Complex chronic pain often develops over time, with layers of primary pain, compensatory pain, nervous system sensitization, inflammation, fear, guarding, and failed treatment attempts building on top of one another. At Manhattan Pain Medicine, we approach complex chronic pain by reverse-engineering the full pain story: what started it, why it persisted, what changed in the body, and what needs to happen next.
Complex chronic pain requires a personalized approach. Dr. Siefferman explains how comprehensive care can help.
Our team organizes conditions and treatments into related zones of expertise to make it easier to explore the care paths most relevant to your symptoms and goals.
Use the zone tags above to browse dedicated pages for each focus area, including services, providers, and what to expect during treatment.
Hi, I’m Dr. Jason Siefferman at Manhattan Pain Medicine, and I would like to speak with you about one of our zones of expertise: complex chronic pain. Pain is a sensation and it’s an emotional response to that sensation which, when it’s new, generally indicates that there’s some physiologic process that’s not going correctly. There’s an injury. Something’s not working right. When that signal has been going on for some period of time, the body adjusts to it. It starts to centralize and it becomes more complex.
The second thing that happens is mechanically, when there’s pain in one area of the body, we adjust how we use our body to avoid that pain. If your knee hurts, you’re going to put less weight on that knee. Over time, that means you’re going to put more weight on something else. And these biomechanical compensations will cause new and different pains. These we call secondary pains.
We define complex chronic pain as a zone of expertise because it is a very unique situation. Complex chronic pain can include a number of diagnoses. It’s not diagnosis specific at all. It simply means that pain has been existing for some time and because it has not been treated, there has been an accumulation of other pains building up on top of it like a snowball going down the mountain catching debris as it goes.
So when we meet patients with complex chronic pain, our goal is to understand what happened. To do that, we really have to understand your full history. We have to know broadly what’s going on in your body. So, if you are someone with complex chronic pain, we endeavor to fully understand at the most root levels why it’s happening, why it’s not getting better, and coming up with a plan that will comprehensively address all of those reasons.
When we think of complex chronic pain, we think of a situation where pain began for some reason and it failed to get better, and over time other layers of pain have built up. This may happen because of biomechanical adjustments from that original pain that never healed, or it may happen because the nervous system is becoming sensitized, or there may be some combination. Generally, at the core, there’s an undiagnosed reason for the persistence of that pain. And so when we meet patients with some collection of complex chronic pain, we really want to understand what we need to address in order for the body to heal and for things to get better.
By the time patients reach us, they’ve often been experiencing pain for many years. And usually, it’s not just one pain. Usually, it’s multiple pains that have built up over time. There’s layers of sensitization of the nervous system. And then there’s also usually psychological situations. Complex chronic pain is rarely about a single structure or diagnosis. It can involve the nervous system, the muscles, joints, patterns of compensation, inflammation, past injuries, new injuries, and it may affect sleep. It may affect stress, your ability to work, engage with family, and there’s some cumulative effect of all of these things that sumate over time and add to the complexity.
We view complex chronic pain as one of our zones of expertise because it really does take a collaborative effort across multiple providers with different specialties to understand not only what is going on in the moment, but what happened originally, why it persisted, why it didn’t get better, which layers piled up, and what do we need to do now in order to reverse engineer all of that and get you to where you want to be.
When we approach a situation of complex chronic pain, we understand that that patient has two needs. First, they need some comfort; they need some relief. They’ve been struggling or suffering for some period of time, they need some immediate options that are going to give them some sense of control over their situation. The second thing we do is identify what’s going on in the background. Why did this pain start? How did it start? Why is it persisting? Why is it not getting better?. We really have to understand what’s behind all of this and what’s driving it and why it’s not getting better in order to find a treatment that will actually be durable. Because as you likely know, most pain medications don’t really treat the underlying issue; they’re just a band-aid.
At Manhattan Pain Medicine, we work collaboratively. This is why we have doctors that not just do interventional pain, but also regenerative medicine, pain psychology, rheumatology, pelvic pain, headache. We really try to cover the gamut of reasons for pain so that we can fully understand what’s going on, and we have to come up with a comprehensive treatment plan that will really address the underlying reasons for all of these pains. We call it complex chronic pain because there’s generally not a quick fix in order to get a more robust solution for that patient. We really have to reverse engineer what’s going on. I make an analogy: it’s like if you have a knot and you have to untie a very difficult, complex knot. You see which thread to pull on first, but you don’t always know which thread to pull on next. Unfortunately, the first visit, the second visit, we usually don’t have very solid answers. We have a process of discovery that will lead us to those more solid answers.
