Rethinking Back Pain

What’s New in Psychology?

Rethinking Back Pain  

Jim Windell

            What is one of the most complaints to doctors?

           The answer is back pain. Some 65 million Americans say they have experienced a recent episode of back pain. And around 16 million adults suffer from persistent or chronic back pain.

           But it is not just the pain that people with back pain experience. Back pain limits what people can do in their daily life – often causing days off from work and trips to a doctor’s office.

           A new study, however, that comes from the University of Colorado at Boulder suggests that a novel, four-week psychological treatment renders a good many who suffered from back pain free or almost free of all back pain.

           The findings of this study, published recently in JAMA Psychiatry, revealed that the psychological treatment that produced such amazing results is called Pain Reprocessing Therapy (PRT).

           For the randomized controlled trial, the researchers recruited 151 men and women who had back pain for at least six months at an intensity of at least four on a scale of zero to 10. Those participants assigned to the treatment group completed an assessment followed by eight one-hour sessions of PRT, a technique developed by Los Angeles-based pain psychologist Alan Gordon. The goal of the PRT was to educate the patient about the role of the brain in generating chronic pain. In addition, the treatment aimed at helping participants reappraise their pain as they engage in movements they'd been afraid to do. And, finally, a goal of the treatment was to help them address emotions that may have exacerbated their pain.

           The study found that after treatment, 66% of patients in the treatment group were pain-free or nearly pain-free compared to 20% of the placebo group and 10% of the no-treatment group.

           Before and after treatment, participants also underwent functional magnetic resonance imaging (fMRI) scans to measure how their brains reacted to a mild pain stimulus. When people in the PRT group were exposed to pain in the scanner post-treatment, brain regions associated with pain processing – including the anterior insula and anterior midcingulate – had quieted significantly.

           According to lead author Yoni Ashar, who conducted the study while earning his Ph.D. in the Department of Psychology and Neuroscience at the University of Colorado at Boulder, “The magnitude and durability of pain reductions we saw are very rarely observed in chronic pain treatment trials.” Ashar added that opioids have yielded only moderate and short-term relief in many trials.

           The authors of the study point out that rethinking what causes pain and how great of a threat it is can provide chronic pain patients with lasting relief and alter brain networks associated with pain processing. The findings of this study, the researchers contend, provide some of the strongest evidence yet that a psychological treatment can provide powerful and durable relief for chronic pain, which afflicts about eight percent of all adults in the U.S.

           “For a long time we have thought that chronic pain is due primarily to problems in the body, and most treatments to date have targeted that,” said Ashar, “This treatment is based on the premise that the brain can generate pain in the absence of injury or after an injury has healed, and that people can unlearn that pain. Our study shows it works.”

           Approximately 85% of people with chronic back pain have what is known as “primary pain.”  Primary pain means that tests are unable to identify a clear bodily source, such as tissue damage. This study takes the position that the reason for the pain despite not physical damage has to do with misfiring neural pathways. Different brain regions – including those associated with reward and fear – activate more during episodes of chronic pain than acute pain. Among chronic pain patients, certain neural networks are sensitized to overreact to even mild stimuli.

           If pain is a warning signal that something is wrong with the body, primary chronic pain, according to Ashar, now a postdoctoral researcher at Weill Cornell Medicine, is “like a false alarm stuck in the ‘on’ position.” PRT seeks to turn off the alarm.

           “The idea is that by thinking about the pain as safe rather than threatening, patients can alter the brain networks reinforcing the pain, and neutralize it,” said Ashar.

           The authors emphasize that the treatment is not intended for “secondary pain,” pain that is rooted in acute injury or disease. It is also noted that this study focused specifically on PRT for chronic back pain. Future studies are needed to determine if similar results would be found for other types of chronic pain. However, other similar brain-centered techniques are already emerging among physical therapists and other clinicians who treat pain.

           To read the original article, find it with this reference:

Ashar, Y. K., Gordon, A;. Schubiner, H. et al. (2021). Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial. JAMA Psychiatry Original Investigation, September 29, 2021. DOI: 10.1001/jamapsychiatry.2021.2669

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