The effects of virtual reality neuroscience-based therapy on clinical and neuroimaging outcomes in patients with chronic back pain: a randomized clinical trial.

ABSTRACT: Chronic pain remains poorly managed. The integration of immersive technologies (ie, virtual reality [VR]) with neuroscience-based principles may provide effective pain treatment by targeting cognitive and affective neural processes that maintain pain and therefore potentially changing neurobiological circuits associated with pain chronification and amplification. We tested the effectiveness of a novel VR neuroscience-based therapy (VRNT) to improve pain-related outcomes in n = 31 participants with chronic back pain, evaluated against usual care (waitlist control; n = 30) in a 2-arm randomized clinical trial (NCT04468074). We also conducted pre-treatment and post-treatment MRI to test whether VRNT affects brain networks previously linked to chronic pain and treatment effects. Compared with the control condition, VRNT led to significantly reduced pain intensity (g = 0.63) and pain interference (g = 0.84) at post-treatment vs pre-treatment, with effects persisting at 2-week follow-up. These improvements were partially mediated by reduced kinesiophobia and pain catastrophizing. Several secondary clinical outcomes were also improved by VRNT, including disability, quality of life, sleep, and fatigue. In addition, VRNT was associated with increases in dorsomedial prefrontal functional connectivity with the superior somatomotor, anterior prefrontal and visual cortices, and decreased white matter fractional anisotropy in the corpus callosum adjacent to the anterior cingulate, relative to the control condition. Thus, VRNT showed preliminary efficacy in significantly reducing pain and improving overall functioning, possibly through changes in somatosensory and prefrontal brain networks.

Application of a Clinical Approach to Diagnosing Primary Pain: Prevalence and Correlates of Primary Back and Neck Pain in a Community Physiatry Clinic.

Chronic back or neck pain (CBNP) can be primary (nociplastic or neuroplastic; without clear peripheral etiology) or secondary (to nociceptive or neuropathic causes). Expanding on available models of nociplastic pain, we developed a clinic-ready approach to diagnose primary/nociplastic pain: first, a standard physical exam and review of imaging to rule out secondary pain; and second, a detailed history of symptom presentation to rule in primary pain. We trained a physician who evaluated 222 patients (73.9% female, age M = 59.6) with CBNP; patients separately completed pain and psychosocial questionnaires. We estimated the prevalence of primary CBNP and explored biomedical, imaging, and psychological correlates of primary CBNP. Although almost all patients (97.7%) had at least 1 spinal anomaly on imaging, the diagnostic approach estimated that 88.3% of patients had primary pain, 5.0% had secondary pain, and 6.8% had mixed pain. Patients with primary pain were more likely than the other 2 groups of patients (combined as "non-primary pain") to report certain functional conditions, central sensitization, and features such as sensitivity to light touch, spreading pain, and pain worsening with stress; however, no difference was detected in depression, anxiety, and pain catastrophizing between those with primary and nonprimary pain. These findings are consistent with prior estimates that 85 to 90% of CBNP is "nonspecific." Further research is needed to validate and perhaps refine this diagnostic approach, which holds the potential for better outcomes if patients are offered treatments targeted to primary pain, such as pain neuroscience education and several emerging psychological therapies. PERSPECTIVE: We developed an approach to diagnose chronic primary pain, which was applied in a physiatry clinic to 222 patients with CBNP. Most patients (88.3%) had primary pain, despite almost universal anomalies on spinal imaging. This diagnostic approach can guide educational and psychological treatments tailored for primary pain.

Video telehealth emotional awareness and expression therapy for older U.S. military veterans with chronic pain: A pilot study.

