How This Insight Came About
When I first looked for answers about my pain, doctors focused only on scans and tests. None of them looked beyond medical evidence; no one asked about my life, my fears or how pain had reshaped me.
This article explores how chronic pain is assessed in real clinical practice and what that process truly looks like for patients.
It’s also the first time I’ve invited someone directly to share their professional insight. That someone is Eduardo Fondevila, my physiotherapist: a professional whose clarity, depth and empathy have changed how I understand pain. I still remember our first session: nearly two hours of questions and conversation, a look at my scans and a short physical exam. What stayed with me most wasn’t a single answer, but the atmosphere of professionalism combined with compassion.
One question still echoes in my mind:
“If you could do anything right now, what would you do?”
It opened a door to a kind of healing I hadn’t experienced before.
To make this article as accurate as possible, I asked Eduardo to describe his clinical approach: what questions he asks and what principles guide his work with people living with persistent pain. His response offered a clear and deeply human framework that begins with validation, unfolds through exploration and function, and always ends with hope.
For clarity and easy reading, I have structured his explanation into sections, but the ideas, tone and content remain exactly as he shared them. Below is his perspective on how chronic pain is assessed, a look inside the actual clinical interview for long-lasting pain.
Eduardo Fondevila develops his career in three key areas:
- Clinical practice, as manager of ALFA Fisioterapia, focused on pain and disability management in complex patients.
- Academia, as an associate professor at the University, shares his experience with future clinicians.
- Institutional leadership, as President of the Galician Society of Physical Therapists (SOGAFI), where he helps advance professional standards and pain education.
1. Guiding Approach
The clinical interview for persistent non-oncologic pain must differ from that used for acute or subacute cases – a key distinction in how chronic pain is assessed in modern physiotherapy. There is no single standard model; several valid proposals exist, and those that are effective are largely aligned. The aim is to understand the patient’s experience, beliefs and behaviors; to support new coping strategies and functional recovery through listening, validation and education.
Several complementary frameworks can guide a good interview:
- Motivational Interviewing (Miller & Rollnick) – a well-studied model that facilitates behavioral change.
- Cognitive Functional Therapy (Peter O’Sullivan et al.) – developed for chronic low-back pain but applicable to other regions.
- Behavioral Functional Analysis, from Skinner’s behaviorism – psychology understood as the science of behavior, not psychotherapy.
- Explain Pain (David Butler and Lorimer Moseley) – pedagogical and educational approaches that are inspirational.
- Reflective Listening (Bandura) and the Transtheoretical Model of Change (Prochaska and DiClemente) – useful tools for building a good clinical history.
- Elements from ACT (Acceptance and Commitment Therapy) may also be relevant, though these belong more to psychotherapy.
These frameworks, whether general or physiotherapy-specific, can coexist within the same clinical reasoning process.
2. Core Principles
Validation as the Starting Point
The starting point of any clinical interview for persistent non-oncologic pain and, one of the most crucial moments in how chronic pain is assessed, is the validation of the patient’s history. When a patient says they have pain, they have pain. There are exceptions such as simulation for secondary gain, but these are rare. The norm is that if a patient says they’re suffering, they are. Listening to and validating their story is therefore essential. Yet it’s often overlooked in practice.
Understanding Patient Beliefs
Many patients link their pain to visible damage on imaging, while others, when tests show nothing, conclude it must be psychological. It is essential to hear what the patient thinks, what they have been told and what they believe, and to explain both the real meaning of medical tests and the true function of pain.
Observing Thought, Emotion and Behavior
During data collection, it is important to record cognitive, emotional, behavioral, social, physical and lifestyle factors. These can function as facilitators or barriers to recovery. From a behavioral perspective, every action serves a purpose. Whether they are healthy or not is another matter, but judgment must always stay out of the equation. Patients act according to associative or operant contingencies; identifying these helps design strategies to reinforce or reduce specific behaviors.
Working the Plan Together
Decision-making requires the patient’s negotiation, collaboration and consent. After the phase of validation, a second phase begins: not to question the patient, but to propose new perspectives that may be challenging. Negotiation is fundamental, and the patient must remain at the center of every decision.
From Pain to Functionality
Regardless of the approach, the structure is clear:
- Begin by validating pain;
- Then gradually shift the focus toward function and what matters most to the patient, always at their pace.
At some point, once pain has been validated, it becomes necessary to “let go of the story.” Neither mind nor behavior should be treated as fixed entities. We are shaped through continuous learning and conditioning. The goal is to learn new coping strategies centered on healthy functionality. Curiously, as this process develops, pain often improves.
3. Sequence of the Interview
Phase 1 – Validation and Listening
This phase marks the starting point of how chronic pain is assessed in practice.
Objective: acknowledge and legitimize the patient’s experience of pain.
Approach: reflective listening – avoid interruptions or premature solutions.