Complex chronic pain is rarely one isolated injury or diagnosis. It often begins with a primary pain generator that does not heal, then the body adapts. Movement changes, muscles guard, joints compensate, nerves become more reactive, inflammation may amplify symptoms, and new pain patterns begin to form.
Over time, these layers can become more disabling than the original problem. Patients may arrive with widespread pain, multiple diagnoses, long treatment histories, hypersensitivity, fear of flares, and a sense that no one has been able to explain how all the pieces fit together.
At Manhattan Pain Medicine, this zone is designed for patients whose pain requires deeper discovery, direct physician evaluation, and a structured process for untangling the knot. The goal is not to chase every symptom separately, but to understand the full pattern and identify which thread to pull first.
Complex chronic pain often requires collaboration across pain medicine, rheumatology, rehabilitation, pain psychology, headache care, pelvic pain, regenerative medicine, and other clinical perspectives. This zone is designed for patients who need a broader, more integrated evaluation of long-standing pain.
Patients may benefit from evaluation when pain has lasted for months or years, spread beyond the original area, failed multiple treatments, become associated with hypersensitivity, flares, guarding, fatigue, sleep disruption, anxiety around movement, or uncertainty about which diagnosis is truly driving the pain.
Complex chronic pain is not solved by treating every symptom at once. We work step by step, using history, examination, imaging, medication response, diagnostic injections, rehabilitation response, and nervous system regulation to understand the order of care. Each response becomes a data point that helps clarify what is driving the pain.
Your evaluation may include a detailed review of the full pain timeline, prior diagnoses, past procedures, medications, imaging, physical therapy response, flare patterns, sensory sensitivity, sleep changes, functional limitations, and emotional impact. The goal is to organize the story into a clearer clinical map, then identify which pain generators and sensitization patterns should be tested first.
Two patients may both have complex chronic pain, but the reasons may be completely different. One may have unresolved mechanical instability, another may have central sensitization, another may have inflammatory disease, and another may have layers of compensation after years of guarding. Understanding the pattern helps determine the order of care.
I cannot say enough good things about Manhattan Pain Medicine. From the moment I walked in, I felt truly cared for and taken seriously. Dr. Nino Mikaberidze, Director of Rheumatology, is exceptional — knowledgeable, compassionate, and incredibly thorough. She takes the time to listen, explains every...
The best care I've received as a chronic pain patient. I traveled from out of state to visit Manhattan Pain Medicine because I could not find knowledgeable doctors in my hometown for my hypermobility, and Ehlers-Danlos syndrome symptoms and comorbidities. Let me tell you, it was worth every travel e...
I was injured in a bicycle accident over 8 years ago. I’ve suffered throughout the years since my accident with nothing seeming to work. PT, Yoga, lifestyle changes, NOTHNG! I finally made an appointment with Dr Kane and I’m feeling an improvement in my life. I no longer stay up all night in pain, a...
One of the best experiences, if not the best, I have ever had at the doctor’s office. From the front desk to the nurses to the PA assisting the doctor this was a great experience. Dr.Nino actually listened to me and came up with a game plan. Would recommend this practice to as many people as I could...
I have very unique & severe nerve pain from CRPS which has no known specific cure. Dr. Siefferman has a huge tool box, far greater than the other 23 Drs. I have seen. He saved me from jumping off a bridge and continues to help me with both treatments and advice. Dr. S. is in a different league!
After two years of searching and feeling lost and let down, I finally found real help at Manhattan Pain Medicine. With Dr. Siefferman, Adam Rosenberg, Dr. Mikaberidze, and the whole team, I feel heard, supported and understood. Every symptom is being considered and I’m finally getting answers with m...
Why is Dr Dr. Tayyaba Ahmed one of the top pevic Floor specialists - 1- She wants to know a full history of what led the patient to get to this point. 2 - She listens intensley to the patient 3- She does not rush you 4- Extremely skilled at giving pelvic floor injections 5- I thank my luck stars she...
