Rewiring the Brain: An Evidence-Based Approach to Help Patients with Chronic Back Pain

Explaining neuroplasticity

The nervous system coordinates the actions of the mind and body, and it is continually changing based on the environment. The ability of the nervous system to adapt is known as neuroplasticity. Neuroplasticity refers to the brain's ability to modify, change, and adapt its function and structure in response to learning, experience, or injury. Neuroplasticity can be helpful, such as when you remember how to cook a favorite meal without a recipe, drive to work without following directions, or avoid touching a hot surface. However, neuroplasticity can also be harmful, such as in the development of chronic persistent pain. In chronic pain, neuroplasticity may make faulty connections and cause the brain and nervous system to become hypersensitive to what would otherwise be normal sensations and activities. In cases of chronic pain, the brain creates a memory of the original pain and remembers that initial pain response when faced with new situations. In this way, activities that wouldn’t normally cause pain become painful and difficult, and psychological and physical stress exacerbate the pain response in the body. 

How can we help our patients with chronic pain without tissue damage?

There are several familiar modalities to consider when treating a patient with chronic pain including physical medicine, medication, and psychological intervention. Pain reprocessing therapy (PRT) is an evidence based approach utilized in the treatment of chronic pain. It uses a combination of cognitive, somatic, and exposure-based techniques to retrain the brain on how to appropriately respond to signals, and break the cycle of chronic pain. Through regular sessions, patients will learn how to dissociate their pain with feelings of fear, which is commonly a driver of symptoms. Pain will lessen over time as patients no longer view their pain as a structural or anatomical issue and instead understand that it is caused by a faulty connection in the brain.

Should pain reprocessing therapy be considered in my claims?

A recent study published in September of 2021 evaluated the effect of pain reprocessing therapy in the treatment of patients with chronic back pain. The patient population was made up of 151 adults aged 21 to 70 years old who met certain criteria:

• Complaints of chronic low to moderate back pain,
• Experienced pain on an average of at least half the days of the previous 6 months,
• Overall complaints of pain for an average of 10 years, 
• Absence of leg pain. Those patients who complained of leg pain worse than back pain were excluded from the study.

During the study, participants were randomized to treatment with either pain reprocessing therapy, non blinded placebo, or usual care. Patients assigned to the usual care group agreed to not start any new treatments until after the posttreatment assessment had been completed. Patients assigned to the PRT group received 1 telehealth session with a physician and 8 psychological treatment sessions over 4 weeks. The treatment goal was to help patients relabel their pain as non-dangerous brain activity, rather than tissue injury. A combination of cognitive, somatic, and exposure based techniques were utilized. 

The researchers found that 33 of 44 participants that had been assigned to the PRT group were  pain-free or nearly pain-free at post treatment follow-up compared with 10 out of 51 participants in the placebo group and 5 out of 50 participants in the usual care group. Improvement in pain was measured through longitudinal functional magnetic resonance imaging (fMRI) which revealed reduced prefrontal responses to evoked back pain, and increased resting prefrontal somatosensory connectivity in the patients in the PRT group versus the patients who in the placebo or usual care group. These findings indicate that the changes in neuroplasticity caused by pain reprocessing therapy were visible on a brain MRI when back pain in these patients was evoked. At the one year post treatment follow up, 73% of patients who had been treated with PRT were pain-free or nearly pain-free compared with 20% in the placebo group and 10% in the usual care group. Other post treatment benefits were noted, including reductions in disability and anger and improvements in sleep and depression in the PRT group versus both controls. These improvements were largely maintained 1 year post treatment as well. The findings of this study strongly suggest that psychological treatment focused on changing the way that patients think about their chronic pain without tissue damage can provide significant and long lasting relief in pain. 

Pain reprocessing therapy is a safe and effective, evidenced-based, drug-free treatment for patients with chronic low back pain. The use of this therapy can greatly improve a patient’s pain, leading to an improvement in their quality of life and return to the workplace. Consider approving  requests for pain reprocessing therapy in patients with chronic low back pain to reduce reliance on the medical system, reduce pain, and increase function. 

By Aliza Krug, PA-C 

Aliza Krug is a Certified Physician Assistant and Medical Professional Legal Consultant and is the Clinical Director of Arbicare, a Utilization Management Organization focusing on improving the care of injured people. She has more than a decade of experience working with patients in both an urgent care and orthopedics setting, and has helped numerous injured workers in a clinical setting.

“Neuroplasticity - Pain Management.” PainHEALTH, https://painhealth.csse.uwa.edu.au/pain-module/neuroplasticity/. 

Pain reprocessing therapy. Pain Reprocessing Therapy Institute. (2021, October 2). Retrieved November 5, 2021, from https://www.painreprocessingtherapy.com/pain-reprocessing-therapy.

Voss, P., Thomas, M. E., Cisneros-Franco, J. M., & de Villers-Sidani, É. (1AD, January 1). Dynamic Brains and the changing rules of neuroplasticity: Implications for learning and recovery. Frontiers. Retrieved November 5, 2021, from https://www.frontiersin.org/articles/10.3389/fpsyg.2017.01657/full.

Yoni K. Ashar, P. D. (2021, September 29). Effect of pain reprocessing therapy vs Placebo and usual care for patients with chronic back pain. JAMA Psychiatry. Retrieved November 5, 2021, from https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2784694.

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