Retraining the Brain May Eliminate Chronic Back Pain

Megan Brooks

October 06, 2021

Psychological therapy that changes an individual's beliefs about pain not only provides lasting chronic pain relief but also alters brain regions related to pain generation, new research shows.

In the first randomized controlled test of pain reprocessing therapy (PRT), two thirds of patients with chronic back pain (CBP) who received 4 weeks of PRT were pain free or nearly pain free afterward ― and for most patients, relief was maintained for 1 year, the researchers found.

"Primary chronic back pain can be dramatically reduced or even eliminated by psychological treatment focused on changing how threatening we perceive the pain to be," first author Yoni Ashar, PhD, Department of Psychiatry, Weill Cornell Medical College, New York City, told Medscape Medical News.

"We were very surprised" by the impact, Ashar admitted, given that large reductions in pain have rarely been observed in studies that tested psychological therapies for chronic back pain.

The study was published online September 29 in JAMA Psychiatry.

Rethinking Pain

CBP is a leading cause of disability, and treatment is often ineffective. In about 85% of cases of primary CBP, a definitive cause of the pain can't be identified.

In these cases, fear, avoidance, and beliefs that pain indicates injury may contribute to ongoing CBP.

PRT educates patients about the role of the brain in generating chronic pain; helps them reappraise their pain as they engage in movements that they had been afraid to undertake; and helps them address emotions that may exacerbate pain.

The study included 151 adults (54% women; mean age, 41 years) who had had primary CBP of low to moderate severity (mean pain intensity, 4 of 10) for an average of 10 years.

Fifty participants were randomly allocated to undergo PRT (one telehealth session with a physician and eight PRT sessions over 4 weeks), 51 to receive placebo (subcutaneous saline injection in the back), and 50 to continue their routine, usual ongoing care.

Large group differences in pain were observed after treatment. The mean pain score was 1.18 in the PRT group, 2.84 in the placebo group, and 3.13 in the usual-care group. Hedges g was -1.14 for PRT vs placebo and -1.74 for PRT vs usual care (P < .001).

Two thirds (66%) of adults in the PRT group were pain free or nearly pain free following treatment (pain intensity score of 0 or 1 out of 10), compared with 20% of those in the placebo group and 10% of those who received usual care.

Treatment effects were maintained at 1-year follow-up. The mean pain score was 1.51 in the PRT group, 2.79 in the placebo group, and 3.00 in the usual-care group. Neither age nor sex moderated the effect of PRT on pain intensity.

Retraining the Brain

The researchers say the effects of PRT on pain were mediated by lessening the belief that pain indicates tissue damage. Of note, PRT also reduced experimentally evoked back pain and spontaneous pain during fMRI, with large effect sizes.

"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," Ashar said in a news release.

The authors note that study participants were relatively well educated and active. The participants reported having long-standing low to moderate pain and disability at baseline.

The physician and therapists were experts in delivering PRT. Future studies should test generalizability to other patient populations, therapists, and treatment contexts.

"Our clinical experience shows that PRT is effective for other primary chronic pain conditions as well," said Ashar, including primary knee pain and tension headache.

Restoring Function

Commenting on the findings for Medscape Medical News, Shaheen E. Lakhan, MD, PhD, neurologist and pain specialist in Newton, Massachusetts, said he has long experience using psychological approaches to address pain, with good results.

"Imagine telling a person suffering from decades of chronic pain that your pain is all in your head. I've done that for years as a board-certified pain physician managing only the most severe and debilitating forms of pain. When used to ground brain retraining, I could ultimately restore function to people living with chronic pain," Lakhan said.

"The statement is true ― the brain ultimately processes signals from throughout the body, forms the perception of pain, and links it to emotional brain centers, among others. Pain is an important survival mechanism so that when your body is at threat of injury, you protect yourself from further damage and withdraw. The problem lies when pain outlasts its welcome and chronifies," said Lakhan, senior vice president of research and development, Click Therapeutics, in Boston, Massachusetts.

The investigators in this study "eloquently prove" that with 4 weeks of PRT, patients can learn that chronic pain is largely a "brain-generated false alarm and that constantly affirming this truth can actually reduce or eliminate it," Lakhan said.

"Further, the brain areas implicated with pain are calmed after going through the therapy to both resting pain and pain induced by extending the back," he noted.

"Pain reprocessing therapy can improve the lives of chronic [pain patients] who have low to moderate levels of pain and disability; however, much work needs to be done to make this scalable and universally available and covered by insurers as a treatment modality," Lakhan added.

He cautioned that he has not seen therapies such as this work when there is significant depression, withdrawal, or lack of control over one's situation such that one behaves in a helpless manner ― "a terrible state of mind called learned helplessness."

The study was funded by the National Institutes of Health, the National Center for Advancing Translational Sciences, the Radiological Society of North America, the German Research Foundation, the Psychophysiologic Disorders Association, the Foundation for the Study of the Therapeutic Encounter, and community donations. Ashar received grants from the National Institutes of Health during the conduct of the study and personal fees from UnitedHealth Group, Lin Health, Inc, Pain Reprocessing Therapy Center, Inc, and Mental Health Partners of Boulder County outside the submitted work. Lakhan has disclosed no relevant financial relationships.

JAMA Psychiatry. Published online September 29, 2021. Full text

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