I am sure you would have captured this already as a high profile journal, but thought this was a really interesting study:
The endpoints for PRT look enviable for any pharmacological therapy out there I think? Here in the UK NICE basically don’t really recommend any drugs for chronic back pain. Having a read of the description of PRT in the appendix shows it’s pretty much similar to the points BBM raise re pain pathway, and pain/fear cycle.
I thought the choice of comparator arms were interesting too, with the placebo being clearly labelled as such to the patient. The response in this arm was also probably clinically relevant? - so if we actively say to patients they are receiving a placebo, what is the harm in giving people PRT plus and educational sessions re placebos and a saline injection? Both ethically and clinically?
Anyway - I thought this was a really interesting study. Just slightly frustrated it is published in JAMA Psychiatry, as not really the best audience for this. Although a mind related issue, surely this is more relevant to pain and rehab clinicians?
This article caught my eye too. So much so, I gave it to many of my colleagues to review, discuss and critique.
I did a skim of it and to me there is a lot to appreciate. The results are as good as I’ve seen in this population.
That said, as a practicing clinician the limitations noted by the authors stand out to me.
“The study sample was relatively well educated and active and reported long-standing low to moderate pain and disability at baseline. The physician and therapists were experts in the treatment model.” The second author, Gordon, has written books on the topic and management provided in the study.
I look at the patients studied and, (3 bad words) “in my experience,” have seen positive outcomes clinically. Its the exclusion criteria I wish had these outcomes, because those characteristics continue to challenge clinicians everywhere.
Either way, I hope those in healthcare, or those seeing patients with persistent back pain take a look and have a discussion.
There have been two other articles come out I think compliment this study.
a small pilot but appears to have similar theme:
Donnino, Michael W., et al. “Psychophysiologic symptom relief therapy for chronic back pain: a pilot randomized controlled trial.” Pain Reports 6.3 (2021).
and amongst people with pain problems deemed a success through education; what do they value in pain education
Leake, Hayley B., et al. “What do patients value learning about pain? A mixed-methods survey on the relevance of target concepts after pain science education.” Pain 162.10 (2021): 2558-2568.
The Leake paper I find particularly interesting. It does seem quite a small sample size, but a sizable response for psychophysiologic symptom relief therapy. The course looks pretty intensive though, and was delivered by someone with extensive experience. In terms of actually implementing, how quickly can people be trained to deliver this kind of treatment and get the same results? Also I presume this was delivered face to face? But is much efficacy lost if a lot of the treatment is delivered remotely on web-based systems?
I expect there is also a significant portion of people that might not amenable to giving this a go…
Here in the UK NICE recommend physical and psychological programmes, but there really is a lack of detail to help clinicians as to what an appropriate programme looks like, as well as a lack of programmes actually being available.
Thanks for starting the thread. Matthew has brought up great points already. I have a few complaints regarding assumptions of the educational material and methodology regarding comparators. I’ll focus on comparators here.
The effects observed are reported as large compared to the other arms of the study; neither of which are appropriate comparators. Instead, a watch and wait list and a similar talk therapy should have been examined to adequately assess effectiveness of this specific approach. Open label placebo research is a contentious topic at this time … Ted Kaptchuck is leading researcher out of Harvard. He’s known for conducting pill based OLP studies. The issue here is placebo is misleading as the context/environment, expectations, ritual, beliefs, and therapeutic alliance are more what’s creating the observed effect rather than the “placebo”. Comparing PRT to a placebo injection + educational material doesn’t make a lot of sense to me if our goal is to truly assess is this intervention superior to other approaches of similar methodology. I suspect we could replace much of the educational material with our own language and achieve a similar observed effect. Leading to my issues with the assumptions of the educational material, there’s a strong neurocentric approach in these materials that I would not personally feel comfortable relaying to individuals for risking invalidation or takeaway narratives of “it’s all in your brain/head”. All that said, the outcome effects are what they are, I’m simply not impressed with the baseline quantitative pain reporting and the end point generally speaking being attributable to PRT. The between group difference is only 1 - 2 points in quantification of pain … 4 weeks of PRT vs injection vs “usual care” (which I’m not entirely sure what this entails but according to the appendix, a future manuscript is forthcoming) I suspect the cost to benefit here is lacking. Finally, I think it’s worth mentioning the COI of this study, Curable app is a for profit app that is advised by some of the authors on this manuscript.