What is the recommended treatment approach for patients with functional pain?

Treatment of Functional Pain

Functional pain requires a multimodal treatment approach prioritizing nonpharmacologic interventions (cognitive-behavioral therapy, physical therapy, patient education) combined with nonopioid pharmacologic options when needed, with opioids explicitly avoided as they lack efficacy for this pain mechanism. 1, 2

Initial Treatment Framework

First-Line: Nonpharmacologic Interventions

Cognitive-behavioral therapy (CBT) is the strongly recommended first-line psychological treatment, with moderate-quality evidence showing sustained pain relief for 4 weeks to 2 years and improvements in disability and catastrophic thinking. 1, 3, 2 CBT trains patients in behavioral techniques and helps modify situational factors and cognitive processes that exacerbate pain. 1

Physical therapy and exercise programs should be initiated early, with high-quality evidence demonstrating:

• Pain reduction and improved function for 2-18 months 1, 3, 2
• Particular effectiveness for chronic low back pain, osteoarthritis, and fibromyalgia 1
• Supervised, individually tailored graded exercise or strength training when patients cannot initiate activity independently 1

Patient education on pain neurophysiology is essential to help patients understand their condition and manage expectations around functional restoration rather than complete pain elimination. 1

When Psychosocial Factors Dominate

If fear of movement, catastrophizing cognitions, or other psychosocial factors underlie a disabled sedentary lifestyle, multidisciplinary intervention combining CBT with physical exercise is specifically indicated. 1 This combination reduces long-term pain and disability more effectively than single modalities. 1

Pharmacologic Considerations

Limited Role of Medications

For functional pain disorders (nociplastic pain), analgesic pharmacotherapy is rarely helpful on its own and should always be embedded in a multidisciplinary setting. 4 The evidence for pharmacologic interventions in functional pain is substantially weaker than for nociceptive or neuropathic pain mechanisms. 4

If medications are considered, options include:

• Tricyclic antidepressants or SNRIs (duloxetine, venlafaxine) for accompanying mood symptoms or sleep disturbance 3, 2
• Anticonvulsants (gabapentin, pregabalin) may be tried but evidence is limited for functional pain specifically 3, 2
• Acetaminophen or NSAIDs have minimal efficacy for functional pain and carry cardiovascular and gastrointestinal risks with prolonged use 1

Critical Pitfall: Opioid Avoidance

Opioids are explicitly not recommended for functional pain and should be avoided entirely. 1, 2 The CDC guidelines state that nonpharmacologic and nonopioid pharmacologic therapy are preferred for chronic pain, with opioids considered only when benefits for pain AND function outweigh risks—a threshold functional pain rarely meets. 1 Opioids lack efficacy for nociplastic pain mechanisms and carry substantial risks of dependence, tolerance, and worsening of central sensitization. 1, 4

Multidisciplinary Team Approach

An interdisciplinary team should be assembled for complex functional pain, including: 1, 2

• Pain specialists or primary care providers experienced in pain management
• Physical therapists for exercise prescription and functional restoration
• Behavioral health specialists (psychologists, social workers) for CBT and addressing psychosocial factors
• Occupational therapists for ergonomic adaptations and assistive devices when functional limitations exist 1

Multidisciplinary pain programs, when available, should be utilized as they demonstrate superior outcomes compared to conventional single-modality treatment, with pain intensity reductions sustained for 4 months to 1 year. 1

Addressing Accompanying Symptoms

Sleep disturbance should be specifically addressed through:

• Education on sleep hygiene practices 1
• Referral to specialized sleep therapy or sleep clinics if disturbance persists 1

Weight management should be discussed if obesity is present, as it contributes to pain and disability. Options include dietitian referral, community lifestyle services, or bariatric interventions. 1

Psychopathology (depression, anxiety) requires treatment in collaboration with the patient's primary care physician, as these conditions significantly impact quality of life and pain perception. 1, 4

Long-Term Management Strategy

A long-term approach with periodic follow-up evaluations should be developed, focusing on: 1

• Functional goals rather than complete pain elimination
• Quality of life improvements
• Addressing treatment-related adverse events
• Monitoring for aberrant behaviors if any controlled substances are prescribed

Regular reassessments are critical as the pain experience may change over time with development of new comorbidities or life stressors. 1 Any new pain report requires careful investigation to distinguish worsening of existing pathology from new conditions. 1

Common Pitfalls to Avoid

• Do not start with opioids: They lack efficacy for functional pain and worsen outcomes 1, 3, 2
• Do not use benzodiazepines routinely: They carry abuse risks and are not recommended for chronic pain 3
• Do not rely on pharmacotherapy alone: Medications must be embedded in multimodal treatment 4
• Do not ignore psychosocial factors: Fear avoidance, catastrophizing, and mood disorders require specific intervention 1, 4
• Do not prescribe muscle relaxants long-term: Evidence is insufficient beyond acute exacerbations 3