OBJECTIVES: Emotional Awareness and Expression Therapy (EAET) targets trauma and emotional conflict to reduce or eliminate chronic pain, but video telehealth administration is untested. This uncontrolled pilot assessed acceptability, feasibility, and preliminary efficacy of group-based video telehealth EAET (vEAET) for older veterans with chronic musculoskeletal pain. METHODS: Twenty veterans were screened, and 16 initiated vEAET, delivered as one 60-minute individual session and eight 90-minute group sessions. Veterans completed posttreatment satisfaction ratings and pain severity (primary outcome), pain interference, anxiety, depression, functioning, social connectedness, shame, and anger questionnaires at baseline, posttreatment, and 2-month follow-up. RESULTS: Satisfaction was high, and veterans attended 7.4 (SD = 0.6) of 8 group sessions; none discontinued treatment. Veterans attained significant, large reductions in pain severity from baseline to posttreatment (p < .001, Hedges' g = -1.54) and follow-up (p < .001, g = -1.20); 14 of 16 achieved clinically significant (≥ 30%) pain reduction, and 3 achieved 90-100% pain reduction. Secondary outcomes demonstrated significant, medium-to-large improvements. CONCLUSIONS: In this small sample, vEAET produced better attendance, similar benefits, and fewer dropouts than in-person EAET in prior studies. Larger, controlled trials are needed. CLINICAL IMPLICATIONS: Group vEAET appears feasible and highly effective for older veterans with chronic pain.

Emotion-Focused Psychodynamic Interview for People with Chronic Musculoskeletal Pain and Childhood Adversity: A Randomized Controlled Trial.

Childhood adversity and emotional conflicts are associated with the presence and severity of chronic musculoskeletal pain (CMP), yet common treatments for CMP do not address such risk factors. We developed a single session, emotion-focused psychodynamic interview, based on Emotional Awareness and Expression Therapy and Intensive Short-term Psychodynamic Therapy, and we tested the interview's effects on pain-related outcomes and potential psychological mediators in a randomized, controlled trial. Adults (N = 91; ages 21-70, M = 44.64; 87.9% women) reporting CMP and at least 3 adverse childhood experiences completed measures at baseline and 6-week follow-up. Participants were randomized to immediate interview or waitlist control conditions. The 90-minute interview was conducted via videoconference, and the interviewer elicited disclosure of adversities and conflicts, linked these with pain, and encouraged the experience and expression of adaptive emotions. Analyses indicated that conditions did not differ significantly on change in pain severity; however, compared to control, the interview led to a significantly greater reduction in pain interference (P = .016, ηp2 = .05) and a similar trend for anxiety (P = .058, ηp2 = .04). The interview also significantly changed several potential mediators: pain-related anxiety (P = .008, ηp2 = .06), pain controllability (P = .016, ηp2 = .06), and psychological (P < .001, ηp2 = .15) and brain attributions (P = .022, ηp2 = .05) for pain. Participants viewed the interview as very valuable. We conclude that addressing childhood adversities and conflicts in a psychodynamic interview is beneficial for people with CMP. PERSPECTIVE: This study found that, compared to waitlist control, a 90-minute, remotely-administered, emotion-focused, psychodynamic interview improved pain interference, and anxiety among adults with chronic musculoskeletal pain and childhood adversity. Intensive emotional work can be done in a single session to the benefit of patients with chronic musculoskeletal pain.

Reattribution to Mind-Brain Processes and Recovery From Chronic Back Pain: A Secondary Analysis of a Randomized Clinical Trial.

