By: John T. Sorrell, Ph.D.
A 2019 systematic review (1) of 25 original research studies published between 1983 and 2016 examined factors that predict improvements in physical functioning following comprehensive rehabilitation services for individuals struggling with chronic musculoskeletal pain. Results suggest the answer is no to the question, “Is pain intensity reduction a necessary outcome focus on chronic pain management?” Pain intensity reduction is not as important an outcome compared to other variables that account for meaningful change in physical function after comprehensive treatment.
The aforementioned review found that more important variables associated with restoring physical function after treatment include higher levels of initial physical functioning and low levels of emotional distress. This argues for focusing treatment on increasing physical and emotional functioning, rather than focusing on reducing pain using a traditional method such as a number rating scale. Chronic pain research inconsistently shows meaningful reductions in pain intensity after treatment through both comprehensive treatment programs, as well as conventional treatments focusing exclusively on medical intervention medication (i.e. interventional procedures such as injections, and surgeries).
A separate study (2), and a very important one in understanding if reducing pain should be a primary goal in chronic pain treatment, focused on altered central pain modulation among patients with chronic pain. It looked to determine if this patient population had a disruption in function of ascending and descending pathways of pain, thus not reducing the experience of pain. The study found that there was disruption in these pain pathways and it was predicted by high sensory sensitivity (they used genetic testing to determine this), and psychological factors (somatization and poor self-expectation of recovery), before or soon after an acute pain experience.
These results suggest that when a person with chronic pain has greater sensory sensitivity and/or high somatic focus and poor expectations of recovery following treatment, pain intensity or pain quality is less impacted by treatment interventions. It argues instead to focus treatment towards sensory sensitivity and psychological factors such as an individual’s primary focus of attention and expectations of treatment.
Whether or not pain intensity reduction is a necessary outcome following treatment, in my opinion, depends, at least in part, on who is asked this question. From the person’s perspective suffering from chronic pain, especially when the sole focus is on pain, it would be a fairly clear and definitive, “yes, it matters!” When someone struggling with chronic pain is asked to consider what else in their life would be important to change if pain intensity could not be altered, there might be a variety of interesting responses. I suspect many of these responses would revolve around being active and connected with loved ones, important life activities, working and thriving in their careers, or feeling more calm, happy, or content. To really get at the core of this issue/question, I believe it is important to consider what is the primary or paramount goal of a comprehensive chronic pain management program.
If the goal is to reduce pain, the data from research say the results will be mixed. Some will have reported pain reduction, others will not. And, it is hard to say why or who will experience this change. I would argue instead that the more important variables to focus on in comprehensive chronic pain management treatment include improving physical function and activity, quality of life, psychological well-being, and reconnecting with important areas of life such as returning to work, reducing disability, or increasing social connections.
Indeed, there is considerable research showing that these treatment outcome variables mentioned above are more likely and consistently to result in improvements compared to reducing pain intensity. Extending further our understanding of what accounts for positive changes in treatment outcomes, such as functioning for people suffering with chronic pain, research has examined process variables (such as how you relate to pain) that focus on changing an individual’s response to pain, rather than focusing on pain intensity or even emotional distress (3).
Results from this line of research indicate that significant improvements in life functioning (e.g., aligning behavior and actions with what is important to a person even if pain persists) may not require changes in either pain intensity or emotional distress. This argues for helping a person clarify what in their life is most important, finding ways to reconnect with those life values, and living their life more rather than trying to reduce pain or distress about pain.
In some ways, research seems to be indicating that chronic pain treatment might be in the midst of a paradigm shift from the management of chronic pain towards the management of life in the context of chronic pain. As additional studies examine process variables among people with chronic pain, we may see additional evidence supporting this paradigm shift and underscoring the importance of focusing on process variables such as connection with life values in treatment.
John Sorrell is a licensed clinical psychologist specializing in chronic pain. In addition to being the Chief Clinical Officer at Upside Health, Dr. Sorrell sees patients both in private practice and at a county health system.
1 Tseli, Elena; Boersma, Katja; Stålnacke, Britt-Marie; Enthoven, Paul; Gerdle, Björn; Äng, Björn O.; Grooten, Wilhelmus J.A. Prognostic Factors for Physical Functioning After Multidisciplinary Rehabilitation in Patients With Chronic Musculoskeletal Pain, The Clinical Journal of Pain: February 2019 – Volume 35 – Issue 2 – p 148-173. doi: 10.1097/AJP.0000000000000669
2 Clark J, Nijs J, Yeowell G, Goodwin PC. What Are the Predictors of Altered Central Pain Modulation in Chronic Musculoskeletal Pain Populations? A Systematic Review. Pain Physician. 2017 Sep;20(6):487-500. PMID: 28934779.
3 Vowles KE, Witkiewitz K, Levell J, Sowden G, Ashworth J. Are reductions in pain intensity and pain-related distress necessary? An analysis of within-treatment change trajectories in relation to improved functioning following interdisciplinary acceptance and commitment therapy for adults with chronic pain. J Consult Clin Psychol. 2017 Feb;85(2):87-98. doi: 10.1037/ccp0000159. Epub 2016 Dec 19. PMID: 27991806.