The Meaning of Pain in the Clinical Management of Patients With Disorders of Consciousness: Is It a Neglected Issue?

BACKGROUND: Pain is a critical yet frequently underestimated component in the care of patients with acquired brain injury (ABI) and disorders of consciousness (DoC). Because these individuals often lack the ability to communicate verbally or purposefully, clinicians face substantial challenges in recognizing and managing pain, despite its profound influence on autonomic stability, behavioural responsiveness, rehabilitation engagement and overall prognosis. CONTENT: This position paper synthesizes current knowledge on the multidimensional nature of pain and reviews the main behavioural, autonomic and neurophysiological tools available to assess nociception and pain-related processing in non-communicative patients. By integrating evidence from standard clinical scales with advanced physiological markers and neuroimaging findings, we highlight how preserved activity within the so-called pain matrix challenges traditional assumptions about pain absence in DoC populations. CLINICAL IMPLICATIONS: The paper argues for a shift toward multimodal, patient-centred approaches that combine behavioural observation with objective physiological indicators to improve diagnostic accuracy and ensure ethically responsible care. Practical guidance is provided on selecting appropriate assessment tools, interpreting behavioural and physiological signs of nociception, and implementing more effective pain management strategies. CONCLUSIONS: Accurate pain assessment is essential not only to promote recovery and facilitate rehabilitation but also to uphold the central ethical principle of safeguarding the dignity of patients with disorders of consciousness. SIGNIFICANCE STATEMENT: Understanding pain in Disorders of Consciousness (DoC) is a major clinical and ethical challenge, as residual nociceptive processing may be underestimated. This study advances a multidimensional framework integrating behavioural and neurophysiological evidence, moving beyond simple detection toward interpretation of pain meaning. It has direct implications for improving pain assessment, guiding personalized management and supporting more accurate and ethically grounded care in non-communicative patients.