Importance: In primary chronic back pain (CBP), the belief that pain indicates tissue damage is both inaccurate and unhelpful. Reattributing pain to mind or brain processes may support recovery. Objectives: To test whether the reattribution of pain to mind or brain processes was associated with pain relief in pain reprocessing therapy (PRT) and to validate natural language-based tools for measuring patients' symptom attributions. Design, Setting, and Participants: This secondary analysis of clinical trial data analyzed natural language data from patients with primary CBP randomized to PRT, placebo injection control, or usual care control groups and treated in a US university research setting. Eligible participants were adults aged 21 to 70 years with CBP recruited from the community. Enrollment extended from 2017 to 2018, with the current analyses conducted from 2020 to 2022. Interventions: PRT included cognitive, behavioral, and somatic techniques to support reattributing pain to nondangerous, reversible mind or brain causes. Subcutaneous placebo injection and usual care were hypothesized not to affect pain attributions. Main Outcomes and Measures: At pretreatment and posttreatment, participants listed their top 3 perceived causes of pain in their own words (eg, football injury, bad posture, stress); pain intensity was measured as last-week average pain (0 to 10 rating, with 0 indicating no pain and 10 indicating greatest pain). The number of attributions categorized by masked coders as reflecting mind or brain processes were summed to yield mind-brain attribution scores (range, 0-3). An automated scoring algorithm was developed and benchmarked against human coder-derived scores. A data-driven natural language processing (NLP) algorithm identified the dimensional structure of pain attributions. Results: We enrolled 151 adults (81 female [54%], 134 White [89%], mean [SD] age, 41.1 [15.6] years) reporting moderate severity CBP (mean [SD] intensity, 4.10 [1.26]; mean [SD] duration, 10.0 [8.9] years). At pretreatment, 41 attributions (10%) were categorized as mind- or brain-related across intervention conditions. PRT led to significant increases in mind- or brain-related attributions, with 71 posttreatment attributions (51%) in the PRT condition categorized as mind- or brain-related, as compared with 22 (8%) in control conditions (mind-brain attribution scores: PRT vs placebo, g = 1.95 [95% CI, 1.45-2.47]; PRT vs usual care, g = 2.06 [95% CI, 1.57-2.60]). Consistent with hypothesized PRT mechanisms, increases in mind-brain attribution score were associated with reductions in pain intensity at posttreatment (standardized ß = -0.25; t127 = -2.06; P = .04) and mediated the effects of PRT vs control on 1-year follow-up pain intensity (ß = -0.35 [95% CI, -0.07 to -0.63]; P = .05). The automated word-counting algorithm and human coder-derived scores achieved moderate and substantial agreement at pretreatment and posttreatment (Cohen κ = 0.42 and 0.68, respectively). The data-driven NLP algorithm identified a principal dimension of mind and brain vs biomechanical attributions, converging with hypothesis-driven analyses. Conclusions and Relevance: In this secondary analysis of a randomized trial, PRT increased attribution of primary CBP to mind- or brain-related causes. Increased mind-brain attribution was associated with reductions in pain intensity.

Cognitive enrichment and education quality moderate cognitive dysfunction in black and white adults with multiple sclerosis.

OBJECTIVE: To examine the extent to which three sociobehavioral proxies of cognitive reserve-years of education, education quality, and cognitive enrichment-differ in their prediction of cognitive performance among Black and White people with MS (PwMS). METHODS: 82 PwMS (Black n = 41, White n = 41) underwent a neurological examination and a neuropsychological evaluation that included tests of word recognition (Wechsler Test of Adult Reading) as well as measures of verbal memory, visuospatial memory, and processing speed (the Brief International Cognitive Assessment for MS; BICAMS). Participants rated their lifetime engagement in various cognitively-enriching activities (Cognitive Reserve Scale). RESULTS: For the full sample, education quality and cognitive enrichment were more strongly associated with cognitive performance than were years of education. Cognitive enrichment was not associated with cognitive performance among participants with high education quality. In contrast, among participants with low education quality, cognitive enrichment was strongly associated with cognitive performance, suggesting that high engagement in cognitively-enriching activities provided similar protection to high education quality. Furthermore, among Black participants, cognitive enrichment and educational quality moderated the relationship between disability level and cognitive performance. In contrast, among White participants, cognitive enrichment did not provide additional protection beyond the buffering effect of education quality. CONCLUSIONS: PwMS can successfully build reserve through multiple routes, including formal education or informal cognitive enrichment. Treatment for MS should incorporate cognitively-enriching activities to build resilience against cognitive decline, particularly for members of marginalized racial/ethnic groups, who are at greatest risk for poor health outcomes, and for whom years of education may not best reflect education quality.

The Effects of Virtual Reality Neuroscience-based Therapy on Clinical and Neuroimaging Outcomes in Patients with Chronic Back Pain: A Randomized Clinical Trial.

