Over the years I’ve worked clinically I’ve noticed that many people with pain have had ongoing rehab. Like almost never-ending. One programme after another. In some cases this has gone on for years. A new goal is set as soon as an old goal is reached. And on and on.
While sometimes this endless rehab has been initiated by the individual, more often than not in a compensation setting it’s been at the behest of the insurer. The end goal in many cases is ‘return to work’. Understandable because weekly compensation is the greatest cost to an accident insurer.
But today I’m thinking about when it’s OK (or even good!) to push pause. Take a break from constant ‘improvement.’ Make room for what can sometimes be called ‘a plateau’ – a time when pain, functional improvements, medication seems to flatten out, at least for a time.
I found it pretty hard to locate research on plateau’s, goal-setting, and outcomes for people living with chronic pain. I’m sure there are studies out there, but nothing practical in terms of deciding (a) when a plateau has been reached or (b) the impact of taking a break from striving for ‘more’ and ‘better.’
One paper by Huffman et al (2019) looked at trajectories 6 – 12 months after interdisciplinay chronic pain programmes. Their analysis included opioid weaning, which adds another layer of complexity to the mix, but they found three trajectories: (1) mild symptoms and durable benefits; (2) moderate symptoms and durable benefits; and (3) intractable symptoms. They found a 4th group with immediate post-treatment improvement and worsening at follow up. Now I’m not bothered by the ‘symptoms’ measurement, to me it’s the functional limitations and quality of life that really matter given how poorly many chronic pain conditions respond to any treatment for pain intensity. I’m interested in who responded to this treatment, and what happened next. The predictors of those in group (1) were being white (racial majority), lower depression, and believing the treatment helped. Those in group (3) tended to be from an ethnic minority, were depressed, thought the treatment wasn’t that helpful, had lower educational attainment, and were older and male.
This was a large study. A study in people who hadn’t got better with typical treatment like outpatient pharmacotherapy, surgery or interventions. They’d had physiotherapy, psychology, and other single discipline treatments. They had marked pain, functional limitations and distress. The programme was over 3 – 4 weeks, full time, and in a tertiary treatment setting. It’s been running for decades, and the treatment team are highly experienced and used to working collaboratively. This should be the best place for people to get help. AND MANY DIDN’T achieve positive results.
The paper omits so much that could inform practice. It’s silent about post-programme support. It doesn’t discuss personal goals or direction – it used the Pain Disability Index (Tait, et al., 1987), which is a pretty broad-brush measure. It focuses on a narrow range of outcomes, and assumes that grouped results can apply (but ergodicity is not a feature in pain…see Sundstrom et al., 2025). But it does give us a message consistent with most meta-analyses about chronic pain treatments.
The takeaway I want you to have from this study is that many people who had been doing all the right things before the programme (ie they’d been doing the other treatments), responded a bit during the programme, but later didn’t do so well. And this, in what is one of the best programmes for chronic pain in the world.
If people attending this programme were in New Zealand, with treatment funded by ACC, our national accident insurer, their rehabilitation would continue. The form of ongoing rehab would vary – from individual community programmes, to vocational rehab, to job seeking assistance. Some would get ongoing psychology. Some will see yet another specialist.
But for a moment, I’d like to think about what it might feel like to be someone who went on the programme and who didn’t improve. Someone who didn’t think the treatment was all that hot. Who was still low in mood. Someone with significant social factors impacting on their ability to firstly engage with the programme, and then to generalise what they’d learned to their world. Who then, at least in NZ, would continue to get ‘case managed’ to yet another treatment aimed at ‘achieving goals.’
What might that be like?
And how much value is there in repeating failed treatment after failed treatment without pause?
Don’t know about you, but I don’t like failing. It’s a real motivation-killer. It evokes shame and avoidance and fear. When I fail at something I need some time to regroup. Lick my wounds, so to speak. I don’t think I’m very special in this regard. And I know what it’s like to keep aiming for a thing but never reaching it. It’s not nice.
A couple of things to ponder:
- Pain management programmes, even the very best in the world, don’t inevitably lead to ‘returning to normal’ because chronic pain and the accompanying problems are complex and hard to change. Expecting people to pop out at the end of a programme ready to move to the next thing is wishful thinking. When it happens, it’s wonderful – but small changes are more typical, and pain intensity is often not the thing that shifts. It takes time to put the pieces together into daily life, and life outside a programme is always more complex than during one. The factors influencing outcomes are NOT about what the individual does as much as their ethnicity, education, gender, educational level and mood. Suggesting people aren’t motivated ignores these very real predictors.
- When outcomes aren’t what people hope for, it’s probably a good time to push pause on setting new goals. Give everyone a chance to catch their breath, to feel sad and maybe even angry that it didn’t ‘fix things.’ I don’t mean stopping supports here – I mean, stopping the ‘let’s set a new set of goals’ because, frankly, it’s just not the right time. And then when the person’s had some time, let’s not repeat the same thing and expect a different result. Let’s take some time to look at the factors that are associated with poorer outcomes – ethnicity, low mood, lower educational achievement, not believing the treatment was helpful. And when turning to the next thing, take these into account. Perhaps the next treatment could be with people from the same ethnic group. Perhaps their mood could be treated before entering the programme, or the programme intensity could be titrated to accommodate lower energy, poorer concentration, more negativity. Content might need to be at the level of their education – less written work maybe, or simpler concepts, or more active sessions. And perhaps they could be asked about the kind of treatment they think might be useful – using motivational interviewing to help them make a decision about what to do next.
Pushing pause isn’t equivalent to pushing stop. It’s a pause. It’s giving a person time to ponder and make sense of things. It’s something clinicians probably need also.
Huffman, K. L., Mandell, D., Lehmann, J. K., Jimenez, X. F., & Lapin, B. R. (2019). Clinical and Demographic Predictors of Interdisciplinary Chronic Pain Rehabilitation Program Treatment Response. J Pain, 20(12), 1470-1485. https://doi.org/10.1016/j.jpain.2019.05.014
Sundstrom, F. T. A., Lavefjord, A., Buhrman, M., & McCracken, L. M. (2025). Are people with chronic pain more diverse than we think? An investigation of ergodicity. Pain. https://doi.org/10.1097/j.pain.0000000000003573
Tait R, Pollard C, Margolis R, Duckro P, Krause SJ. (1987). The pain disability index: Psychometric & validity data. Arch Phys Med Rehabil 68:438-441