This article, based on findings of a small study of people with chronic back pain in Belgium reported in the journal JAMA Neurology, tells readers that if they can only “think differently” and stop “fearing” their pain, such attitude changes combined with “cognition-targeted motor control training” does significantly more than standard physical therapy and back pain “education” to reduce the pain and increase ability to function.
The problem is that the story doesn’t really explain the differences between the standard and experimental therapies, the latter of which is composed of a sort of physical “desensitization” to feared physical movements; and fails to offer any details about the base level of the subjects’ pain, how pain was measured, or why the researchers looked for (and didn’t find) brain changes in the study group.
We were glad the article included an outside expert, who makes clear that the experimental intervention is time intensive, costly, not covered by insurance and — although “promising” — still unproven with respect to long-term benefit compared to standard therapies. That provided some much needed information for the reader.
(Note: Due to an editing error, this story originally was marked with a 2-star score. It has been updated to reflect the correct rating of 3 stars.)
This study focuses on behavioral and educational approaches designed to reframe how patients think about their pain. By emphasizing that “hurt doesn’t mean harm,” the hope is that patients will become more active and that activity may actually reduce pain. This “pain catastrophizing” theory is not really new. As such the description of this study doesn’t make clear what is different from prior studies evaluating this approach. Nonetheless, such efforts are important and need to be replicated in larger studies, so were glad the story ended on that note.
The only mention of cost is at the very end. “The program, however, is quite time-intensive and is not covered by insurance,” Patel said. “Although it’s promising, we really have to see the benefit long-term to justify the cost,” she added.
This isn’t really enough information for a patient to know if it’s within their reach.
The article quotes/attributes a “significant” and “clinically important” reduction of pain, and elsewhere “50 percent less pain,” but offers no baseline of pain against which to compare the outcomes, or what range and level of increased functionality or diminished “fearfulness” was measured.
Although physical therapy and a 12-week program of education about the origins of pain designed to reshape people’s understanding of the pain pathway are not likely to cause harm, it would have been useful to know if any experimental treatment subjects dropped out, failed to finish the program, or felt worse than those in the control group. There is also the potential in such studies for “victim blaming,” or imposing the onus of attitude change on pain patients. Some of the comments of the principal investigator in the article (i.e. patients “should learn to put pain into the right perspective and…avoid fear of moving”) may impose additional burdens on some pain patients.
There aren’t many details about the people in the study, including the substantial age range (18 to mid-60s); the sources of the back pain; the way the pain was measured before and after the interventions, and so on. The reader also won’t learn about the surveys and tests (including brain MRIs) used to measure primary and secondary outcomes. And most of all, the reader will have a hard time understanding just what the two arms of the study involved and what the differences are, given that both involved forms of education and physical therapy. While the background for the intervention is discussed in detail, the nature of the study is barely mentioned.
No mongering here. It is clear that current treatments for chronic low back pain offer patients limited benefits.
An outside expert was quoted and we detected no conflicts of interest that should have been disclosed.
We’ll give this a just-passing rating. There are several brief statements about alternatives. Relevant statements include, “People with chronic back pain often try painkillers and other treatments without success” and “They assigned another 25 men and 35 women to standard care — exercise, and back and neck education.”
The article makes clear that this is an experimental therapy.
Even the careful reader may have a hard time figuring out what is novel about the therapy or the study protocol. This is especially the case with respect to the use of MRI to scan the brains of participants for “morphological” changes — a part of the research that was especially meaningful to the investigators because, in their view, the absence of such changes in the experimental group suggests that such changes are not necessarily a good indicator of pain control or pain abatement.
The story did not appear to rely on a news release.
Systematic, Criteria-Driven
The tale of two “negative” studies. Or, how spin is applied to make research findings look more impressive. A must read. https://johnmandrola.substack.com/p/the-tale-of-two-negative-studies
The @nytimes chose to interview one of the editors of the @AnnalsofIM (publisher of this paper) who "gushed with extraordinary glee: It’s huge! There are very few things that reduce your mortality by 30%."
Turns out coffee is not one of those few things despite all that glee. https://twitter.com/garyschwitzer/status/1533202075928215558
Comments (4)
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Mark Schoene
April 23, 2018 at 12:16 pmInteresting area of study. There are a few holes in the HealthDay article. However, this is a challenging area to write about—unless a journalist goes back and reads all the previous studies in this area. Even the HNR review seemed to subtly oversimplify the nature of the “neuroscience intervention,” suggesting it is an offshoot of “pain catastrophizing” theory—when it is far more complex than that.
Regarding the review criteria, it seems a little harsh to criticize this journalist for not providing information on the costs of the neuroscience approach or the control treatment—or on insurance coverage for either intervention. The study in question simply didn’t provide any information about the costs of these interventions or their status under Belgian insurance programs. Neither approach is available in any kind of standardized form in the US—so the likely costs are completely up in the air. The journalist at least mentioned costs, via the quote from the “independent expert.”
What more could the journalist offer about costs in this situation? This is not a rhetorical question. Am genuinely interested in what HNR suggests in this type of situation.
Mark Schoene
Editor, The BackLetter
Newbury MA
Joy Victory
April 23, 2018 at 2:24 pmHi Mark, thanks for writing in. That’s a very valid question! In this case, because the story mentioned that this type of treatment is in use for phantom pain, there is the ability to find out a comparative cost, which is usually enough information for us.
Mark Schoene
April 26, 2018 at 4:20 pmThanks for your response. I did some literature searching—looked at multiple randomized trials and recent systematic reviews— and I couldn’t find treatment programs for phantom limb syndrome that are at all similar to the 18-session “neuroscience education cognition-targeted motor control program” at the Belgian hospitals.
The costs of back pain treatments are notoriously difficult to figure in the US healthcare system—and are likely not comparable to those in the Belgian public/private insurance system.
Do you really think a journalist tackling a difficult topic (complicated multimodal treatment for chronic back pain) should also have to delve into the phantom limb literature to assess potential back pain treatment costs?
HNR is demanding the impossible in this situation. Journalists shouldn’t be graded down—with potential harm to their reputations—for not providing information that is simply not available. I support that criterion in general but in this situation the answer should be “n/a” or “not applicable.”
Mark Schoene
Editor, The BackLetter
Consumer Representative
Cochrane Back and Neck Group
Joy Victory
April 27, 2018 at 11:22 amThe story is discussing availability for US patients, and gives the impression that the treatment is something you could ask for and find. The reporter spoke to an expert who’s familiar with the treatment and has some idea what it cost. Why not ask the source about costs and report the response in the story? That would have been sufficient for us.
That said, we appreciate your feedback and will take it into consideration on future reviews.
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