Chronic pain remains poorly managed. The integration of innovative immersive technologies (i.e., virtual reality (VR)) with recent neuroscience-based principles that position the brain as the key organ of chronic pain may provide a more effective pain treatment than traditional behavioral therapies. By targeting cognitive and affective processes that maintain pain and potentially directly changing neurobiological circuits associated with pain chronification and amplification, VR-based pain treatment has the potential for significant and long-lasting pain relief. We tested the effectiveness of a novel VR neuroscience-based therapy (VRNT) to improve pain-related outcomes in n = 31 participants with chronic back pain, evaluated against usual care (n = 30) in a 2-arm randomized clinical trial ( NCT04468074) . We also conducted pre- and post-treatment MRI to test whether VRNT affects brain networks previously linked to chronic pain and treatment effects. Compared to the control condition, VRNT led to significantly reduced pain intensity (g = 0.63) and pain interference (g = 0.84) at post-treatment vs. pre-treatment, with effects persisting at 2-week follow-up. The improvements were partially mediated by reduced kinesiophobia and pain catastrophizing. Several secondary clinical outcomes were also improved, including disability, quality of life, sleep, and fatigue. In addition, VRNT was associated with modest increases in functional connectivity of the somatomotor and default mode networks and decreased white matter fractional anisotropy in the corpus callosum adjacent to anterior cingula, relative to the control condition. This, VRNT showed preliminary efficacy in significantly reducing pain and improving overall functioning, possibly via changes in somatosensory and prefrontal brain networks.

Experiential training of mental health graduate students in emotional processing skills: A randomized, controlled trial.

Emotional processing interventions for trauma and psychological conflicts are underutilized. Lack of adequate training in emotional processing techniques and therapists' lack of confidence in utilizing such interventions are barriers to implementation. We developed and tested an experiential training to improve trainees' performance in a set of transtheoretical emotional processing skills: eliciting patient disclosure of difficult experiences, responding to defenses against disclosure, and eliciting adaptive emotions. Mental health trainees (N = 102) were randomized to experiential or standard training, both of which presented a 1-hr individual session administered remotely. Before and after training and at 5-week follow-up, trainees were videorecorded as they responded to videos of challenging therapy situations, and responses were coded for demonstrated skill. Trainees also completed measures of therapeutic self-efficacy, anxiety, and depression at baseline and follow-up. Repeated-measures analysis of variance indicated all three skills increased from pre- to posttraining for both conditions, which were maintained at follow-up. Importantly, experiential training led to greater improvements than standard training in the skills of eliciting disclosure (η² = .05, p = .03), responding to defenses (η² = .04, p = .05), and encouraging adaptive emotions (η² = .23, p < .001) at posttraining, and the training benefits for eliciting disclosure were maintained at follow-up. Both conditions led to improved self-efficacy. Trainees' anxiety decreased in the standard training, but not in the experiential. One session of experiential training improved trainees' emotional processing therapy skills more than didactic training, although more training and practice likely are needed to yield longer lasting skills. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Feasibility and Efficacy of a Brief Mindfulness-Based Smoking Intervention Delivered via the Internet: A Randomized Controlled Trial.

Background: A growing body of literature suggests that mindfulness-based interventions are effective in reducing smoking. However, existing mindfulness interventions are often lengthy and require extensive interaction with a therapist, making them inaccessible to a large percentage of the population. The current study addressed this issue by testing the feasibility and efficacy of a single session, web-based, mindfulness intervention for smoking cessation. Methods: Participants (N = 80) took part in a fully online cue exposure exercise interspersed with brief instructions on how to cope with cravings for cigarettes. All participants were randomly assigned to receive either mindfulness-based or coping as usual instructions. Outcomes included participant satisfaction with the intervention, self-reported craving following the cue exposure exercise, and cigarette use 30 days post-intervention. Results: Participants in both groups found the instructions moderately helpful and easy to understand. Participants in the mindfulness group reported a significantly smaller increase in craving than those in the control group following the cue exposure exercise. Averaging across conditions, participants reported smoking fewer cigarettes in the 30 days following the intervention than in the 30 days prior, however there were no between group differences in cigarette use. Conclusion: Mindfulness-based interventions for smoking reduction can be effectively implemented in a brief, single-session online format. These interventions are easy to disseminate and can reach a large number of smokers with minimal participant burden. Results from the current study suggest that mindfulness-based interventions can help participants control craving in the face of smoking-related cues, although perhaps not change smoking quantity. Future research is needed to explore factors which may increase the efficacy of online, mindfulness-based interventions for smoking cessation, while still maintaining their accessibility and reach.

Virtual Human-Delivered Interviews for Patients With Chronic Pain: Feasibility, Acceptability, and a Pilot Randomized Trial of Standard Medical, Psychosocial, and Educational Interviews.