Possible questions
- “Can you tell me how your pain began and how it has changed over time?”
- “What have the different professionals or medical tests told you about your pain?”
- “How does this pain affect your life right now?”
- “What worries you most about all this?”
- “What would you like other people to understand about what you feel?”
Phase 2 – Exploring Beliefs and Meanings
Objective: identify what the patient believes about the cause and meaning of pain.
Approach: listen to their beliefs without correcting immediately; that information will serve later for education.
Possible questions
- “What do you believe your pain is due to?”
- “What do you think when you look at your imaging or test results?”
- “Have you ever considered that your pain might also have a psychological component? How does that idea make you feel?”
- “What things do you think could help you improve?”
- “Is there anything you noticed that makes your pain worse or better?”
This process helps uncover common beliefs, such as equating pain with structural damage or feeling invalidated when imaging shows nothing.
Phase 3 – Functional Behavioral Assessment
Objective: identify cognitive, emotional, behavioral, social, physical and lifestyle factors that can help or slow recovery.
Key idea: each behavior exists for a reason; what matters is finding what makes it persist.
| Factor | Example Questions |
| Cognitive | “What thoughts appear when your pain increases?” “Do you fear that certain movements might harm you more?” |
| Emotional | “What emotions does pain bring up for you?” “Do you feel frustration, anxiety or fear when it appears?” |
| Behavioral | “What do you usually do when the pain appears?” “Have you stopped doing any activity because of fear?” |
| Social | “How has pain affected your relationships or your work?” “Who can you count on for support?” |
| Lifestyle | “How have you been sleeping lately?” “How are your eating habits and activity level?” “Do you have moments of rest or enjoyment?” |
Phase 4 – Negotiating Focus and Moving Toward Functionality
Objective: progressively shift focus from pain to functionality and personal values.
Approach: after validation, identify meaningful activities and small achievable goals, always paced and co-negotiated.
Possible questions
- “If the pain continued but bothered you less, what would you like to do again?”
- “Which activities are important to you?”
- “What would a good day look like for you?”
- “What small change would you like to achieve this week?”
Phase 5 – Education and Collaborative Planning
Objective: clarify misconceptions, explain the actual function of pain and design a shared plan.
Possible questions
- “Does the explanation about how pain works make sense to you?”
- “Which part feels most difficult to accept or understand?”
- “Would you like to try a controlled exposure, an exercise or a lifestyle change?”
- “What could make it difficult for you to achieve that?”
At this point, expectations must be made clear: this process does not involve pills, massages or magical exercises. It is about learning new coping strategies and behaviors, always recognizing the economic and social limitations of each patient’s life.
Throughout this process, learning is consolidated in three dimensions:
- Giving meaning to pain
- Exposure with control
- Lifestyle changes within the limits of each person’s condition
Phase 6 – Closure and Reinforcement of Hope
Objective: conclude the interview by reinforcing autonomy, meaning and realistic hope.
Possible closing lines
- “You have done a great job explaining your story; that is already part of the process.”
- “You have understood that pain has meaning and that it can change.”
- “We can work so that pain limits you less, reinforcing what matters to you.”
- “It is always possible to improve; there is always a way out.”
4. Elements to Document
During the clinical interview for persistent non-oncologic pain, it is important to record:
- Cognitive factors
- Emotional factors
- Behavioral patterns
- Social context
- Physical aspects
- Lifestyle factors
Each element should be noted as either a facilitator or a barrier to recovery.
5. Common Barriers to Identify
Three behavioral patterns often stand in the way of recovery:
- Fear-avoidance behaviors
- Catastrophizing
- Psychological rigidity
If necessary, they can be assessed with questionnaires during the clinical interview.
6. Expected Experience for the Patient
Patients should expect to be heard, respected and clearly informed; listening itself is part of how chronic pain is assessed by clinicians who see empathy as treatment. They must feel that they are the core participant in the recovery process. Once their story has been validated, the goal is to help them connect with what is valuable and reinforce healthy behaviors through committed action. Persistent pain rarely fades through treatment alone; improvement comes through learning new coping strategies. This process doesn’t rely on medication, passive treatments or quick fixes.
Clear expectations are essential from the start.
The message, however, is one of hope: there is always a way out and improvement is possible. For many people, pain resolves completely; for others, it lessens. Even when it persists, daily life can expand, allowing for greater function and fulfillment.
Conclusion
The clinical interview for persistent non-oncologic pain begins with validation and progresses through listening, negotiation and education. It centers on meaning, functionality and realistic hope.
I’ll close with Eduardo’s words, which I hope help you as much as they helped me. Be kind to yourself and stay curious.
“You can always get better and find a way out of the hell you’re living in now. There is hope.”
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“Clinical Clarity Workbook – A map for precise diagnosis“
Until next time,
Alina