Pain Reprocessing Therapy vs Placebo and Usual Care for Chronic Back Pain

Although chronic low back pain (CLBP) is a major cause for disability, approximately 85% of patients do not have a clear pathologic cause of pain. MRIs typically reveal findings such as degenerative disc disease, bulging discs, facet arthropathy, and spinal stenosis; however, these findings are seen in a majority of individuals who are asymptomatic.¹ In addition, medical treatment for CLBP is often ineffective. Randomized controlled trials (RCTs) have not shown surgery to be more effective than conservative forms for treatment² and injections generally fare no better than placebo injections in meta-analyses of RCTs.³

The emergence of the neuroscience theories of predictive processing and clinical data suggest that the brain plays a major role in the precipitation, maintenance, and reinforcement of CLBP.⁴ This study was conducted to determine if a novel psychological intervention could alter central neural circuits and reduce pain. A total of 151 adults with CLBP were randomized to three arms: 1) a treatment as usual (TAU) arm; 2) an open-label placebo back injection arm; and 3) an arm treated with a single medical assessment followed by 8 individual psychotherapy sessions (over 4 weeks) of pain reprocessing therapy (PRT). The medical assessment determined that 43 of the 45 participants who entered the PRT treatment arm did not have a clear pathologic cause of pain, and these participants were educated on the major role of the brain in generating real physical pain. The PRT therapy is designed to demonstrate through a series of exercises that pain is not indicative of tissue damage and that it can be reversed by changing the mental perception of the pain and engaging in physical activities with less fear of the pain itself. In addition, fMRI scans were performed on all the participants before treatment and at a 1 month follow-up visit.

Of the 151 participants, the mean age was 41, the mean pain score was 4.1 of 10, mean disability score was 23 of 100, and the mean duration of pain was 10 years. After 1 month, 33 of the 50 participants (66%) assigned to the PRT arm (and 75% of the 44 who actually received PRT) were pain-free or nearly pain-free (pain scores of 0-1); compared with 10 of 51 (20%) of those assigned to the placebo injection arm and 5 of 50 (10%) assigned to the TAU arm. This result was highly significant, both statistically and clinically. Treatment outcomes were highly correlated with a changing attribution of pain from a peripheral injury to brain-generated pain in the absence of tissue damage. The results were largely maintained at a 1-year follow-up evaluation.

fMRI revealed several findings in the PRT treatment arm, including reduced anterior insula responses and increased connectivity of the prefrontal cortex and insula regions to the somatosensory and anterior midcingulate cortices. These findings are consistent with other studies showing neural circuitry involved in pain reduction.

This study demonstrated that it is possible to reverse CLBP in a majority of individuals when they are exposed to a different model for causation of pain and treatment is specifically directed towards achieving pain elimination, rather than pain management. Future studies that replicate these findings in more diverse populations with a larger set of therapists are needed. If replicated, this model could offer relief for millions with chronic functional pain syndromes. It should be noted that this model has also been used clinically with tension and migraine headaches, irritable bowel syndrome, pelvic pain syndromes, and chronic fatigue.

Primary care doctors can help their patients with CLBP by doing the following:

1. Avoid over-interpreting MRI findings of DDD, bulging discs, facet arthropathy, and spinal stenosis by explaining to patients that these findings are seen in a majority of asymptomatic individuals and are not likely to be the primary cause of CLBP.
2. Conduct careful assessments to rule out structural causes of chronic pain, and when no specific process is found, consider a nociplastic pain process, i.e., pain generated by neural circuits rather than a structural process.
3. Offer education to patients regarding the fact that their pain is real, not “all in their head,” and it is not their fault and that this type of pain may be reversible.
4. For patients who are interested in pursuing this model of treatment, offer resources such as PPDAssociation.org and TMSwiki.org.

References

1. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations.  Am J Neuroradiol. 2015;36(4):811-816. http://www.ajnr.org/content/36/4/811
2. Jonas WB, Crawford C, Colloca L, et al. Are Invasive Procedures Effective for Chronic Pain? A Systematic Review. Pain Med. 2019;20(7):1281-1293.  https://academic.oup.com/painmedicine/article/20/7/1281/5094687?login=false
3. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017;166(7):493-505. https://www.acpjournals.org/doi/10.7326/M16-2459
4. Van den Bergh O, Witth M, Petersen S, et al. Symptoms and the Body: Taking an Inferential Leap. Neurosci Biobehav Rev. 2017;74(Pt A):185-203. https://www.sciencedirect.com/science/article/abs/pii/S0149763416304729?via%3Dihub