Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial

Chronic back pain (CBP) is a leading cause of disability, and in approximately 85% of cases, no specific peripheral pathology can be identified. Current psychological treatments provide limited pain reduction, suggesting a need for novel approaches. This study investigated whether Pain Reprocessing Therapy (PRT)—a psychological treatment designed to help patients reframe their pain as a non-dangerous brain-generated phenomenon rather than tissue injury—could provide substantial pain relief by shifting patients' beliefs about pain's causes and threat value.

The researchers conducted a randomized controlled trial with 151 adults (mean age 41 years, 54% female) reporting low-to-moderate chronic back pain (baseline mean pain intensity 4.1/10). Participants were randomly assigned to receive either PRT (8 therapy sessions plus 1 physician evaluation over 4 weeks), open-label placebo (saline injection plus education about placebo mechanisms), or usual care. The primary outcome was pain intensity one week at post-treatment, with follow-up assessments at 1, 2, 3, 6, and 12 months. The study included functional MRI scans at baseline and post-treatment to examine changes in brain activity and connectivity associated with pain processing.

Results demonstrated large treatment effects for PRT compared to both control conditions. At post-treatment, the PRT group reported mean pain intensity of 1.18/10, compared to 2.84/10 for placebo and 3.13/10 for usual care (effect size g = -1.14 to -1.75, p < .001). Notably, 66% of PRT participants (73% of those who initiated treatment) were pain-free or nearly pain-free (pain score 0-1/10) at post-treatment, compared to only 20% in placebo and 10% in usual care. These improvements were largely maintained at 1-year follow-up. Mediation analyses revealed that reductions in pain-related fear beliefs (Tampa Scale of Kinesiophobia) mediated treatment effects on pain reduction. Brain imaging showed that PRT reduced evoked pain-related activity in the anterior prefrontal cortex, anterior midcingulate, and anterior insula, while increasing connectivity between prefrontal/insular regions and primary somatosensory cortex.

These findings suggest that psychological treatment focused on changing patients' beliefs about pain causation and threat can produce substantial and durable pain relief for individuals with primary chronic back pain. The results support neurobiological models proposing that chronic pain is partially maintained by threat-related brain predictions and that reappraising pain as non-dangerous can provide significant clinical benefits. However, the study sample was relatively homogeneous (well-educated, active individuals), and future research should examine generalizability to diverse populations and treatment delivery contexts. The approach offers a promising alternative to current standard treatments and aligns with recent advances in pain neuroscience.