OBJECTIVE: Seminal advances in virtual human (VH) technology have introduced highly interactive, computer-animated VH interviewers. Their utility for aiding in chronic pain care is unknown. We developed three interactive telehealth VH interviews-a standard pain-focused, a psychosocial risk factor, and a pain psychology and neuroscience educational interview. We then conducted a preliminary investigation of their feasibility, acceptability, and efficacy. We also experimentally compared a human and a computer-generated VH voice. METHODS: Patients ( N = 94, age = 22-78 years) with chronic musculoskeletal pain were randomly assigned to the standard ( n = 31), psychosocial ( n = 34), or educational ( n = 29) VH interview and one of the two VH voices. Acceptability ratings included patient satisfaction and expectations/evaluations of the VH interview. Outcomes assessed at baseline and about 1-month postinterview were pain intensity, interference, emotional distress, pain catastrophizing, and readiness for pain self-management. Linear mixed-effects models were used to test between- and within-condition effects. RESULTS: Acceptability ratings showed that satisfaction with the VH and telehealth format was generally high, with no condition differences. Study attrition was low ( n = 5). Intent-to-treat-analyses showed that, compared with the standard interview, the psychosocial interview yielded a significantly greater reduction in pain interference ( p = .049, d = 0.43) and a marginally greater reduction in pain intensity ( p = .054, d = 0.36), whereas the educational interview led to a marginally greater yet nonsignificant increase in readiness for change ( p = .095, d = 0.24), as well as several significant improvements within-condition. Results did not differ by VH voice. CONCLUSIONS: Interactive VH interviewers hold promise for improving chronic pain care, including probing for psychosocial risk factors and providing pain-related education.

Neurophysiological and psychosocial mechanisms of fibromyalgia: A comprehensive review and call for an integrative model.

Research into the neurobiological and psychosocial mechanisms involved in fibromyalgia has progressed remarkably in recent years. Despite this, current accounts of fibromyalgia fail to capture the complex, dynamic, and mutual crosstalk between neurophysiological and psychosocial domains. We conducted a comprehensive review of the existing literature in order to: a) synthesize current knowledge on fibromyalgia; b) explore and highlight multi-level links and pathways between different systems; and c) build bridges connecting disparate perspectives. An extensive panel of international experts in neurophysiological and psychosocial aspects of fibromyalgia discussed the collected evidence and progressively refined and conceptualized its interpretation. This work constitutes an essential step towards the development of a model capable of integrating the main factors implicated in fibromyalgia into a single, unified construct which appears indispensable to foster the understanding, assessment, and intervention for fibromyalgia.

A mixed-methods investigation into the us versus them mentality in Facebook groups for chronic pain.

OBJECTIVE: Social media groups for chronic pain have become increasingly popular, but the effects of these groups are largely unknown, and members may be exposed to both helpful and harmful group processes. We created a Facebook intervention for adults with chronic pain and used a mixed-methods design to evaluate the effects of group membership on social support, including examining social dynamics that may benefit or impede existing pain care. METHOD: A total of 119 adults participated in either peer-led or professionally-guided Facebook groups for 1 month. Chronic pain support was assessed at baseline, post-intervention, and 1-month follow-up, and qualitative data were collected to explore social dynamics. RESULTS: Chronic pain support increased for participants in both group types from baseline to post-intervention and then decreased at follow-up. Thematic analysis of qualitative data (i.e., participant posts and comments in response to posts) revealed an overarching theme: us versus them-a dichotomizing view of the world that distinguishes people with pain (us) versus everyone else who does not understand pain (them). Participants discussed their tendency to withdraw socially due to feeling misunderstood regarding their pain. CONCLUSIONS: Facebook groups for chronic pain enhance perceptions of support among peers. Although generally beneficial, group cohesion may facilitate an us versus them mentality, resulting in isolation and potentially poorer outcomes. Future research should explore ways to maintain benefits of the us versus them mentality, while reducing its costs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

"I don't have chronic back pain anymore": Patient Experiences in Pain Reprocessing Therapy for Chronic Back Pain.

