Can Chronic Back Pain Be Unlearned? A Landmark Brain-Retraining Trial

Why This Study Matters

"The claim was radical: that in some chronic back pain, the alarm outlives the injury, and the alarm itself can be retrained."

For decades, the model of back pain was mechanical. Find the damaged disc, the pinched nerve, the worn joint, and treat the structure. That model works well for acute injury and for clear structural problems. It fails a large group of people whose pain has lasted for months or years, whose imaging shows nothing that explains the severity, and who have tried adjustment, therapy, injections, and medication without durable relief. Something else is going on in that group, and this trial went after it directly.

Pain reprocessing therapy rests on a simple but unsettling premise. Pain is not a direct readout of tissue damage. It is the brain's best guess about danger, built from many inputs, and that guess can get stuck in the on position. When it does, ordinary movement and ordinary body signals get flagged as threats, and the pain becomes self-sustaining. If that is true for a given person, then the target is not the spine. It is the interpretation. The 2022 trial by Ashar and colleagues put that premise to a randomized test with a real placebo arm, which is rare and demanding in pain research.

The Study: What Ashar and Colleagues Tested

The trial enrolled 151 adults in Boulder, Colorado, with chronic back pain of at least six months and a relatively low level of structural pathology. Average pain was mild to moderate, and people with red-flag or major structural causes were screened out. That inclusion criterion matters and I will return to it, because it defines who the results apply to (Ashar and colleagues, 2022).

Participants were randomized into three arms. The first received pain reprocessing therapy: about eight one-on-one sessions over four weeks, plus an assessment session, teaching patients to reinterpret their pain sensations as non-dangerous and to approach feared movements with a sense of safety rather than alarm. The second arm received an open-label placebo, a subcutaneous saline injection that everyone knew was inert. The third arm continued their usual care, whatever that already was. Outcomes were measured right after treatment and tracked out to one year.

"A placebo arm and a usual-care arm in the same trial is the honest way to ask whether a therapy beats both belief and time."

The three-arm design is the strength here. Comparing against usual care alone tells you whether a treatment beats doing nothing new. Adding a genuine placebo arm tells you whether it beats expectation and attention. A therapy that clears both bars is far more convincing than one that clears only the low one.

What They Found

The headline number is striking. Using a threshold of pain-free or nearly pain-free, defined as a pain intensity of 0 or 1 on a 0-to-10 scale after treatment, the pain reprocessing therapy group hit 66 percent. The open-label placebo group reached 20 percent. The usual-care group reached 10 percent (Ashar and colleagues, 2022).

The size of the gap is not trivial. The between-group effect sizes were large, reported as a Hedges g of 1.14 for the therapy versus placebo and 1.74 for the therapy versus usual care, both highly statistically significant. In plain terms, the therapy did not just edge out the comparison groups. It separated from them cleanly. And the authors reported that most of the benefit held at one-year follow-up, which addresses the usual worry that pain treatments look good for a month and then fade.

The trial also collected brain imaging that pointed to reduced activity in pain-related brain regions and shifts in how patients appraised the cause of their pain. I read that as supporting evidence for the mechanism rather than proof on its own. The behavioral result, two out of three people recovering, is the part that should get a patient's attention.

How Pain Gets Learned: The Mechanism

This is the part I want patients to understand, because the mechanism is not vague and it is not "it is all in your head." Start with central sensitization. When pain signals bombard the spinal cord and brain long enough, the central pain pathways undergo a prolonged but reversible increase in excitability. After that shift, low-threshold inputs that should feel like nothing, an ordinary bend or a light touch, can drive a pain response out of all proportion to the tissue involved (Woolf, 2011). The volume knob on the alarm has been turned up, and it stays up.

"The pain is real. The alarm has simply become louder than the threat that first set it off."

Layer the psychology on top. The fear-avoidance model describes how pain-related fear feeds the loop. When movement hurts and feels dangerous, people avoid it. Avoidance brings short-term relief but long-term cost: hypervigilance to every twinge, muscle guarding, and physical deconditioning, all of which keep the pain system on high alert (Vlaeyen and Linton, 2000). The person is not weak or imagining things. They are caught in a self-reinforcing biological and behavioral loop.

Pain reprocessing therapy targets that loop at the interpretation step. Its core move is to help a person experience feared sensations while reappraising them as safe, brain-generated signals rather than evidence of fresh harm. This is closely related to the idea that the brain constantly predicts danger and updates those predictions from experience. Give the brain repeated evidence that a movement is safe, and the prediction, and the pain it produces, can be revised downward. That is the throughline connecting the imaging, the fear model, and the recovery numbers.

Centrally-Mediated Pain Is Not the Same as a Fresh Injury

Here is where a lot of internet coverage of this study goes wrong. It takes a result about a specific kind of pain and sells it as a theory of all pain. That is not honest, and it is not what the trial showed. The researchers deliberately enrolled people with chronic pain and low structural pathology. They screened out red flags and major structural causes. So the clean reading is this: for long-lasting back pain that is centrally maintained, retraining the alarm can work remarkably well. For an acute injury or a clear structural problem, that is a different clinical situation.

Acute mechanical pain has a job. It tells you to protect a tissue while it heals. You do not want to override that alarm with reappraisal in the first days after a real strain. The skill is in telling the two apart, and that is a clinical judgment, not a slogan. A careful history and exam sort acute and structural presentations from centrally-mediated ones, and screen for the small number of dangerous causes that need medical care rather than any conservative treatment at all.

Where Hands-On Care Fits Alongside Brain Retraining

I do not read this study as a threat to what I do. I read it as a map of the other half of the problem. When a spinal segment restricts and the muscles around it guard, movement becomes stiff and painful, and that pain is exactly the input that keeps a sensitized alarm firing. An adjustment plus targeted soft-tissue work can release that mechanical restriction so the next movement is tolerable. That does not retrain the brain by itself, but it lowers the cost of the very exposure that brain retraining depends on. It is hard to reappraise a movement as safe while your low back is locked and screaming.

"One approach makes the feared movement possible. The other makes it feel safe. Chronic pain often needs both."

This is not a fringe pairing. The American College of Physicians already recommends nonpharmacologic care first for chronic low back pain, and its list explicitly includes both manual approaches like spinal manipulation and psychological approaches like cognitive and mindfulness-based therapies (Qaseem and colleagues, 2017). Brain retraining sits squarely in that psychological lane. The evidence base is telling us to combine movement, hands-on care, and the mind-body work, not to pick a tribe. I have written before about the broader link between manual therapy and mental health, and why treating a nervous system means treating both the body and the brain, in a companion piece on manual therapy and mental health.

What I Tell Patients in Brookside

I treat patients every week who have been told there is nothing wrong with their back, as if that settles it. It does not settle anything for the person still in pain. What this research lets me say honestly is that clean imaging plus persistent pain is a recognized pattern, not a mystery and not a character flaw. The alarm system has learned to overreact. That is a real, physical process with a real, physical treatment path.

In the room, my job is the mechanical half and the on-ramp. I restore motion to a stiff, guarded spine so that walking, bending, and the graded exposure that calms a sensitized system become possible. If a person's pain is clearly driven by fear and avoidance, I say so plainly and point them toward the mind-body work, because that is where the strongest evidence for that pattern now sits. I am not going to claim an adjustment rewires your brain. I am going to get you moving and be honest about the rest. For the fuller picture of how I approach persistent back pain in general, the back pain chiropractor resource lays out the mechanical side in detail.

Related from The Forward Review

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