29 September 2021

Give patients with back pain therapy – study suggests

29 September 2021

Patients who suffer with back pain with no specific underlying cause could benefit from therapy which teaches them how to rethink pain, a new study suggests.

Researchers found that a significant proportion of patients with chronic back pain managed to stay pain free for a year after they went through a specific type of therapy.

Patients were given pain reprocessing therapy (PRT), which aims to help people understand that their pain is due to mind-brain processes rather than bodily injury.

Researchers said that the therapy can help a patient “reframe the pain as a ‘false alarm’ of danger”.

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.

The authors of the new study said that PRT and related treatments that combine psychological and behavioural approaches can be helpful for “many, or even most” patients with chronic back pain.

But they stressed that patients with specific causes of pain such as sciatica may not benefit.

The new study, published in the journal Jama Psychiatry, examined data on 151 adults with an average age of 41 with low to moderate pain who had suffered for an average of 10 years.

The team of US-based researchers used scans and follow-up assessments to test whether or not the therapy helped patients.

One group were given an appointment with a doctor followed by eight PRT sessions over four weeks.

Another group was given were given a dummy drug as an injection and a final group were given standard care.

They found that after a year, 66% of people in the PRT group were “pain free” compared with 20% in the placebo group and 10% who received the usual standard of care.

“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,” said lead author Yoni Ashar, from the University of Colorado 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 it works.”

The authors explained that around 85% of chronic back pain have no known cause such as an injury or illness – this is sometimes referred to as primary chronic pain.

It has been suggested that “misfiring neural pathways” are at least partially to blame.

Studies have previously shown that different brain regions — including those associated with reward and fear — activate more during episodes of chronic pain than acute pain.

Dr Ashar said that 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 idea is that by thinking about the pain as safe rather than threatening, patients can alter the brain networks reinforcing the pain, and neutralise it.”

Before and after treatment, participants had MRI scans to measure how their brains reacted to a mild pain stimulus.

And when people in the PRT group were exposed to pain in the scanner post-treatment the brain regions associated with pain processing had “quieted significantly”, the authors added.

The paper concludes: “Psychological treatment centred on changing patient’ beliefs about the causes and threat value of pain may provide substantial and durable pain relief with chronic back pain”.

Earlier this year, the National Institute for Health and Care Excellence (Nice) recommended that people with chronic primary pain should be offered a range of treatments to help them manage their condition.

These can include exercise programmes and the psychological therapies CBT and acceptance and commitment therapy (ACT). Acupuncture is also recommended as an option for some.

Nice said that people with chronic primary pain should not be offered pain relief such as paracetamol, non-steroidal anti-inflammatory drugs, benzodiazepines or opioids.

“This is because, while there is little or no evidence that they make any difference to people’s quality of life, pain or psychological distress, they can cause harm, including possible addiction,” Nice said in a statement.

Its guideline recommends that an antidepressant can be considered for some patients.

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