Pragmatic trials assessing effectiveness complement efficacy trials for improving clinical care. Efficacy trials of novel interventions, especially for regulatory purposes, may not translate to obvious effectiveness once the interventions enter routine clinical practice. This translation gap may exist for a number of reasons, relating to ''real world'' populations and health care systems, or the presence of unidentified confounders and comorbidities. While pragmatic trials have limitations, approaches such as those suggested here should be considered by the clinical and academic pain community.