The staff was friendly and helpful. Dr. Siefferman was thoughtful, listened, asked questions and proposed simple safe ways to come to further conclusions regarding my pain and discomfort. The office staff including Dr. Siefferman is responsive even after the initial in-person visit. Very pleased.
Dr. Siefferman is a brilliant provider. While my pain is still a work in progress, Dr Siefferman always gives me options and explains his reasoning behind things. He listens to my feedback and concerns. I never feel rushed; and am grateful he works to meet me where I am. I highly recommend him.
What a great find! They listen to me, I listen to them and the diagnosis is made and a plan developed to develop an approach to treat all of my chronic pain. I wish I could have discovered this type of treatment sooner. This doctor and group give me hope.
Complex chronic pain is pain that has lasted long enough to develop additional layers. It may involve the original injury or pain generator, compensatory movement patterns, muscle guarding, joint stress, nerve sensitivity, inflammation, emotional distress, and central sensitization. The pain is often no longer explained by one structure alone.
Pain can spread when the body changes how it moves to protect the original painful area. Those compensations can overload other joints, muscles, nerves, or connective tissues. At the same time, repeated pain signals can make the nervous system more reactive, causing symptoms to feel more widespread or intense.
Central sensitization occurs when the nervous system becomes overly reactive after repeated or prolonged pain signaling. The body may begin to amplify normal sensations, respond strongly to minor irritation, or create severe flares after triggers that would not usually cause significant pain.
This can happen when the nervous system becomes sensitized. Normal signals such as light touch, cold, heat, pressure, or tight clothing may be interpreted as painful or threatening. This does not mean the pain is imagined. It means the nervous system is processing input in a heightened state.
Treatments may fail when they target the most painful area without identifying the reason that area became painful. In complex chronic pain, the painful structure may be only one layer of the problem. Treatment often needs to account for the original driver, compensations, inflammation, nerve sensitivity, and nervous system regulation.
Evaluation begins with a detailed pain timeline and clinical pattern. The team reviews where the pain started, how it spread, what triggers it, what relieves it, what treatments have been tried, and what each response reveals. Diagnostic injections, medication trials, imaging review, physical examination, and rehabilitation response may all help clarify the pain generators.
Diagnostic blocks are targeted injections of local anesthetic used to temporarily quiet a specific nerve, joint, or pain pathway. If the pain improves in a meaningful and time-limited way, that response can help confirm which structure or pathway is contributing to the pain.
Patients with complex chronic pain need relief, but durable improvement usually requires understanding what is driving the pain. MPM often works on both paths at once: reducing distress and improving function while continuing to test, refine, and confirm the underlying diagnosis.
No. Pain psychology does not mean the pain is “all in the head.” Complex chronic pain affects the nervous system, emotions, attention, sleep, fear, and decision-making. Pain psychology helps patients regulate the nervous system, process medical trauma, build coping strategies, and participate more effectively in the treatment plan.
In some patients, long-term opioid therapy can contribute to opioid-induced hyperalgesia, a state in which the nervous system becomes more sensitive to pain. Short-acting opioids may also create cycles of withdrawal between doses that activate the stress response. Medication decisions are individualized, but MPM’s goal is to treat the pain mechanism rather than rely only on symptom suppression.
The answer depends on the drivers involved. Some patients improve significantly when the main pain generators are identified and treated. Others require long-term management, flare planning, rehabilitation, nervous system regulation, or ongoing medical care. The goal is to create a clearer diagnosis, reduce suffering, improve function, and give patients a practical plan for managing their body.
Before care begins, our team helps patients understand the practical side of treatment, including insurance verification, out-of-network benefits, cost-share estimates, self-pay options, and billing questions. We believe patients should have as much clarity as possible before moving forward.
Complex chronic pain is not one diagnosis. It is a pattern that develops when pain persists long enough for the body to adapt around it. A primary injury or pain generator may begin the process, but over time the body changes posture, movement, muscle tone, sleep, stress response, and nervous system sensitivity. New layers of pain may build on top of the original problem.
