The health headlines were all abuzz this week about a new study on chronic pain out of Boulder, Colorado. The headline for the article I first read was: ‘How therapy, not pills, can nix chronic pain.‘ As a patient, and a health writer, I’m frustrated to read headlines that perpetuate a narrative that chronic pain is a psychological problem that is “all in the head.” However, I resolved to stay open to the conclusions drawn from the study.
What did the study actually say?
Pain Reprocessing Therapy (PRT) claims to shift your beliefs about the cause and threat value of chronic pain, by framing pain as a “false alarm” rather than something dangerous. By helping patients to reconceptualize their pain as a “reversible, brain-generated phenomenon,” not ongoing physical damage, the study authors concluded that PRT provides significant, durable pain relief.
A small sample of 151 individuals with low-moderate back pain were divided into three groups: a treatment group, a placebo group, and a group who received the “usual care” for back pain. The treatment group received eight one-hour sessions of a new type of therapy called Pain Reprocessing Therapy (PRT) over four-weeks. All three groups reported their pain levels at the end of the study. In addition, the researchers used fMRI imaging to determine if the therapy had changed brain activity in participants when they evoked back pain in the laboratory.
In the treatment group, 66% of participants reported being pain-free or nearly pain-free at the end of the study, compared to 20% of participants in the placebo group, and 10% in the usual care group. Even one year later, fMRI imaging showed that participants in the treatment group had a lower prefrontal cortex response to evoked back pain than the other two groups, although the meaning of this finding was unclear.
What does this study not say?
The study proves that, in a small sample of people with mild back pain, PRT reduced pain. It opens the door to further investigation on how pain perceptions held by individuals with low back pain affect pain intensity, and how learning to reappraise pain sensations as safe may help reduce pain levels. However, this is a far cry from the ‘revolution in how we understand and treat all forms of chronic pain’ that articles reporting on the study proclaim! We would need a sample size of thousands, in different settings, to confirm the findings that PRT can reduce mild low back pain. Furthermore, it is impossible to draw conclusions about how PRT would work for people with different pain conditions, like fibromyalgia, until a study is repeated in those populations.
Psychology and Pain
In some cases, chronic pain is a disorder of the pain processing system itself: sensitized nerve endings send pain signals, which are prioritized and amplified in the spinal cord, and finally interpreted as a significant, dangerous threat in the brain. Rather than “all in the head”, we can consider this type of pain to be “all in the brain and central nervous system” (far less catchy, I’m afraid). This is in contrast to conditions like arthritis, which are caused by inflammation in physical tissues like joints.
To my knowledge, no research exists showing a mechanism of action for how thoughts and emotions of the mind can control or terminate central nervous system neurons firing pain signals. The authors of this PRT study argue that other psychological pain interventions, like cognitive behavioural therapy or mindfulness, teach patients to improve their daily functioning despite pain, by learning to be less reactive to pain signals. In contrast, Pain Reprocessing Therapy, apparently teaches conscious strategies to reduce and down-regulate pain signals directly. This study shows a correlation (PRT correlates with pain reduction), and the brain imaging results were inconclusive. That is a far cry from proof of the researchers’ theory about how PRT works, showing direct causal evidence that RPT dials down pain signals.
There are limitations to the role the brain plays in perpetuating chronic pain. For example, fibromyalgia, was, up until recently, thought to have been 100% caused by central nervous system sensitization. However, now a new body research shows fibromyalgia is also a disease of the body, including small fiber neuropathy, and immune dysregulation. Therefore, I think the claim that pain is an entirely “reversible brain-generated phenomenon” is a stretch too far.
In the past, claims that pain conditions were psychological in origin were used to discredit and disbelieve patients, particularly women. Even though the “all in your head” narrative has been weaponized to discredit pain patients, we have to stay open to the possibility that PRT may be one tool, among many, in a chronic pain management toolkit. None of these treatments, like psychology or medication, need to be ‘either/or’. Responsible health writing plays a role in shaping these narratives.
The health headline for a medical news website stated ‘Psychology, not Pills Provide Long-lasting Pain Relief’, setting it up as one or the other, whereas the research article had the much tamer name `Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial` (albeit, in a psychiatry journal). As someone with a health condition, it’s important to notice the bias in reporting, and how that shapes the headline and article. For example, I found a reasonable headline reporting on the PRT study which says “Chronic pain treatment should include psychological interventions.” For tips on how to find credible health information, and avoid misinformation and conflicts of interest, these are some helpful tips.
Ashar YK, Gordon A, Schubiner H, et al. Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial. JAMA Psychiatry. Published online September 29, 2021. doi:10.1001/jamapsychiatry.2021.2669