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Integrating mechanistic-based and classification-based concepts into perioperative pain management: an educational guide for acute pain physicians
  1. Yian Chen1,
  2. Eric Wang2,
  3. Brian D Sites3 and
  4. Steven P Cohen4
  1. 1Anesthesiology, Stanford University School of Medicine, Stanford, California, USA
  2. 2Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
  3. 3Anesthesiology and Orthopaedics, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
  4. 4Anesthesiology, Neurology, Physical Medicine & Rehabilitation and Psychiatry & Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
  1. Correspondence to Dr Steven P Cohen, Anesthesiology, Pain Medicine Division, Johns Hopkins School of Medicine, Baltimore, Maryland 21205, USA; scohen40{at}


Chronic pain begins with acute pain. Physicians tend to classify pain by duration (acute vs chronic) and mechanism (nociceptive, neuropathic and nociplastic). Although this taxonomy may facilitate diagnosis and documentation, such categories are to some degree arbitrary constructs, with significant overlap in terms of mechanisms and treatments. In clinical practice, there are myriad different definitions for chronic pain and a substantial portion of chronic pain involves mixed phenotypes. Classification of pain based on acuity and mechanisms informs management at all levels and constitutes a critical part of guidelines and treatment for chronic pain care. Yet specialty care is often siloed, with advances in understanding lagging years behind in some areas in which these developments should be at the forefront of clinical practice. For example, in perioperative pain management, enhanced recovery protocols are not standardized and tend to drive treatment without consideration of mechanisms, which in many cases may be incongruent with personalized medicine and mechanism-based treatment. In this educational document, we discuss mechanisms and classification of pain as it pertains to commonly performed surgical procedures. Our goal is to provide a clinical reference for the acute pain physician to facilitate pain management decision-making (both diagnosis and therapy) in the perioperative period.

  • Acute Pain
  • Fibromyalgia
  • Pain, Postoperative

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  • YC and EW are joint first authors.

  • Twitter @sites_brian

  • Contributors SPC and BDS: conceived of study. EW, YC, BDS and SPC: wrote and edited manuscript. SPC: guarantor.

  • Funding Funded in part by a grant from MIRROR, Uniformed Services University of the Health Sciences, U.S. Dept. of Defense, grant # HU00011920011. The sponsor did not play a role in study design or performance, or analysis or interpretation of data.

  • Competing interests SPC: serves as a consultant for Avanos and SPR, which make radiofrequency equipment and peripheral nerve stimulators, that have been studied for perioperative pain.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.