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Rethinking the causes of pain and its extent can provide lasting relief for patients with chronic pain and alter the brain networks associated with pain management, according to new research from the University of Colorado at Boulder.
The study, published on September 29 in JAMA Psychiatry, found that two-thirds of patients with chronic back pain who underwent a four-week psychological treatment called reprocessing pain therapy (PRT) were painless or almost painless after treatment. And the most sustained relief for a year.
The results provide some of the strongest evidence to date that psychological treatment can provide powerful, long-lasting relief for the chronic pain, which afflicts one in five Americans.
“For a long time, we thought that chronic pain is primarily due to issues in the body, and most treatments to date have targeted this,” said lead author Yoni Ashar, who led the entire study. by earning his doctorate in the Department of Psychology and Neuroscience at CU Boulder. “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 that it works.”
Failed neural pathways
About 85% of people with chronic back pain suffer from what is called “primary pain,” which means that tests are unable to identify a clear bodily source, such as tissue damage.
Failures in neural pathways are at least in part to blame: Different regions of the brain, including those associated with reward and fear, activate more during episodes of chronic pain than during acute pain, studies show. And among patients with chronic pain, some 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, Ashar said, is “like a false alarm stuck in the ‘on’ position.”
PRT seeks to deactivate the alarm.
“The idea is that by thinking of pain as harmless rather than threatening, patients can alter the brain networks that reinforce pain and neutralize it,” said Ashar, now a postdoctoral researcher at Weill Cornell Medicine.
For the randomized controlled trial, Ashar and lead author Tor Wager, now Diana L. Taylor Distinguished Professor of Neuroscience at Dartmouth College, recruited 151 men and women who had suffered from back pain for at least six months at an intensity of ‘at least four on a scale of zero to 10.
People in 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: To educate the patient on the role of the brain in the generation of chronic pain; to help them re-evaluate their pain as they engage in movements they were afraid to do; and to help them deal with emotions that can exacerbate their pain.
Pain is not “all in your head”
“This does not suggest that your pain is not real or that it is all in your head,” Wager pointed out, noting that changes in neural pathways in the brain can persist long after an injury is gone, reinforced by such associations. “What this means is that if the causes are in the brain, the solutions can be there too.”
Before and after treatment, participants also underwent functional magnetic resonance imaging (fMRI) scans to measure their brain’s response to a mild painful stimulus.
After treatment, 66% of patients in the treatment group were painless or almost painless compared to 20% in the placebo group and 10% in the group without treatment.
“The magnitude and durability of the pain reductions that we have observed are very rarely seen in chronic pain treatment trials,” Ashar said, noting that opioids have provided only moderate relief and short term in many trials.
And when people in the PRT group were exposed to pain in the CT scan after treatment, the areas of the brain associated with pain processing – including the anterior insula and anterior midcingulate – calmed down considerably.
The authors stress that treatment is not intended for “secondary pain” – that which is rooted in acute injury or illness.
The study focused specifically on PRT for chronic back pain. Future and larger studies are therefore needed to determine if it would give similar results for other types of chronic pain.
Meanwhile, other similar brain-centric techniques are already emerging among physiotherapists and other clinicians who treat pain.
“This study suggests a fundamentally new way of thinking about both the causes of chronic back pain for many people and the tools available to treat this pain,” said co-author Sona Dimidjian, professor of psychology and neuroscience and director of the Renee. Crown Welfare Institute at CU Boulder. “It offers a potentially powerful option for people who want to live pain free or almost pain free. “
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