Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain

Abstract

IMPORTANCE Chronic back pain (CBP) is a leading cause of disability, and treatment is often ineffective. Approximately 85% of cases are primary CBP, for which peripheral etiology cannot be identified, and maintenance factors include fear, avoidance, and beliefs that pain indicates injury.OBJECTIVE To test whether a psychological treatment (pain reprocessing therapy [PRT]) aiming to shift patients' beliefs about the causes and threat value of pain provides substantial and durable pain relief from primary CBP and to investigate treatment mechanisms. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial with longitudinal functional magnetic resonance imaging (fMRI) and 1-year follow-up assessment was conducted in a university research setting from November 2017 to August 2018, with 1-year follow-up completed by November 2019. Clinical and fMRI data were analyzed from January 2019 to August 2020. The study compared PRT with an open-label placebo treatment and with usual care in a community sample. INTERVENTIONS Participants randomized to PRT participated in 1 telehealth session with a physician and 8 psychological treatment sessions over 4 weeks. Treatment aimed to help patients reconceptualize their pain as due to nondangerous brain activity rather than peripheral tissue injury, using a combination of cognitive, somatic, and exposure-based techniques. Participants randomized to placebo received an open-label subcutaneous saline injection in the back; participants randomized to usual care continued their routine, ongoing care. MAIN OUTCOMES AND MEASURES One-week mean back pain intensity score (0 to 10) at posttreatment, pain beliefs, and fMRI measures of evoked pain and resting connectivity. RESULTS At baseline, 151 adults (54% female; mean [SD] age, 41.1 [15.6] years) reported mean (SD) pain of low to moderate severity (mean [SD] pain intensity, 4.10 [1.26] of 10; mean [SD] disability, 23.34 [10.12] of 100) and mean (SD) pain duration of 10.0 (8.9) years. Large group differences in pain were observed at posttreatment, with a mean (SD) pain score of 1.18 (1.24) in the PRT group, 2.84 (1.64) in the placebo group, and 3.13 (1.45) in the usual care group. Hedges g was −1.14 for PRT vs placebo and −1.74 for PRT vs usual care (P < .001). Of 151 total participants, 33 of 50 participants (66%) randomized to PRT were pain-free or nearly pain-free at posttreatment (reporting a pain intensity score of 0 or 1 of 10), compared with 10 of 51 participants (20%) randomized to placebo and 5 of 50 participants (10%) randomized to usual care. Treatment effects were maintained at 1-year follow-up, with a mean (SD) pain score of 1.51 (1.59) in the PRT group, 2.79 (1.78) in the placebo group, and 3.00 (1.77) in the usual care group. Hedges g was −0.70 for PRT vs placebo (P = .001) and −1.05 for PRT vs usual care (P < .001) at 1-year follow-up. Longitudinal fMRI showed (1) reduced responses to evoked back pain in the anterior midcingulate and the anterior prefrontal cortex for PRT vs placebo;(2) reduced responses in the anterio...

The Efficacy and Effectiveness of Education for Preventing and Treating Non-Specific Low Back Pain in the Hispanic Cultural Setting: A Systematic Review

“…The effect sizes were generally small, but above the cut-off value for clinical relevance ( Table 2 ) [ 54 , 55 ]. These results are generally consistent with those from studies conducted in other cultural settings [ 56 , 57 ]. In fact, the small size of the effect on disability triggered by education is in line with most medical treatments for LBP [ 6 , 7 , 58 ]…”

Preliminary study: quantification of chronic pain from physiological data

“…This research 3 along with another randomized controlled study 27 demonstrated interventions that not only reduced but in many cases cured chronic pain by retraining the brain. Techniques for retraining the brain away from chronic pain include psychological therapies, 1 , 25 , 28 , 29 , 33 , 38 , 42 , 46 , 47 , 51 , 57 , 62 , 68 – 70 , 88 , 89 , 97 education, 61 , 64 , 67 , 79 , 85 biofeedback, 31 , 76 , 80 activities, 2 , 17 , 44 , 54 , 55 , 63 , 87 , 91 , 92 , 96 and meditation.…”

“…In particular, functional magnetic resonance imaging (fMRI) has been used to demonstrate changes in the brain that are consistent with chronic pain. 3 – 6 , 12 , 13 , 24 , 34 , 53 , 56 , 74 , 77 , 83 One recent randomized controlled study 3 found significant changes in fMRI of subjects with chronic back pain before and after psychological pain treatment, showing a possibility of using fMRI in pain measurement. However, fMRI is rather expensive and hard to do for routine use.…”

Corticostriatal circuits in the transition to chronic back pain: The predictive role of reward learning

“…Increasing the variability of behavioral responses and fostering explorative behavior may be a valuable treatment target in patients with chronic pain. 45 Behavioral treatments targeting operant-learning mechanisms are available, 46,47 and Ashar et al 48 showed that brain connectivity patterns may predict successful cognitive-behavioral treatment of CBP. Moreover, the transition from subacute to CBP was prevented in patients treated with Levodopa combined with naproxen and was associated with a normalization of altered vmPFC-NAc connectivity specifically in female patients with SABP, while naproxen alone did not have beneficial effects.…”