Rethinking what causes pain and how great a threat it is can provide chronic pain patients with lasting relief and alter the brain networks associated with pain processing. This is what new research conducted by the University of Colorado Boulder establishes.
The study, published in JAMA Psychiatry, found that two-thirds of chronic back pain patients underwent a four-week psychological treatment called Pain Reprocessing Therapy (PRT) they experienced zero or very little pain after treatment. Most of them retained chronic back pain relief for 12 months.
The findings provide some of the strongest evidence that psychological treatment can provide powerful and lasting relief for a problem that afflicts 13 million people in Italy, and is a leading cause of disability worldwide.
Chronic pain is not just a physical matter
"For a long time we thought that chronic pain was mainly due to problems in the body, and most treatments to date have targeted this," says lead author. Yoni Ashar. "This treatment is based on the premise that the brain can generate pain in the absence of injury, or even after an injury has healed, and that people can unlearn this painful stimulus."
85% of people with chronic back pain has so-called "primary pain," which means that tests cannot identify a clear bodily source, such as tissue damage.
The fault lies at least in part with the non-functioning neural pathways: Several brain regions, including those associated with reward and fear, are activated more during chronic pain episodes than in acute pain, according to studies. And among patients with chronic painful experiences, some neural networks are sensitized to overreact to even mild stimuli.
While pain is generally a warning sign that something is wrong with the body, primary chronic pain, Ashar said, is "like a false alarm stuck in the 'on' position."
PRT psychological therapy tries to silence the alarm.
“The idea is that by thinking of pain as safe rather than threatening, patients can alter brain networks and eventually neutralize it,” Ashar says. For the randomized controlled trial, Ashar and colleagues recruited 151 men and women who had been suffering from back pain for at least six months with an intensity of at least four on a scale of zero to 10.
Those in the treatment group completed an assessment followed by eight one-hour sessions of PRT, a technique developed by the psychologist Alan Gordon. The objectives? First: educate the patient on the role of the brain in the generation of chronic pain. Second: reevaluate the pain while engaging in movements that you were afraid to do. Third: learning to cope with the emotions that can exacerbate the pain.
Pain is not "all in your head"
This study obviously does not suggest that the pain is not real or that it is "all in the head". It only says that if one of its components (even a significant one) has neurological causes, there may also be solutions of this type. Specifically, the findings provide some of the strongest evidence that psychological treatment can provide powerful and lasting relief.
Before and after treatment, participants also underwent functional magnetic resonance imaging (fMRI) scans to measure how their brains reacted to a mild pain stimulus. After treatment, 66% of patients in the treatment group were painless or nearly painless compared with 20% in the placebo group and 10% in the no treatment group.
And when people in the PRT group were exposed to pain in the scanner post-treatment, the brain regions associated with pain processing, including the anterior insula and anterior cingulate, calmed down significantly.
The next steps
The research team has particularly focused on psychological treatment for chronic back pain, so future and larger studies are needed to determine whether it would yield similar results for other types of chronic pain.
This study suggests a fundamentally new way of thinking about both the causes of chronic back pain and the tools available to treat it in a lasting way. I can't wait, now that the ailments are making themselves felt for me too, to see where this approach will go.