At Manhattan Pain Medicine, we evaluate complex chronic pain by reverse-engineering the story. We ask what started the pain, how it changed, why it failed to heal, what the body did to compensate, and which systems are now keeping the pain active.
Chronic pain often grows through a snowball effect. When one area hurts, the body protects it. A painful knee changes walking. A painful neck changes shoulder use. Pelvic pain changes sitting, standing, breathing, and hip mechanics. Over time, those compensations place stress on other structures and create new pain generators.
The result can become difficult to interpret. The original pain may still matter, but the secondary pains may become louder, more disabling, or more visible. Patients may begin to feel as though the entire body is failing, when in reality the body has been adapting around an unresolved problem for too long.
When the nervous system receives distress signals for months or years, it can become sensitized. This means the system becomes more reactive, more protective, and more likely to amplify input. A minor strain, light touch, cold temperature, tight clothing, or normal movement may trigger a disproportionate pain response.
We often describe sensitization as a fire. When the flames are large, it becomes difficult to see which structures are actually burning underneath. Before we can accurately diagnose every focal pain generator, we may need to calm the larger sensitized system enough to see the underlying anatomy more clearly.
Many patients with complex chronic pain arrive with a long list of symptoms, diagnoses, treatments, and disappointments. The pain may feel like a jumbled knot, with symptoms crossing regions and systems. A spine issue may affect the hip. A pelvic pain generator may change the back. A joint instability pattern may drive muscle guarding. Inflammation may sensitize nerves. Medical trauma may keep the body in a fight-or-flight loop.
Our job is not to pull every thread at once. It is to understand which thread is most likely to loosen the knot first.
Neurologic sensitization occurs when nerves, the spinal cord, the sympathetic nervous system, or the brain become overly reactive to input. Patients may experience burning, tingling, electric pain, widespread sensitivity, allodynia, hyperalgesia, temperature sensitivity, or severe flares after minor triggers.
Immune and inflammatory sensitization occurs when inflammation keeps tissues and nerves in a heightened state. This may occur with autoimmune disease, seronegative inflammatory conditions, mast cell activation, post-infectious syndromes, or inflammatory reactions around joints, tendons, ligaments, or nerves.
Psychological sensitization does not mean the pain is imaginary. It means that the experience of long-term pain, fear, grief, medical trauma, and uncertainty can affect how the brain and body respond to pain. The conscious brain may struggle to stay engaged with a body that has felt unsafe for too long.
Discovery is the first phase of care. In complex chronic pain, discovery is not a single appointment or a quick answer. It is an iterative process that uses history, examination, imaging, medication response, procedure response, rehabilitation response, and patient tracking to build a clearer map.
We ask patients to describe pain in a granular way. Instead of treating “back pain” or “pelvic pain” as one symptom, we separate each distinct pain pattern. Each pain has a location, quality, trigger, timing, behavior, and response. These details help identify which symptoms may be separate characters in the same play.
When appropriate, diagnostic blocks may be used to test specific structures or pathways. A targeted injection of local anesthetic can temporarily turn down a joint, nerve, fascial plane, or sympathetic pathway. The response helps us understand whether that structure is part of the pain pattern.
Treatment for complex chronic pain moves along two paths at the same time. The first path is comfort. Patients need relief, stability, and a sense of control. The second path is diagnosis. We continue working to confirm what is driving the pain so that care can become more durable.
In complex chronic pain, every response matters. A treatment that helps, helps. A treatment that fails still teaches us something. A treatment that creates a flare may reveal that the system is too sensitized, the wrong structure was targeted, inflammation is active, or the body needs a different sequence of care.
Rather than treating failed responses as dead ends, we use them as data points. Each response helps refine the working hypothesis and determine the next step.
Maintenance begins when the patient has a clearer map of the pain pattern and the major drivers are more stable. The goal is to help patients understand their body well enough to respond to familiar flares before they rebuild into a larger pain cycle.
Patients may learn which structures trigger which symptoms, which activities require pacing, which treatments help specific flares, when to rest, when to move, and when to return for evaluation. For many patients, this knowledge restores a sense of control after years of uncertainty.
Complex chronic pain may take time to untangle. But when the pattern becomes clearer, the treatment path can become more precise, more collaborative, and more manageable.
