Dynamic Interactions in Chronic Pain-Related Outcomes: 
A Secondary Data Analysis of a Pragmatic Clinical Trial With Sequential, Multiple Assignment, Randomized Trial Design

Abstract Objective Effective chronic pain management is essential for maintaining psychological health and quality of life. Chronic pain often co-occurs with psychological and physiological concerns such as sleep-related impairment, fatigue, and pain catastrophizing, all of which interact and influence treatment outcomes. This study explored the dynamic interactions among chronic pain-related outcomes in adults undergoing complementary and integrative health and/or standard rehabilitative care interventions. Materials and Methods Using a secondary analysis of a pragmatic clinical trial, we analyzed data from 182 adults with chronic pain who completed data at both pre- and post-intervention time points at a pain treatment facility. We investigated associations between 10 patient-reported outcomes: pain intensity, anger, anxiety, depression, fatigue, pain interference, physical function, satisfaction with social roles and activities, pain catastrophizing, and sleep-related impairment. Cross-sectional network analyses evaluated static relationships at pre- and post-intervention, and cross-lagged panel network analysis captured temporal dynamics. Results Pain interference, depression, anxiety, and fatigue showed the highest strength centrality in the cross-sectional networks, and sleep-related impairment, pain interference, physical function, and pain intensity exhibited the highest out-expected influence centrality in the cross-lagged panel network model. Bootstrap analyses confirmed network stability and moderate accuracy. Conclusion These findings highlight that relying solely on cross-sectional relationships between outcomes can overlook the evolving relationships between them during an intervention. Understanding these dynamic patterns is critical for refining intervention strategies and tailoring them to effectively target key outcomes. Incorporating such insights into clinical practice can lead to more adaptive and impactful chronic pain management approaches. Clinical Trial Registration Identifier: NCT03297905.