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
Skillfully Well & Painfully Aware 
I’ve always known that the pain I have from fibromyalgia does not mean there is any physical thing wrong. That knowledge has not helped one iota.
Same. I think that’s why I was frustrated with the claim this applies to ‘chronic pain’ generally when the study was actually people with mild low back pain. If someone was worried they had a degenerative disease when they don’t, maybe this info would help them, but otherwise, pain in the nervous system is still painful.
Thank you for addressing this. I was getting very annoyed by people’s reactions to the headlines. Of course, I went directly to the research to find out the truth, which you explain so well!
I’m glad I wasn’t the only one! Thanks for reading 🙂
Thank you for finding and sorting out this article. I agree that it may be a helpful PART of treatment for chronic pain. I try to stay open to any type of treatment.
I think you have it exactly right, and I also feel very skeptical of either extreme (“All you need is this ONE thing to cure you!” … Or “Nothing works and this is probably useless too!”). It’s tricky with the psychology recommendations, because clearly stress is interconnected with pain so therapy and mindfulness can be very useful, but psychology can also be used to discredit pain as made up by ‘crazy hypochondriacs’. So you need to be open but careful, and it’s a thin line sometimes. I’m glad this article was useful for you!
I saw something very similar said in the UK news this week and my blood boiled! You’ve covered this latest piece of research really well. While there’s obviously a reciprocal relationship between mental health and physical health, not everything is caused by mental health nor can everything be solved by focusing on mental health. Pain is a very real thing for most people – it’s not just “in their head”. Yes, there will be some with pain linked more to processing or psychological trauma reasons perhaps, but that’s a small amount compared to the number of chronic pain patients worldwide. If someone told me they were going to take away my prescription painkillers (uh-oh, the “opioid crisis”!) and I had to try CBT, I’d be hard pushed not to punch them. I have widespread inflammation, fibromyalgia and nerve damage from metal screws in my back. It’s not something that can be wished away or thought differently about or desensitized.
“In the past, claims that pain conditions were psychological in origin were used to discredit and disbelieve patients, particularly women. ” < Absolutely and I think this sort of "research" will go against patients, particularly women, who live with chronic pain.
Caz xx
You summarized all my feelings about this so well! It feels like screaming in the wind sometimes or being stuck in some Victorian era ‘women are hysterical’ time warp sometimes! My physio will happily point out the muscle spasms, nerve damage, and joint hypomobility if they want to see fibro is a real, physical illness. So many patients are advocating for the need for meds AND non-drug interdisciplinary treatments, but you still hear stories where people are cut off their meds and referred to a CBT class or support group. The urge to punch someone in the face is a rational reaction in that case! Of course, therapy is helpful for the emotional suffering aspect of pain, which is part of a feedback loop and distress intensifies pain, but that’s very different from making mental health the sole cause of the pain.
If they really want people to incorporate non -drug therapies, why not subsidize physio, occupational therapy, nutritionists, rehab exercise trainers, etc …. Because it’s too expensive I guess, but they are really invested in psychosomatic explanations that responsiblize the patient for their own treatment (“stop being crazy and you’ll get better!”). You’re absolutely right that the opioid hysteria also feeds into this narrative too. xx
That is a really excellent point! Why won’t they pay for a nutritionist and physical therapy. These professions go a long way in helping the fibromyalgia patient. When it comes down to it, what is going to help for the exhaustion? No one has an answer for that!!! I’m glad to see so much discussion around this issue.
Yes, an expert on management fatigue, sleep, pacing would be really helpful, maybe some kind of rehab or occupational therapy specialization! But instead it’s just these CBT and pain management support groups that get the focus. It’s frustrating when you hear about all of the hysteria over medication prescriptions, criminalizing patients, when you probably could help some people to reduce their doses by properly funding these other services, especially via home care. Probably quite a few people would happily reduce their pain meds if they had adequate, ongoing alternative treatments that they could afford. That being said, medications also have their place too. As does therapy and this new PRT method. The either/or mentality is the problem.