pregabalin): 매 neuropathic.
- **SNRI** (duloxetine): 매 fibromyalgia.
- **Topical** (lidocaine, capsaicin).
- **Opioids**: 매 last resort, 매 short-term.

→ 매 CDC 의 opioid crisis 의 lesson.

### 매 biological factor
- **BDNF**: 매 neuroplasticity.
- **Inflammation**: 매 IL-6, TNF-α.
- **Sleep deprivation**: 매 pain ↑.
- **Stress / cortisol**: 매 sensitization.
- **Microbiome**: 매 emerging research.

### 매 cognitive worker 의 specific
- **Sedentary pain**: 매 neck / back.
- **Repetitive strain**: 매 RSI / carpal tunnel.
- **Eye strain**: 매 20-20-20 rule.
- **Movement break**: 매 Pomodoro.
- **Posture / ergonomics**.

### 매 anti-pattern
- 매 "매 push through pain".
- 매 stay in bed 만.
- 매 opioid 의 long-term.
- 매 single-cause search.
- 매 "매 imaging 의 verdict 의 trust".
- 매 "매 mind 만" 의 dismiss (real biology).

## 💻 패턴 (응용 — productivity / wellness)

### Pain monitoring (cognitive worker)
```python
class PainLog:
    def __init__(self):
        self.entries = []
    
    def log(self, severity, location, activity, time_of_day):
        self.entries.append({
            'severity': severity,  # 0-10
            'location': location,
            'activity': activity,
            'time': time_of_day,
        })
    
    def trend(self, days=30):
        recent = self.entries[-days*3:]  # 매 ~3 entries / day
        return {
            'avg_severity': np.mean([e['severity'] for e in recent]),
            'common_locations': collections.Counter(e['location'] for e in recent).most_common(3),
            'trigger_activities': collections.Counter(e['activity'] for e in recent if e['severity'] >= 6).most_common(3),
        }
```

### Pomodoro + movement break
```python
def deep_work_with_break():
    return [
        ('25 min', 'deep work — sit'),
        ('5 min', 'walk + stretch + 20-20-20 (look 20ft for 20 sec)'),
        ('25 min', 'deep work — stand desk'),
        ('5 min', 'movement break — neck rotations + wall press'),
        ('25 min', 'deep work'),
        ('15 min', 'long break — outside walk'),
    ]
```

### Graded exposure (return to activity)
```python
def grade_exposure(activity, baseline_min, weeks=12):
    """매 baseline (no flare) 의 60-80% 의 start, 매 매주 10% ↑."""
    schedule = []
    current = baseline_min * 0.7
    for week in range(weeks):
        schedule.append({
            'week': week + 1,
            'activity': activity,
            'duration_min': round(current),
            'note': 'stop if pain >= 6/10 for >24h',
        })
        current *= 1.1
    return schedule
```

### Mindfulness session
```python
def mbsr_session(duration_min=20):
    return [
        ('1 min', 'Settle — feel chair, feet, hands.'),
        ('3 min', 'Breath awareness — natural rhythm.'),
        ('5 min', 'Body scan — toes → head, neutral observation.'),
        ('5 min', 'Pain area — turn TOWARD with curiosity, not resistance.'),
        ('3 min', 'Whole body awareness.'),
        ('3 min', 'Open awareness — sounds, thoughts as visitors.'),
    ]
```

### Cognitive reframing (CBT)
```python
def reframe_catastrophic_thought(thought):
    """매 user-side reframing template."""
    return {
        'original': thought,
        'evidence_for': [],
        'evidence_against': [],
        'alternative_thought': '...',
        'severity_now (0-10)': 0,
    }

# 매 example
thought = "이 통증은 영원할 거야, 나는 망했어"
reframed = {
    'original': thought,
    'evidence_for': ['지금 매우 아프다'],
    'evidence_against': ['과거 이런 통증이 결국 가라앉은 적 있다',
                          '의사는 신경적 과민이지 조직 손상이 아니라고 했다',
                          '운동 후 가끔 좋아진다'],
    'alternative': "지금 매우 불편하지만 일시적이고, 내가 할 수 있는 것이 있다.",
    'severity_now': 5,  # 매 down from 8
}
```

