Yoni K. Ashar, PhD
Yoni K. Ashar, PhD, is a postdoctoral associate in the department of Psychiatry at Weill Cornell Medical College in New York City. Dr. Ashar is the lead author of the JAMA Psychiatry study on PRT for chronic back pain.
Acute low back pain, which is incredibly common, can last from a few days to a few weeks. But for about 20 percent of people, the pain persists. When it lasts more than 12 weeks, it’s considered chronic, and some people suffer for years.
New research suggests that part of the problem is that many doctors are treating the wrong body part. The brain—not the back—causes about 85 percent of chronic back pain, Yoni K. Ashar, PhD, wrote in JAMA Psychiatry in September 2021.
“That may seem hard to believe, but that is the commonly accepted number from many research studies,” he told Bottom Line Health. The good news is that it’s entirely possible to teach your brain how to unlearn pain.
Pain is like an alarm that goes off to warn you of danger. Acute pain triggers brain pathways that cause fear, worry, and anxiety. Brain researchers have a saying: “Nerves that fire together wire together.” That means that, over time, the brain pathways between pain, fear, and anxiety become like the grooves made by wagon wheels: They are easy to follow, and they go both ways. When you think you are going to have pain, your brain produces it. When you have a twinge of pain or mild pain, your brain produces fear and anxiety. People with chronic primary pain live in a vicious cycle of worry, fear, avoidance, and months or years of pain.
The study that Dr. Ashar and his colleagues published in JAMA Psychiatry was the first clinical trial of pain reprocessing therapy (PRT).
PRT was developed by psychotherapist Alan Gordon, LCSW, to treat primary chronic back pain. It starts with education about the cause of primary pain. Once the patient accepts that pain does not always mean harm, he or she learns that pain is reversible.
The next stage, somatic tracking, teaches patients to pay attention to bodily sensations in a focused manner, such as during guided meditation. Patients are taught to develop a more open, accepting, and fearless approach to pain sensations.
Finally, in the exposure therapy stage, patients resume activities that they had avoided. If the therapy works, they find that they no longer have pain while gradually resuming normal activities.
Gordon and his colleagues were getting remarkable results in their clinical practice, so they wanted to test their results in a controlled clinical trial. They, along with Dr. Ashar, recruited 151 people who were diagnosed with primary chronic back pain by a physician. The average number of years with back pain was about 10. The patients reported back pain of at least four on a scale of one to 10.
Before treatment started, all study participants had brain imaging that showed the areas of the brain responsible for pain. The researchers measured the brain’s pain responses before and after the trial during a mild task that caused back stress. People in the trial were randomly assigned to receive two PRT therapy sessions per week for four weeks, to get an inactive back injection of saltwater (a placebo), or to continue whatever they were doing for back pain (usual therapy).
The results surprised even the research team. That amount of pain relief is very rare in pain studies using medications, injections, physical therapy, and surgery.
PRT and other mind-body treatments don’t have to be the only treatment for chronic primary pain, but they should be part of the treatment. Primary chronic back pain is real pain, and there is no single approach that works for everybody.
For years, chronic pain has been treated with medications, injections, physical therapy, or surgery. The role of the mind in chronic pain can’t be ignored any longer.
