What’s the Evidence?
There are a number of promising treatments for chronic pain. This Might Hurt focuses on a handful of related new treatments that are low-risk, affordable, and supported by data from randomized controlled trials.
One of the treatments, Pain Reprocessing Therapy (PRT), was recently found to cure back pain in 66% of people randomly assigned to it.
Another of them, EAET (Emotional Awareness and Expression Therapy) was recently studied by the NIH, found to be effective, and listed as a “best practice” to fight the opioid epidemic by the Department of Health and Human Services.
The treatments do not utilize drugs, injections, surgeries, or herbal supplements, and they are rooted in recent findings in neuroscience.
Dr. Howard Schubiner summarizes three studies recently published on the treatments depicted in This Might Hurt.
NEWLY PUBLISHED Randomized Trials
JAMA Psychiatry recently published a new brain imaging study on back pain (number of participants=151): “Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain,” written by Yoni Ashar, Tor Wager, Alan Gordan, Howard Schubiner, Christie Uipi, et al, and conducted under the supervision of the Wager Lab at the University of Colorado-Boulder, September 29, 2021.
66% of patients randomized to Pain Reprocessing Therapy were pain-free or nearly pain-free at posttreatment, compared with 20% for placebo injections, and 10% for usual care. Treatment effects were largely maintained at 1-year follow-up. Average duration of pain was 10 years.
A similar finding was published in a separate study from Harvard (number of participants=35) which found that 64% of people with back pain became pain-free after a Mind-body Education (4 weeks) followed by a Mindfulness-Based Stress Reduction (MBSR) treatment (8 weeks). For the comparator group of patients — who were given only MBSR (8 weeks) without the mind-body education component — only 25% of them become pain-free. This suggests that making a clear mind-body diagnosis and educating patients about retraining the brain to unlearn symptoms can make psychological treatments like MBSR twice as effective.
Here’s a recently published study comparing EAET with CBT for Military Veterans with Chronic Musculoskeletal Pain:
At post-treatment for 53 veterans, 41.7% of those who were randomly assigned to EAET had greater than 30% pain reduction, one-third had greater than 50%, and 12.5% had greater than 70%. Only 1 of the randomly assigned CBT patients achieved at least 30% pain reduction.
Scientific Studies REFERENCED IN THE FILM
Recent neuroscience has demonstrated that chronic pain is associated with profound brain changes, especially noticeable in the default mode network:
The landmark, NIH-funded randomized controlled trial which demonstrated that EAET (Emotional Awareness and Expression Therapy) was more than twice as effective at providing a 50% or more pain reduction compared with CBT (Cognitive Behavioral Therapy).
EAET (Emotional Awareness and Expression Therapy) was recently studied in a large randomized controlled trial, found to be effective, and listed by the HHS as a “best practice” to combat the opioid epidemic.
“Emotional awareness and expression therapy (EAET) is an emotion-focused therapy for patients with a history of trauma or psychosocial adversity who suffer from centralized pain conditions. In this approach, patients are taught to understand that their pain is exacerbated or maintained by unresolved emotional experiences that influence neural pathways involved in pain. Patients are taught to become aware of these unresolved experiences, which include suppressed or avoided trauma, adversity, and conflict, and to adaptively express their emotions related to these experiences. Patients learn that control over pain can be achieved through emotional awareness and expression. Enhancing the patient’s capacity to approach an experience rather than inhibit or avoid important emotions and interpersonal interactions leads to increased engagement in life activities. Research indicates that EAET has a positive impact on pain intensity, pain interference, and depressive symptoms.” (from p. 38)
4. In the film we cite a study showing major changes in the default mode network in this brain scan of a person with chronic, debilitating abdominal pain. The 14-year-old, Casey, was sent for a brain scan before and after pain reprocessing therapy, and the shifts in his default network after successful therapy were profound. (He was treated by Alan Gordon, LCSW of the Pain Psychology Center in Los Angeles.) This story was also featured in episodes of the television show, “The Doctors.”
Schubiner, Howard, “Neural Pathway Pain— A Call for More Accurate Diagnoses,” Practical Pain Management, December 2017.
5. One of a few therapies featured in the film, ISTDP (Intensive Short-Term Dynamic Psychotherapy) is designed to release powerful emotions that can sometimes trigger chronic pain. This study is a systematic review of its effectiveness:
6. Most people develop degenerative disk disc “disease” or herniated or slipped discs, even though these changes often result in no pain. They are a normal, healthy sign of aging like grey hair or wrinkly skin. Dr. Schubiner presents these astonishing MRI statistics derived from this study of people who have no pain, but very “scary” MRIs findings in their backs.
W. Brinjikji, P.H. Luetmer, et al, “Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations,” AJNR Am J Neuroradiol 36:811–16, April, 2015 www.ajnr.org
“The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age.”
A carefully collected and annotated bibliography of all the medical research supporting the various treatments featured in this film (i.e. Emotional Awareness and Expression Therapy, Pain Reprocessing Therapy, and ISTDP), including relevant neuroscience research, was created by the PPDA. You can find it here.
