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

Sorry, there are a lot of replies and I don't really have time or motivation to go through them all. I'm aware of the issues. The point is that they can be mitigated to a certain extent (e.g. having an attention control as a comparitor, as in this trial). There will always be bias when there are subjective measures. As I pointed out in an earlier reply today, pain is subjective, so there is no other option than having a subjective outcome. That doesn't mean that we shouldn't bother doing any research. As I said in the previous comment to hutan: how do you believe studies like this could be better?

 

Have you looked at the neuroscience?

 

Yes, I agree the placebo is terrible in this case. I agree with another poster that it should be a different psychological treatment, perhaps relaxation therapy.

 

Yes, I spend much of my time working on perception. I spent much of today checking through the neuroscience quoted in the Brain Retraining/ Pain Reprocessing literature. It is just handwaving importation of buzzwords. Neuroscience is not sufficiently advanced to make any real difference to theories of pain causation in disease that might be relevant to these treatment programmes. This is not real science. Sorry, but having spent my life in translational medicine and trial design I do have some practical knowledge of this.

 

I think we can even extend that and say that most actions have no rational basis. What they do usually have is a consistent action-and-outcome sequence. That is, doing X results in Y, and Y is desirable, so then is doing X. It's possible, even likely, that it does for completely different reasons than any person would decide is why they do X in the expectation of Y, when the simple explanation is simply that Y occurs, and humans simply don't have the capacity to do much more.

This is why figuring things out is so hard. In fact it's so hard that history is mainly made of two things: wars (and generally breaking stuff), and figuring out how things work, and the impacts it has.

Because it usually doesn't matter if the reasons we do things are rational, all that matters in most cases is that by doing X, we get Y, and when we want Y, then it can be deemed somewhat rational, but the internal rationalizations people have about how X lead to Y are almost always wrong. Because most people are wrong about most things. This is why almost all of us have to go to school for 12 or so years. And it's not a bad thing, it's just that figuring things out from scratch is usually impossible, and almost never happens.

 

Fair enough but this is the fundamental issue and the reason why you're finding no agreement with your position here.

But 'mitigated to a certain extent' isn't good enough if you're trying to draw conclusions about whether a therapy works. You can never know to what extent you've failed to mitigate and therefore you can't interpret any results.

It means exactly that, if that research is an open-label trial with subjective measures.

I can't think of a solution to the problem. Maybe @Jonathan Edwards knows of a solution. But if there isn't one, that doesn't mean that open-label/subjective-measures studies should continue just because there's no better way of doing them. Such studies have no value and should be stopped. It's not ethical to waste patients' time and effort by putting them through worthless research.

 

Does this mean that you support doing studies that can’t possibly (edit: or reasonably) provide any useful information?

Do you think that’s an acceptable use of resources, on an economic, societal and ethical level?

It seems to me like you fail to consider that ‘their best’ might not be ‘good enough’ at all. We can’t just lower the scientific standards to accommodate pseudoscience.

 

Plus, I don't see how this is much different than Deepak Chopra-esque invocation of quantum this and that. Quantum field theory is the most tested scientific theory we have. It is valid, useful, correct, predictive. It doesn't mean that it can be invoked to explain consciousness, and other things that we don't understand.

But the current level of neuroscience is many orders of magnitude below that. Hence why it's almost always invoked in the same vaguely generic: look at the neuroscience. The. Neuroscience. It's just an invocation, neuroscience is very far from being advanced enough to explain those things.

It has certainly shown that pain is experience bidirectionally with the brain, but not how. As textbook example of how a little knowledge can be dangerous. So damn dangerous it has destroyed millions of lives. Including mine, which I very much resent, but would just as much by itself if it didn't happen to me. It's just wrong.

 

The article gives references to the current state of pain neuroscience in the first four paragraphs. How exactly is the study not consistent with that evidence?

 

No, it's not true that they can't provide "any useful information". As I said, with appropriate methodology, bias can be minimized, and you can provide useful information.

 

Actually, this is not true (and I've given detailed and logical reasons why) and is not the opinion of the wider scientific community. It's a little odd that it is the overwhelming opinion of s4me, which is why I only spend a limited amount of time responding here. Perhaps you should invite more scientists to contribute here who work in this area.

 

If you are going to state that as a fact, I suggest that you prove your assertion by providing a description of study design you believe is suited to provide valuable information about any psychosomatic aspects of ME/CFS.

If you can’t do that, you can’t claim that it’s true. That would be fine, but then you would have to be clear that it’s your guess and not a fact.

 

As per my post above - please provide a concrete example that is applicable for the specific situation of ME/CFS.

Nobody here care about opinions - they are often wrong. We care about facts and proofs.

 

I think he said that the ‘evidence’ and the ‘current state of neuroscience’ is quite bad.

 

No but it does mean that we need to stop doing useless research and find better ways of assessing theories. I review ME/CFS research projects for major funding bodies internationally and would have no problem recommending a project on Brain Retraining or whatever if there was any science there and any attention to basic methodology. But what I have seen would not encourage me to do so..

The key message of PACE is that the treatments being tested really don't do very much at all even if they do something. And we know that exposure to such treatments has a lot of unwanted effects. Even if you think the problem is psychological amplification the treatments must be considered major failures just because so many people end up seriously aggrieved. It isn't actually that difficult to get a result even with serious methodological problems if you have a treatment that makes a big impact, as these biopsychosocial-type approaches are claimed to do. More objective surrogate outcomes are perfectly good enough if we think people are actually going to recover.

 

You've given reasons that you believe to be logical but you don't seem to be taking in the counter-arguments, such as the one I just made.

That's an appeal to authority rather than logic, but the people who do double-blind placebo-controlled drug trials would, I expect, share my opinion (and that of others here) about open-label, subjective-measure trials.

It's not odd at all, because most of the trials done in ME/CFS are of this poor type and so we're very familiar with the issues.

BPS scientists have always been free to join, but when pressed on this particular issue in other arenas, they dodge it. They're calling themselves scientists without actually being so.

 

I agree with all your points.

 

The critical point is that those circuits regulate attentional and behavioural responses to pain (something that is very important to animal survival). Those circuits cannot cause pain on their own and while behavioural responses can potentially be modified, the attentional and emotional responses are much more hard-wired than some medical practitioners or psychologists suggest.