Can Therapy Help Reduce Back Pain?

A just-released publication by psychologist and neuroscientist Yoni Ashar and colleagues in JAMA Psychiatry begins by clarifying that as many as 20 percent of Americans suffer from chronic back pain. The study compared three pain treatments: a short-term, problem-specific psychotherapy treatment, a placebo treatment, and a standard pain protocol. The results showed major differences in outcomes, with the psychological treatment showing by far the strongest pain relief.

Chronic pain generally begins in response to an injury, then lingers for months or years after.

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Research design

Subjects in this study included 151 adults, half men and half women, all of whom had been suffering mild to moderate levels of chronic back pain.

The subjects were assigned to one of the three groups described above:

• Pain reprocessing therapy (PRT)
• A placebo treatment of an injection into the back of a saline (salt-water) solution
• Standard back therapy treatment

Treatment outcomes

Two-thirds of the subjects who received the psychotherapy for two sessions a week over a period of four weeks rated their pain after treatment at either 0 or 1 (on a scale from 0 to 10). That is, they became essentially pain-free. Subjects in the placebo group averaged some, but significantly less, pain reduction. Subjects in the standard treatment group experienced virtually no pain reduction by the end of the treatment period.

The psychotherapy treatment

PRT treatment includes a combination of cognitive, somatic, and exposure-based techniques. The therapist explains why pain from an initial injury persists and then encourages the subjects to begin to go ahead with movements that had been painful for them.

Ashar et al. referred to their adaptation of what is basically a cognitive behavioral therapy method as PRT, that is, pain reprocessing therapy. Their treatment protocol evolved from the researchers’ understanding of the psychological nature of chronic pain.

As I've previously noted in Psychology Today, MRI scans show when the back or other body structure has suffered tissue damage. Some months after a wounding event, however, a second MRI often will show that the tissue damage that originally evoked the pain has been healed. Nonetheless, long after the physical healing had been completed, some people still continued to experience pain in association with certain movements, the movements that had been painful when the injury first occurred.

The continuation of back pain after the actual physical damage has healed occurs because the brain remembers which movements initially felt painful. When someone who has experienced a real back injury later begins to make the same movement, their brain may continue to tell the body, "This movement is potentially a threat to your back." This message then initiates the same physical pain sensation that initially had protected the body from further injury.

All of which is to say that pain responses that initially had been protective can linger far beyond the time when they served a positive end. The pain now just promotes ongoing suffering and limitations of movement.

PRT psychotherapy teaches the brain that this threat message is no longer needed. Amazingly, as the brain learns a new message—that the pain belief is incorrect and the pain is unnecessary— the pain sensations gradually cease.

Like most CBT treatments, in addition to addressing problematic beliefs, PRT also addresses the behaviors that have been sustaining these beliefs. As the patient gradually experiments with movements that used to hurt, these movements eventually cease to produce pain.

Conclusions and relevance

The study concluded that psychological treatment centered on changing patients' beliefs about the causes and purposes of their pain "may provide substantial and durable relief" from what may have been as much as many years of back pain suffering.

Further Comments from Dr. Ashar

Asked about his subsequent thoughts about this research, Dr. Ashar explained, "Research like this requires a lengthy process, especially in a case like this where we are challenging the conventional wisdom of how to treat a widespread and seemingly purely physical medical phenomenon.

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"Our first step was to propose an understanding of why pain from an earlier injury continues long after the injury itself has healed. The next step was to create a talk therapy based on this theory.

At that point, we designed and eventually implemented the scientifically rigorous research study that JAMA Psychiatry just published. Because our outcomes thankfully proved to be so impressive, we were able to publish the results in a particularly well-respected medical journal.

Now, via a pain relief program called Lin.health where I serve as a senior clinical advisor, my final goal on this project is to make PRT chronic pain treatment inexpensively available to as many sufferers as possible. Why should people live with ongoing pain when with this simple treatment method the pain so often goes away?”