Breaking the cycle of chronic back pain: new study reveals the power of shifting pain beliefs

By Dr. Chinta SidharthanReviewed by Danielle Ellis, B.Sc.Oct 3 2023

In a recent study published in JAMA Network Open, researchers examined whether pain processing therapy involving the reattribution of pain to processes of the brain or mind instead of being indicative of tissue damage or injury could bring pain relief and help improve the recovery process.

Background

Although pain is commonly attributed to peripheral pathophysiologies such as osteoarthritis or bulging disc, these findings are often not the major cause of the pain symptoms. Studies have reported that cases of nociplastic chronic pain including tension headaches and chronic back pain are largely driven by threat learning processes and central upregulation. The belief that the pain is related to tissue injury or damage also results in disuse and avoidance behavior due to fear, which slows the recovery process and results in persistent pain.

Pain reprocessing theory aims to help the patients reattribute the pain to reversible and non-dangerous brain pathways and consider the pain as a “false alarm” and not indicative of tissue damage. Furthermore, clinical trials have demonstrated that pain reprocessing therapy has been effective in helping adults with chronic back pain of low to moderate severity become completely or almost pain-free posttreatment compared to usual care or placebo.

About the study

In the present study, the researchers used free-text, open-ended responses to understand the patient’s perceptions of pain using natural language approaches. Compared to questions in the multiple-choice format, natural language methods provide a substantially less confined approach to understanding the beliefs, concepts, and spontaneous thoughts of patients. Furthermore, natural language methods are scalable and quantitative, which makes them useful for analyzing larger datasets, including electronic health records.

The dysfunction in symptom disorders that are medically unexplained is often driven by the misattribution of symptoms to a disease or bodily damage. While the symptom attributions have not been investigated in depth in chronic pain patients, incidental imaging findings such as small disc bulges often further the misattribution of pain to tissue damage. The researchers hypothesized that the reattribution of pain to processes related to the brain would result in pain relief.

Participants between the ages of 21 and 70 years who were suffering chronic back pain for at least one-half of every month for the previous six months and had a pain intensity of four or higher for at least a week were recruited for a previous clinical trial, the data from which was used for the present study. Participants with nociplastic or primary chronic back pain were targeted, while those with metastasizing cancer, severe mental illness, litigations or compensations related to pain, or with worse leg pain than back pain were excluded.

Patients were randomized to three interventions, namely pain reprocessing theory, usual care, and placebo. The pain reprocessing theory group underwent an hour-long session of telehealth with a physician and eight one-hour-long therapy sessions. The treatment used somatically focused, guided, reappraisal exercises and insights into the connections between psychological and emotional states and pain.

The placebo group watched two videos on the use of placebos to relieve pain and was administered a subcutaneous saline injection into the back. The usual care group continued with the methods of care they were currently using and did not begin any new treatments during the course of the study.

The measurements were based on the participants’ short answers to the question of ‘which three main factors were thought to cause their pain’ and pain-intensity measures obtained from various questionnaires.

Results

The results indicated that pain reprocessing theory increased the reattribution of chronic pain to processes of the brain and mind and decreased pain intensity. Furthermore, the changes in the mind-brain attribution scores posttreatment also mediated the impact of pain reprocessing theory over a one-year follow-up. Additionally, improvements in the mind-brain attribution scores resulted in reduced activity avoidance behavior and harm beliefs, as well as catastrophizing.

The analyses of the natural language method indicated a shift from words with biomedical attributions such as disc, weight, sport, and activity in the pretreatment stage to emotion and neurobiology-related words such as anxiety, fear, neural pathways, etc., in the posttreatment stage. Mechanical and structural terminologies such as scoliosis and car had also been replaced by words predominantly related to the mind, such as stress and anxiety.

Conclusions

Overall, the findings suggested that pair reprocessing theory successfully reattributes chronic back pain to causes related to the brain or mind, which also reduces pain intensity. Analysis of natural language methods used in this study also showed a shift from the usage of words associated with biomedical attributions and structural terminologies to words indicating emotions and a neurobiological understanding. The improvements in mind-brain attribution scores were linked to reduced catastrophizing, avoidance behavior, and harmful beliefs.