Dr. Akhil Chhatre, director of spine rehabilitation at Johns Hopkins Hospital, sees hundreds of chronic back pain patients each week.
For the past 10 years, Dr. Chhatre has treated an array of chronic back conditions, including disc herniations, nerve damage, and nonspecific low back pain.
After identifying important rehabilitation goals with the patient, he works to understand the exact nature of each patient’s condition, which can include MRIs and functional tests. In some instances, a block or epidural is needed to identify the source of low back pain to determine a management strategy.
Yet for patients with chronic low back pain, Dr. Chhatre says the fear factor often needs to be addressed.
“There is absolutely a link between fear and chronic low back pain. The link is emotional, and the tie between the feelings that pain evokes and a similar heightened sensation that fear evokes,” he told The Epoch Times.
“Those who do not have fear have a much cleaner and shorter path to recovery and better prognosis.”
Pain-Related Fear and Chronic Low Back Pain
A 2017 study in Switzerland found that enhanced pain-related fear plays a significant role in chronic low back pain by amplifying the experienced disability.
The study, which involved 20 people with chronic low back pain and 20 healthy people, found that pain-related fear dampened neural communications between two key areas in the brain—the periaqueductal gray (PAG) and the amygdala—essential for pain modulation. Researchers found that the PAG processed more negative emotions associated with chronic low back pain than actual pain.
Dr. Chhatre noted that although he doesn’t think fear leads to chronic low back pain, these conditions can affect each other.
Chronic low back pain often starts as a physical injury in the acute or initial stages—whether pressure on the spinal nerves, misalignment of the spine, traumatic injury, fracture, muscle strains or ligament sprains.
But once the pain lasts more than 12 weeks, the brain often becomes sensitized to it. In many cases, a psychosocial component is a likely factor when a specific physical cause can’t be identified.
Researchers previously found that roughly 85 percent of chronic low back pain cases are nonspecific, meaning that there are no anatomical abnormalities that clearly explain pain symptoms.
A 2020 meta-analysis involving a total of 3,949 participants (in 52 studies), of whom 3,013 (in 42 studies) had chronic low back pain, found that pain-related fear, catastrophizing, and depression are significantly associated with reduced movement and more rigid spinal behaviors in patients with low back pain.
The finding comes at a time when low back pain has become a global epidemic, with a recent study in The Lancet finding that in 2020, 619 million people worldwide suffered from low back pain. That number is expected to reach 843 million by 2050.
The Lancet study also reads, “A major challenge in minimizing the burden of low back pain will be to facilitate identification of and access to effective non-pharmacological interventions in order to move away from harmful low-value health-care options, such as opioids.”
Pain reprocessing therapy is one psychological treatment strategy that has been shown to be effective in alleviating chronic low back pain.
Rewiring the Brain With Pain Reprocessing Therapy
In a peer-reviewed study published in JAMA Psychiatry, researchers developed pain reprocessing therapy (PRT), a type of psychological treatment to decondition or unlearn pain sensitization.
Pain sensitization often starts as fear and moves onto movement avoidance because of the brain’s perception of threat due to residual pain that can arise from the activities of daily living. Essentially, a pain-fear-pain cycle forms, which PRT aims to break.
In the study, 66 percent of participants (33 of 50) in a randomized clinical trial of PRT reported being pain-free or nearly pain-free after four weeks of biweekly treatment.
This was compared with 20 percent of participants (10 of 51) who were given a placebo treatment and 10 percent (5 of 50) given usual care.
The reductions in pain following PRT were largely maintained one year later.
During the treatment sessions, participants—under the guidance of PRT-trained therapists—are taught to reconceptualize or rethink chronic pain as a “brain-generated false alarm.”
As participants change their perception of the pain to “nondangerous,” their brains rewire the neural pathways that generate the pain signals, reducing pain.
This technique reduces pain-related activity in several areas of the cerebral cortex that are important for the experience of pain, including the anterior cingulate and insula, according to Tor Wager, professor of neuroscience and director of the Cognitive and Affective Neuroscience Lab at Dartmouth College in Hanover, New Hampshire.
“Estimates from the literature are that 80 to 90 percent of chronic low back pain is primarily related to the brain-body issues that PRT addresses, instead of being related to specific pathology in the back,” Mr. Wager told The Epoch Times in an email.
PRT helps patients learn that spinal and brain pathways can “sensitize after injury,” which is normal and reversible, he said.
“It uses techniques for focusing on the body with attention on pain while reappraising it as safe, reducing fear and avoidance, and facilitating the desensitization process,” Mr. Wager said.
The principles used by PRT overlap with other cognitive and behavioral therapies, but the combination of techniques is unique.
Other psychophysiological therapies to treat low back pain have also shown potential.
Other Promising Psychophysiological Approaches
A pilot study involving patients with nonspecific low back pain found that psychophysiological symptom relief therapy using a similar approach to PRT (mindfulness-based stress reduction) alleviated pain symptoms in patients with chronic nonspecific low back pain.
In Australia, a study by professor James McAuley from the University of New South Wales (UNSW) School of Health Sciences and Neuroscience Research Australia found that patients who underwent a 12-week “sensorimotor retraining” course had clinically meaningful results when compared with those who undertook a 12-week sham treatment course designed as a control.
“People were happier, they reported their backs felt better, and their quality of life was better,” Mr. McAuley told the UNSW Newsroom.
“It also looks like these effects were sustained over the long term; twice as many people were completely recovered. Very few treatments for low back pain show long-term benefits, but participants in the trial reported improved quality of life one year later.”
The Future of Treating Back Pain
Currently, PRT has been adopted by multiple centers in the United States, but how widespread it becomes depends on the availability of information and training, Mr. Wager said.
In Australia, adopting sensorimotor retraining into the work of clinicians, physiotherapists, and exercise physiologists is expected to take place in the near future.
Dr. Chhatre said physical therapists have the option of providing PRT to patients, but it needs to be part of their care plan, which often includes treatments and exercises to manage the physical aspect of chronic low back pain. Patients can also be referred to trained psychologists.
“Most people are not happy just knowing the source of their pain—they want to get some improvement, either with their pain level or their function—and all of this adds up to quality of life,” he said.
“Something as simple as pain reduction and sensory retraining techniques—if we were to write that on a prescription, therapists would offer that.”
Dr. Chhatre also said he usually asks patients questions pertaining to depression, happiness, quality of life, mood, and sleep to determine whether patients need to undertake further psychological intervention.
Regarding exercises, he said he usually starts with physical therapy to establish a strong foundation for moving in space to cater to an injury and prevent further damage.
“Once this strong foundation is established, we can move on to desired goals in terms of exercise or activity. This can include strength training or cardio,” Dr. Chhatre said.
He also stressed the importance of a multidisciplinary approach.
“Lay out some goals at the outset. What are your functional goals? And even mentally—what part of your psyche needs to be addressed, too?” Dr. Chhatre said.
“Part of it boils down to how appropriately patients are treated—how quickly and effectively are [people with low back pain] being treated? Some things are out of their hands, such as some conditions, but if patients are seeing triage and treated in the right fashion, [they] can be prevented from progressing to a chronic pain state.”