No more pills? Psychological treatment could provide lasting relief for chronic pain

BOULDER, Colo. — Chronic back pain is the leading cause of disability worldwide and can be extremely disabling to those who suffer from it. Current treatments include medicating patients with steroid injections, opioid painkillers, and physical therapy to manage the pain. While admitting that it is not “all in the head,” scientists find that two-thirds of chronic back pain patients who underwent a four-week psychological treatment called Pain Reprocessing Therapy (PRT) were pain-free or nearly pain-free post-treatment. Moreover, most maintained the relief for one year.

The new research, led by the University of Colorado-Boulder, suggests that psychological therapy could be beneficial in understanding the origins of pain and altering the brain networks which process pain. The findings contribute some of the strongest evidence that psychological treatments can provide durable relief for chronic pain, which afflicts an estimated 50 million Americans.

The study lead author, Dr. Yoni Ashar, now a researcher at Weill Cornell Medicine, conducted the study in the Department of Psychology and Neuroscience at CU Boulder.

“For a long time we have thought that chronic pain is due primarily to problems in the body, and most treatments to date have targeted that. 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 it works,” says Dr. Ashar in a university release.

‘False alarms’ responsible for chronic pain?

According to scientists, approximately 85 percent of people who suffer from chronic back pain have what doctors call “primary pain,” meaning that tests are unable to identify a clear cause, such as tissue damage. The scientists continued to explain that the misfiring of neural pathways is at least partially to blame for the torturous pain that some people experience. Previous studies have shown that different brain regions, including those dealing with reward and fear, activate more during flare-ups of chronic pain, rather than acute pain.

According to Guy’s and St. Thomas’ NHS Foundation Trust in England, chronic pain is a actual medical condition that causes a great deal of suffering. There are also neurophysiological changes in the central nervous system following persistent pain, although these are not detectable using common scans or tests. Psychologists from the London hospital’s pain management service, INPUT, teach its patients that normal signals of touch, pressure, and movement pass to the central nervous system, but are interpreted as abnormal or painful, which is called central sensitization.

If pain is a warning signal that something is wrong with the body, “primary chronic pain” is like a false alarm stuck in the “on” position. The university’s psychological therapy PRT, along with other pain management services like INPUT, seeks to turn off that alarm.

“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,” Dr. Ashar explains.

Pain relief may be in the mind

For the study’s controlled trial, Dr. Ashar and Professor Tor Wager, a neurologist at Dartmouth College, recruited 151 men and women suffering from back pain for at least six months. Those in the treatment group completed an assessment followed by eight one-hour sessions of PRT, a technique developed by Los Angeles-based pain psychologist Dr. Alan Gordon. The goal was to educate the patients about the role the brain has when generating chronic pain and to help them to engage in movements they were afraid to do while helping them to address the emotions that may play a part in exacerbating their pain.

“This isn’t suggesting that your pain is not real or that it’s ‘all in your head’,” Prof. Wager stresses.

He continued to note that the changes to neural pathways in the brain can linger long after an injury is gone, but are also reinforced by such brain associations.

“What it means is that if the causes are in the brain, the solutions may be there, too,” Wager adds.

Before and after treatment, participants also underwent functional magnetic resonance imaging (fMRI) scans to measure how their brains reacted when subjected to mild pain. After the treatment, 66 percent of patients in the treatment group were “pain-free” or “nearly pain-free,” compared to 20 percent of the placebo group and ten percent of the no-treatment group.

“The magnitude and durability of pain reductions we saw are very rarely observed in chronic pain treatment trials,” Dr. Ashar reports.

Quieting the pain centers of the brain

The doctor adds that when the experiment exposed people in the PRT group to pain in the scanner post-treatment, brain regions associated with pain processing – including the anterior insula and anterior midcingulate — had quieted significantly.

The authors stressed that the psychological treatment would not be suitable for those suffering from “secondary pain,” due to an injury or disease.

The study focused specifically on PRT for chronic back pain, so larger studies in the future will need to determine if the therapy would yield similar results for other types of chronic pain. Meanwhile, other similar brain-centered techniques are already emerging among physical therapists and clinicians who treat pain.

“This study suggests a fundamentally new way to think about both the causes of chronic back pain for many people and the tools that are available to treat that pain. It provides a potentially powerful option for people who want to live free or nearly free of pain,” concludes study co-author Sona Dimidjian, a professor of psychology and neuroscience at CU Boulder.

The report appears in the journal JAMA Psychiatry.

South West News Service writer Georgia Lambert contributed to this report.

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