DEFINING THE THERAPIES IN THE FILM
Emotional Awareness and Expression Therapy (EAET) — This therapy is officially listed as a “best practice” by the Department of Health and Human Services in order to combat the opioid epidemic.
In a trial with fibromyalgia patients published in the journal PAIN, people randomized to EAET had a 50% reduction of pain at more than twice the rate as people randomly assigned to CBT (cognitive behavior therapy, which is the standard treatment). This study, presented in the film, can be read in full here. A description of how the treatment works can be found here.
Pain Reprocessing Therapy (PRT) is a new diagnosis and treatment paradigm that helps patients unlearn chronic pain by retraining their brains. A primary method is to work directly with the fear of pain, which is often a major driver of symptoms.
A few studies have indicated that about 85% of people with chronic back pain do not have structural damage that explains their pain. And many other symptoms like migraines, irritable bowel syndrome, CRPS, and fibromyalgia are also not characterized by structural or tissue damage. PRT helps people retrain their nervous systems to unlearn neuroplastic pain pathways that are creating severe, debilitating, and treatment-resistant pain syndromes.
PRT is part of a radical paradigm shift that new neuroscience has enabled, which challenges conventional pain psychology and medicine. It makes use of breakthroughs in understanding how the brain uses predictive coding for sensory processing, which means that by expecting pain, and by fearing injury, the brain can maintain or even create debilitating pain.
After a successful PRT treatment, patients know intuitively their chronic pain is not a sign of tissue damage. The pain comes and goes without triggering as much fear, usually lessens over time, and is no longer mistaken for a structural injury. The primary author of the study on PRT at the University of Colorado-Boulder, Yoni K. Ashar, PhD, and one of the lead therapists, Alan Gordon, LCSW go into more depth in this article. The PRT protocol was published here.
The first major NIH-funded trial of PRT has shown very promising results for people with an average duration of 10 years of back pain. 66% of those who were randomly assigned to PRT became pain-free or nearly pain-free.
More resources for PRT can be found on our site, here.
Intensive Short-Term Dynamic Psychotherapy (ISTDP) — This treatment has been around since the 1970s and has had dozens of RCTs investigating its effectiveness. Dr. John Sarno recommended it especially for people with severe symptoms that are treatment-resistant. His collaborator, Arlene Feinblatt, built a protocol for helping chronic-pain patients process pain, anxiety, and emotions differently so that symptoms lessen over time.
The innovators of EAET (Mark Lumley and Howard Schubiner), have referred to their therapy as a “simplified form of ISTDP,” which is easier for clinicians to learn and offer to patients. (The book Hidden From View is the ideal handbook for reviewing the differences between EAET and ISTDP, and for suggestions of how to think about combining them with CBT.)
*Note: ISTDP falls under the umbrella term “experiential dynamic therapy” (EDT) which includes other popular, effective therapies like Accelerated Experiential Dynamic Psychotherapy (AEDP). In EDT, the goal is to feel sensations of emotions directly in the body, and to overcome internal blocks against anger, guilt, and sadness. It usually involves slowly changing maladaptive relationship patterns learned in childhood that create high levels of unconscious stress for adults that manifest unconsciously in the body. After a successful therapy, all feelings, including joy, are experienced more fully.
Recent studies for treating chronic pain disorders with EDT:
“Efficacy of Intensive Short-Term Dynamic Psychotherapy for Medically Unexplained Pain: A Pilot Three-Armed Randomized Controlled Trial Comparison with Mindfulness-Based Stress Reduction,”January 2016, Psychotherapy and Psychosomatics, Parvaneh Mohammadkhani, number of patients=63, divided into three groups, ISTDP, Mindfulness Based Stress Reduction (MBSR), and Treatment as Usual.
In this study, patients randomly assigned to ISTDP for 8 sessions of therapy reduced their pain, on average, by 50%.
“Short-term psychodynamic psychotherapy for functional somatic disorders: A systematic review and meta-analysis of within-treatment effects” Journal of Psychosomatic Research, Allan Abbass, MD et al March 2021.
This recently published meta-analysis serves as a bibliography and summary of most of the research available on treating primary pain syndromes with the interventions you see in the film (ISTDP and EAET).
TMS coaching or mentoring — Dr. John Sarno’s preferred term for brain-induced pain was Tension Myoneural Syndrome. While most who research his treatment have dropped this term, it is still a favorite by many clinicians and people who recovered from reading his books, and who now offer coaching based on the “Sarno model.” You can find these peer coaches on the TMS wiki.
Other therapies — Of course, there are many therapies that are helpful for people with chronic pain. We limited our list to these therapies because they were all touched on in the film. During our research, these four therapies came up the most frequently by healthcare professionals who emphasize that a large portion of chronic pain patients have no structural damage that explains their pain.
Much more about the film can be discovered in our FAQ.