In a recently published randomized controlled trial, two-thirds of the patients receiving a novel psychological treatment, pain reprocessing therapy (PRT), reported elimination or near-elimination of chronic back pain. The mechanisms of PRT and related treatments remain poorly understood but are hypothesized to center on pain reappraisal, fear reduction, and exposure-potentiated extinction. Here, we investigated treatment mechanisms from the participants' perspective. A sample of 32 adults with chronic back pain who received PRT completed semi-structured posttreatment interviews about their treatment experiences. The interviews were analyzed with multiphase thematic analysis. The analyses identified 3 major themes reflecting participants' understanding of how PRT led to pain relief: 1) reappraisal to reduce fear of pain, which included guiding participants to relate to pain as a helpful indicator, overcoming pain-related fear and avoidance, and reconceptualizing pain as a "sensation;" 2) the link between pain, emotions, and, stress, which included gaining insight into these connections and resolving difficult emotions; and 3) social connections, which included patient-provider alliance, therapist belief in the treatment model, and peer models of recovery from chronic pain. Our findings support the hypothesized mechanisms of PRT centered on pain reappraisal and fear reduction, but also highlight additional processes from the participants' perspective, including a focus on emotions and relationships. This study underscores the value of qualitative research methods in illuminating the mechanisms of novel pain therapies. PERSPECTIVE: This article presents participants' perspectives on their experience engaging in a novel psychotherapy for chronic pain, PRT. Through pain reappraisal, linking pain, emotions, and stress, and connecting with their therapist and peers, many participants reported an elimination or near-elimination of their chronic back pain with therapy.

Writing about justice and injustice: Complex effects on affect, performance, threat, and biological responses to acute social stress among african American women and men.

OBJECTIVE: Brief, culturally-tailored, and scalable stress coping interventions are needed to address a broad range of stress-related health disparities, including among African Americans. In this study, we develop two brief justice writing interventions and demonstrate a methodological approach for evaluating how prompting African Americans to think about justice and injustice can alter responses to acute social stress. METHODS: African American women and men were randomized to a neutral writing condition or one of two justice-based writing interventions, which prompted them to recall past experiences of personal justice - with (adjunctive injustice) or without (personal justice-only) recalling and writing about injustice. Participants then completed a modified Trier Social Stress Test, during which they received feedback on poor performance. We measured cognitive performance, affect, and perceived threat in response to task feedback. We also measured blood pressure and salivary cortisol stress responses. RESULTS: Men experienced more positive emotion, performed better on the stressor task, and were less threatened by poor performance feedback in the personal justice-only condition. Men also had lower systolic blood pressure reactivity in the justice writing conditions compared to control. Women experienced less positive emotion, performed worse on the stressor task, and were more threatened by feedback in the personal justice-only condition. Women also had lower cortisol recovery after the stressor task in the adjunctive injustice condition. CONCLUSION: Thinking about justice and injustice may alter performance, affect, threat, and biological responses to acute social stress. Still, gender differences highlight that justice thinking is likely to produce heterogeneous and complex stress coping responses among African Americans.

Emotional Awareness and Expression Interview: Examining Interview Content and Patient Experiences in Two Medical Samples.

A single session of Emotional Awareness and Expression Therapy (EAET)-the EAET Interview-was previously shown to lead to clinical benefits for patients with centralized somatic conditions in primary care (Ziadni et al. in Health Psychol 37(3):282-290, 2018) and tertiary care (Carty et al. in Pain Med 20(7):1321-1329, 2019) settings. There has yet to be an examination of patients' experiences of and reactions to the EAET Interview, which is crucial in evaluating possible clinical implementation of the interview. We conducted secondary analyses on 88 patients (M age = 41.32, 90.9% women) from the two prior trials (primary care N = 51; tertiary care N = 37). Analyses examined interview processes (stress disclosure themes, working alliance, and emotional processing) and patients' reactions to the interview (interview credibility and perceived value of the interview), comparing the two samples and examining correlations among these variables. All patients disclosed at least one stressful life experience, commonly interpersonal problems (89.2%) and childhood adversity (51.5%). Patients had moderately high levels of working alliance and emotional processing during the interview and reported high interview credibility and perceived value of the interview. More extensive emotional processing of stressors was associated with more positive patient reactions to the interview, including higher interview credibility (r = .23) and perceived value (r = .32). We conclude that the single-session EAET Interview was valued by most patients, and patients' emotional processing is particularly beneficial. Addressing the trauma and emotional conflicts of patients with centralized somatic conditions is both feasible and valuable in front-line medical settings.