Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain an RCT, 2021, Asher, Gordon et al

There always seems to be an assumption in papers spouting this belief, that tissue damage will always be found if it is there to be found. But this belief of the authors simply isn't true. Many, many people will have tissue damage that nobody looked for, or it was looked for by someone incompetent, or it was looked for using the wrong kind of scan or test, or it was looked for in the wrong place, or the science simply isn't developed enough to find the damage. And, of course, once tissue damage has been dismissed as a possibility it is almost impossible to get anyone to look for it again.

 

Pain is pain it matters not one iota what you think causes it it destroys your quality of life the ability to sleep for a reasonable period of time and regardless of the cause will wear you down . so this so called research/opinion of idiots who have not had to live with a chronic pain condition is worthless waste of time and money . the people who fund this really should wake up to the consequences of ignoring the harm done by denying the lived experience of a very significant number of people .

 

Great job dissecting out this flabby nonsense @Hutan.

Yikes, my health insurance company United Health Group will be promoting this flim-flam snake oil regimen soon--good to know.

 

Only had time to briefly skim this but so much is odd.

One (1) telemedicine meeting with physician and then straight to psychology. Where on earth would that be allowed in any medical system? That is shocking. Really shocking. No physical exam. Wow.

In contrast: The set up in NHS for lower back pain in NW England where I work looks like this:

Patient sees their GP and the vast majority of pts will be managed with conservative treatment (anti inflammatories, perhaps some opioids), physical check to rule out red flags/nasty causes and encouragement to keep gently active. Many patients will recover nicely, others will develop more long term chronic LBP. We have no idea why this is the case.

If pain / situation escalates, then GP or self referral to local physiotherapy / musculoskeletal team. Pt generally seen by senior physio and/or advanced MSK practitioner (AMP) - who can refer directly to rheumatology, surgery, neurology, chronic pain and so forth. AMP will complete thorough physical assessment, refer for scans, if needed, and review and discussion about what support available and what the pt wants - because guess what, there are no magic cures for chronic LBP. And we have no idea why some people develop chronic LBP and others with low back pain recover. It is unknown.

If pain is chronic (and oftentimes people manage for decades by 'getting on with it' before it becomes impossible or they reach crisis point) they may wish further support and be referred in chronic pain team (this is v small section of MSK/physio services) and then it is about support, knowledge especially re medications, management (pacing and remaining v gently active without flaring up their pain) and so forth. Because there is no cure. Chronic pain management does what it says on the tin. There is no assumption or expectation of reduction in pain or cure. It is about helping the most distressed, debilitated patients to lead the best quality of life they can with the least distress. This is done with physios trained in chronic pain, pain consultants and pharmacists, and psychologists (where needed and appropriate).

So, how does this link to the paper - well did they actually reduce the pain? Or did the patients feel that they ought to be nice to the therapists and fill in the forms accordingly? Hutan has pointed out that opioid use was increased in the so-called pain-free/low-pain group. If cured (or thereabouts), then why would anyone be taking an opioid. They have horrible side effects especially long term. Not something you'd do unless you felt the necessity. There doesn't appear to have been much discussion about meds in this research which is shocking. Many people with pain will continue taking meds, with horrible side effects, often for a long time.

The whole context of this work is upside down and backwards. They aim for, assume and hope for cure when probably, at best, in some roundabout way they might have helped pts to understand their pain (a bit) and report it bothers them less. That's confusing feeling better with being better. Exactly what PACE tried to do.

As for statements like: "Since chronic pain patients have altered emotional functioning (Lumley et al., 2011)" Words fail me. No, some people in pain understandably have a tough time trying to get their heads around it (it is a massive unwanted and unexpected visitor after all), funnily enough it can be really upsetting to have to adapt to the often shitty changed life circumstances (and cope with social ambiguity situations when patients do not recover fully) and general grimness of 24/7 pain, which probably interferes with work, sleep, concentration, memory, relationships, exercise, social life, sex and so on. It's kinda like the researchers just can't or won't get into thinking how grim it can be. It as if 'pain' is some other thing that other people feel but not us.

Where have they shown that patient's beliefs about their pain where changed? All assumption and nothing objective or real. No check on validity. In essence: Some questionnaires where completed after a wholly woo, unsafe intervention (no physical exam) and the researchers concluded these changes were meaningful or relevant to the patients. No space to hear what the patients thought of this.

 

Though similarly just because eminent physicians have had people with ME pass through their clinics, this does not necessarily guarantee their personal preferences reflect reality.

 

If the pain had been investigated before and no cause had been found for it I think, in the UK, the NICE guidelines for "primary" chronic pain would get used, and they were written by sadists from the UK. So in answer to your question Where on earth would that be allowed in any medical system? The answer is - in the UK.

https://www.nice.org.uk/guidance/ng193

If pain has been declared (by some sadist somewhere in the medical system) to be "primary" or not real, and the patient is assumed to be a drug-seeker, then no treatment is supposed to be offered other than anti-depressants, acupuncture, psychology, exercise and CBT is supposed to be all that's offered. Certainly, no further examination to find the cause of the pain will be offered, as far as I can tell.

https://www.nice.org.uk/guidance/ng193/chapter/Recommendations#managing-chronic-primary-pain

 

Does anyone understand whether the fMRI findings mean anything, or what they mean if they do mean something?

 

Honestly this is basically phrenology except somehow far dumber. This is beyond bizarre considering it's meant to be used in clinical practice, usually with people who don't have a choice. Even for a cult this would be bizarre stuff, or, you know, typical of a cult. So yeah basically a cult.

 

where is this? In the supplementary material?

 

I think @Woolie might be the person to answer this!

 

His response here. Doesn’t respond to cannabis. Also note that the scale (metric) for opioid use is number of pills, not mg.
There are many types of opioid pills differing in their potency and mg.

https://twitter.com/user/status/1443959561136877569

 

I doubt anybody does much.
The prefrontal region is where higher thoughts and thoughts about self tend to be.

So reduced activity in prefrontal region might indicate not thinking such complicated thoughts about how the pain was for oneself. Or it might indicate less in the way of thought about taking part in an fMRI study or less in the way of thoughts about whether the money on parking the car is running out.

There seems to me to be a huge problem with fMRI comparing patients with controls in that there is no way we would expect patients and controls to have similar thoughts while having an fMRI scan - for a hundred and one reasons.