From left: Jakob Bjertnæs and Petter Christian Borchgrevink have collaborated on a programme aimed at GPs. Doctors receive advice on how to help patients with pain without resorting to unnecessary medical tests and medications.

1.5 million Norwegians have chronic pain. In most cases, doctors cannot find the cause

A number of patients return to their doctor and ask for new tests to be taken, time and time again. “Chronic pain without a known cause is undoubtedly one of the most demanding issues for GPs to work with,” says Jakob Petter Bjertnæs.

Almost two-thirds of individuals who suffer from chronic pain do not have known illnesses that can explain it.

“Only in 37 per cent of the cases did we find that there was an exact cause for the pain, such as arthritis and osteoarthritis,” says Petter Christian Borchgrevink.

He is a senior physician and professor at St. Olav's Hospital at the Norwegian University of Science and Technology (NTNU) and has led a large study from the Trøndelag Health Study (HUNT).

Lower back and neck

The study included 551 people who were representative of people with chronic pain in the general population.

Most had moderate or severe pain. The majority were either working or had retired.

A group of experienced doctors, psychologists, and physiotherapists conducted several thorough clinical examinations of the participants.

They also had access to the participants’ medical records and results from X-ray examinations.

Each participant in the study was thoroughly examined by specialists in pain and pain relief, including doctors, psychologists, and physiotherapists.

The study participants also filled out a form where they self-reported their chronic pain.

The study showed that 80 per cent had chronic musculoskeletal pain with pain in the lower back and neck, which are the most common pain conditions.

New diagnostic system

The World Health Organization (WHO) has published an updated version of the International Classification of Diseases (ICD-11).

This will soon be implemented in the diagnostic system in Norway. It will recognise pain conditions without a known cause, allowing patients with such diagnoses to have their conditions acknowledged by the medical community.

Often explained as "something psychological"

If no exact physical cause for the pain is found, it is easy to come to the conclusion that the cause must be psychological.

Previous views on chronic pain have often left the impression that this must be the case, according to Borchgrevink.

“This is an old-fashioned way of thinking and an incorrect approach that we have followed for far too long,” he says.

The research group he led found nothing to indicate that this is the case.

No higher incidence of mental health problems

Those with chronic pain from an unknown cause had no more psychiatric diagnoses than those with chronic pain associated with a known disease.

Around ten per cent had a psychiatric diagnosis. This finding surprised the researchers.

There were approximately the same number of people in the group with a known cause of the pain and in a control group without pain.

“If we had had a different sample, such as patients at a pain clinic, we probably would have found more people with mental health problems,” Borchgrevink says.

Did not exaggerate their pain

The study also showed that patients did not exaggerate their pain.

In fact, the professionals found more people with chronic pain than they would have expected based on what the participants themselves reported.

“This also surprised us,” says Borchgrevink.

Stop looking for a cause

Borchgrevink believes that this study clearly shows that the continuous investigations that people with chronic pain undergo in the healthcare system must stop.

“When a patient has been thoroughly examined and all relevant blood tests and X-rays have been conducted without finding anything, we must stop. There is no point in continuing the search for an exact cause when it doesn't exist. GPs and patients should rather focus on measures to manage the pain,” he says.

Their results also reinforce the message that it is important to limit the use of opioids, Borchgrevink believes.

GPs recognise the situation

Jakob Petter Bjertnæs is a GP, and is very familiar with the results, which show that in almost two-thirds of the cases, a cause for chronic pain cannot be found.

He believes it is important to share this research with patients.

“Chronic pain without a known cause is undoubtedly one of the most demanding issues for GPs to work with. As much as 30 per cent of a GP’s clinical practice involves pain management,” he says.

A significant problem

Many patients believe that if their doctor does not find something concrete in blood tests or imaging, then not enough has been done to identify the cause. This leads to a desire for even more tests and imaging, often repeated by different doctors, says Bjertnæs.

“Some pain patients like to change their GP because the one they have can't find a cause for their pain. The new GP often faces the expectation of starting over because the previous one was unable to find the cause," he says.

He sees this as a major problem for the healthcare system.

Must take the patient seriously

At the same time, it is very important to take the patient with pain seriously, Bjertnæs believes.

“This involves thoroughly reading the thick medical files that chronic pain patients often have. I usually create a summary of the tests and images that have been taken. Then the patient can clearly see that many images and tests have been conducted, without finding anything that can explain the pain,” he says.

By creating a comprehensive overview, the GP can show the patient that they are being taken seriously, he believes.

Developed a tool

Petter Christian Borchgrevink and Jakob Petter Bjertnæs have collaborated to develop a treatment programme for GPs called NOMED.

They identified 17 factors that maintain and exacerbate chronic pain.

Such factors can include sleep problems, loneliness, poor physical condition, depression, anxiety, worries about work and social security, health anxiety, and brooding.

“Chronic pain can affect relationships with those closest to the patients. Many pain patients struggle with poor relationships with their loved ones. Many have also had painful experiences in their childhoods and as a young adult,” Borchgrevink says.

Have tested the tool

Bjertnæs has tested this programme at his GP's office.

When a patient has accepted that a thorough investigation has been conducted and sufficient tests have been taken, he explains the 17 factors that exacerbate and prolong pain.

“I then ask if the patient is interested in trying a new treatment plan that does not involve medications. The patients are then given homework to read various texts and watch the corresponding videos,” he says.

In the next consultation, he discusses which of these factors are most relevant to the patient to work on further.

Completely obvious

Pain itself can be difficult to explain, but it worsens with various problems in life.

It is possible to address many of the factors that maintain and exacerbate the pain, Borchgrevink believes.

“Most people with chronic pain know, for example, that sleep problems make the pain worse. So do worries about social security and finances. Pain patients find this quite obvious,” he says.

This is actually something GPs can help pain patients with, he believes.

For most people, talking to their GP can be enough, according to Borchgrevink.

“But sometimes you open up a problem that is so big that the GP must refer the patient to a psychologist,” he says.


Borchgrevink et al. A Clinical Description of Chronic Pain in a General Population Using ICD-10 and ICD-11 (The HUNT Pain Examination Study)The Journal of Pain, vol. 23, 2021. DOI: 10.1016/j.jpain.2021.08.007


Translated by Nancy Bazilchuk

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