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STUDY: Treatment for pain versus disability

 •  • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of PainScience.com: a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

Recently I wrote that “We can put a man on the moon, but we can’t fix most chronic pain.” And then I saw this headline in a scientific journal:

“Dispelling the myth that chronic pain is unresponsive to treatment”

Hmm! 🤔 Someone serious thinks it’s a myth that we can’t fix most chronic pain? Is there some source of hope I was unaware of? That’s not quite it. The myth is the idea that nothing works at all, which seems a bit extreme — but some professionals seem to have embraced it and given up on treating pain to some degree. Consider this quote:

“Our duty to patients with chronic pain is not to reduce pain intensity, but to improve their quality of life.”

That sentiment makes a poor impression on patients. My most popular recent tweet expressed a little outrage about it:

“Putting my patient hat on here. Speaking as a chronic pain patient, not even trying to look at this from a clinical perspective… I want the intensity of my pain reduced. Just that. Pretty 🤬 sure THAT would ‘improve quality of life.’”

But modern chronic pain treatment is sometimes crafted to help people more with the fallout from pain — disability and suffering — than the pain itself.

Now to bring a little science. Is it wiser to try to treat disability and suffering rather than pain? Does it help people more? It sounds crazy to most patients, but is it actually just pragmatic, the “art of the possible”?

Saragiotto et al pooled data from all a bunch of scientific reviews and reported that pain is actually the outcome most affected by treatment. Relieving disability and suffering is not obviously easier, and in fact it is probably harder — especially if pain remains! The evidence suggests the obvious: relieving pain is the shortest path to relieving disability and suffering. That doesn’t mean it’s easy, and it doesn’t mean it isn’t worth trying to relieve disability and suffering in addition to pain… and good luck trying to treat one without the other in any case, which would be like trying to flip one side of a coin.

But pain relief should still be the focus, if for no other reason than it’s what patients want, and that matters (a lot). It seems strange that this needs some emphasis, but here we are.

I’ll give the last word to Saragiotto et al.:

“The view that pain is not the best measure of treatment success for chronic pain is not evidence-based. The assumption that behavioural or psychological therapies mainly reduce disability but not pain is not consistent with the data from Cochrane reviews on chronic LBP. Pain intensity should be measured in chronic pain research and clinical practice. Considering pain intensity to be the wrong metric for chronic pain hampers treatment selection and does our patients a great disservice.