### Sleep hygiene (pain modulator)
```python
def pain_sleep_protocol():
    return {
        'consistent_bedtime': '23:00',
        'wake_time': '07:00',
        'wind_down_60min_before': True,
        'no_screen_60min_before': True,
        'cool_room': '18-20 °C',
        'caffeine_cutoff': '14:00',
        'alcohol_limit': '1 drink, not within 3h of bed',
        'magnesium_glycinate': '300-400 mg before bed',
    }
```

### Multidisciplinary care plan (template)
```yaml
# Chronic Pain — Multimodal Plan (12 week)
weeks_1_4:
  pain_neuroscience_ed: 1 / week
  pt_sessions: 2 / week (graded)
  cbt: 1 / week
  movement: walk 20 min daily
  meds: NSAID PRN, gabapentin 300 mg TID

weeks_5_8:
  pt_sessions: 1-2 / week
  cbt: 1 / week
  movement: walk 30 min + tai chi 2x / week
  graded_exposure: return to 50% baseline

weeks_9_12:
  pt: every 2 weeks
  self-managed exercise
  graded_exposure: 80% baseline
  mindfulness: daily 20 min

milestones:
  - week_4: pain severity ↓ 20%
  - week_8: function ↑ 50%
  - week_12: medication taper
```

## 🤔 결정 기준
| 상황 | Approach |
|---|---|
| Acute < 3 mo | RICE + NSAID + early movement |
| Subacute | Graded exposure + PT |
| Chronic (3+ mo) | Multimodal (PNE + PT + CBT + meditation) |
| Phantom limb | GMI + mirror therapy |
| Fibromyalgia | SNRI + tai chi + CBT |
| Neuropathic | Anticonvulsant + topical |
| Cognitive worker | Movement break + posture + sleep |

**기본값**: 매 multidisciplinary + 매 active engagement (medication 만 X). 매 항상 의 의사 consult.

## 🔗 Graph
- 변형: [[Central-Sensitization]] · [[Biopsychosocial]] · [[Pain-Neuroscience-Education]] · [[GMI]]
- 응용: [[CBT]] · [[Yoga]]
- Adjacent: [[Bioenergetics]] · [[Brain-Derived Neurotrophic Factor (BDNF)]] · [[Addiction Neuroscience]] (opioid risk)

## 🤖 LLM 활용
**언제**: 매 productivity wellness routine. 매 cognitive worker burnout. 매 multidisciplinary protocol design.
**언제 X**: 매 specific medical advice (의사 consult). 매 medication recommendation 의 substitute.

## ❌ 안티패턴
- **Push-through-pain culture**: 매 sensitization 의 worsen.
- **Bed rest only**: 매 deconditioning.
- **Opioid long-term**: 매 dependence + 매 hyperalgesia.
- **Single-cause search**: 매 imaging의 over-rely.
- **"Mind only" 의 dismiss**: 매 real biology.
- **Push-then-crash cycle**: 매 graded 의 ignore.
- **No sleep / stress mgmt**: 매 pain modulator 의 ignore.

## 🧪 검증 / 중복
- Verified (Moseley PNE, Engel biopsychosocial 1977, CDC opioid guideline 2022).
- 신뢰도 B.
- Related: [[Bioenergetics]] · [[Brain-Derived Neurotrophic Factor (BDNF)]] · [[Addiction Neuroscience]] · [[Bayesian-Brain-Hypothesis]].

## 🕓 Changelog
| 날짜 | 변경 |
|---|---|
| 2026-05-08 | Phase 1 |
| 2026-05-10 | Manual cleanup — biopsychosocial + GMI + multimodal + 매 protocol / reframe / Pomodoro code |