Mind-body Treatments for Chronic Back Pain

Sponsor

University of Colorado, Boulder (Other)

Overall Status

Completed

CT.gov ID

NCT03294148

Collaborator

The Therapeutic Encounter Foundation (Other), The Radiological Society of North America (Other), The Psychophysiologic Disorders Society. (Other), National Institutes of Health (NIH) (NIH)

151

Enrollment

Location

Arms

27.6

Actual Duration (Months)

5.5

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

Participants with chronic back pain will complete an online prescreen. They will then be randomized to one of two different studies: a placebo vs. waitlist study or a psychotherapy vs. waitlist study, with randomization stratified on pain intensity, age, gender, and opioid use. Participants will then complete an in-person eligibility session, and eligible participants will be scheduled for the baseline assessment session. Following the baseline assessment session, participants will then be randomized to the treatment group or the waitlist group (with a ratio of 2:1 treatment:waitlist), using a computer-generated random sequence.

This scheme will result in three equally sized groups-placebo, psychotherapy, and waitlist-as the investigators will collapse data from the waitlist arms in the two studies for analyses. The investigators do not use a standard three-way randomization because the investigators do not want placebo participants to think they are in a control condition. Thus, the investigators constrain participant's expectations to either injection vs. waitlist or to psychotherapy vs. waitlist.

The placebo treatment is a subcutaneous injection of saline into the back. Participants will know that the treatment is a placebo, i.e., it is an "open label" placebo. Psychotherapy (8 sessions) will be supervised by Alan Gordon and Howard Schubiner.

Functional MRI brain imaging, self-reported clinical outcomes, and behavioral measures will be collected pre- and post-treatment. A brief follow-up survey will be sent at months 1, 2, 3, 6, and 12 after the final assessment session. These will provide longer term data about the trajectory and durability of patient improvement.

Additionally, a group of healthy controls, with no history of back pain, will complete the baseline assessment. They will serve as a comparison group to probe whether the patterns of observed brain activity is specific to CBP patients.

Condition or Disease	Intervention/Treatment	Phase
Chronic Pain Back Pain Lower Back Chronic Back Pain, Low	Other: Open-Label Placebo Treatment for Chronic Back Pain Behavioral: Psychotherapy Treatment for Chronic Back Pain	N/A

Study Design

Study Type:

Interventional

Actual Enrollment :

151 participants

Allocation:

Randomized

Intervention Model:

Parallel Assignment

Intervention Model Description:

Participants will be randomized to one of two different studies: a placebo vs. waitlist study or a psychotherapy vs. waitlist study, with randomization stratified on pain intensity, age, gender, and opioid use. After an eligibility session, eligible participants will be randomized to the treatment group or the waitlist group (with a ratio of 2:1 treatment:waitlist), using a computer-generated random sequence. This scheme will result in three equally sized groups-placebo, psychotherapy, and waitlist-as the investigators will collapse data from the waitlist arms in the two studies for analyses. The investigators do not use a standard three-way randomization because the investigators do not want placebo participants to think they are in a control condition. Thus, the investigators constrain participant's expectations to either injection vs. waitlist or to psychotherapy vs. waitlist.Participants will be randomized to one of two different studies: a placebo vs. waitlist study or a psychotherapy vs. waitlist study, with randomization stratified on pain intensity, age, gender, and opioid use. After an eligibility session, eligible participants will be randomized to the treatment group or the waitlist group (with a ratio of 2:1 treatment:waitlist), using a computer-generated random sequence. This scheme will result in three equally sized groups-placebo, psychotherapy, and waitlist-as the investigators will collapse data from the waitlist arms in the two studies for analyses. The investigators do not use a standard three-way randomization because the investigators do not want placebo participants to think they are in a control condition. Thus, the investigators constrain participant's expectations to either injection vs. waitlist or to psychotherapy vs. waitlist.

Masking:

Single (Outcomes Assessor)

Masking Description:

Researchers will not know which treatment the participants will be receiving (placebo or psychotherapy).

Primary Purpose:

Treatment

Official Title:

Mind-body Treatments for Chronic Back Pain

Actual Study Start Date :

Aug 7, 2017

Actual Primary Completion Date :

Nov 25, 2018

Actual Study Completion Date :

Nov 26, 2019

Arms and Interventions

Arm	Intervention/Treatment
Experimental: Placebo The open-label placebo treatment the investigators will use is based on past open-label placebo trials (Kam-Hansen et al., 2014; Kaptchuk et al., 2010; Kelley et al., 2012). Prior to treatment administration, patients will view a brief (~3 min) video summarizing scientific findings regarding the therapeutic power of placebo treatments. The video will describe established findings regarding placebo and suggest that placebos may still work even when patients know the treatment is a placebo. The video will state that believing in the placebo is not necessary, and the investigators ask only that patients keep an open mind. Patients will then receive a subcutaneous injection of 1ml medical grade saline into the lower back. The injection will be administered near the location of the pain, as specified by the participant. The investigators will use a standard needle used in subcutaneous injections of 27 gauge with a length from 1in to 1.5in.	Other: Open-Label Placebo Treatment for Chronic Back Pain Subcutaneous injection of 1ml medical grade saline into the lower back.
Experimental: Psychotherapy Psychotherapy will consist of one initial medical history session with Co-I Schubiner, followed by twice weekly 50 minute psychotherapy sessions for 4 weeks with a therapist, for a total of 9 sessions maximum. The purpose of the initial medical history session is to help evaluate the likelihood that the patient's back pain is caused by structural conditions in the back. Dr. Schubiner will then speak with patients for a 1 hour session in which he collects their medical history and discusses different possible causes of their back pain with them. This session will be conducted by phone, by HIPAA-compliant Zoom, or by another HIPAA-compliant videoconferencing technology in consultation with the OIT team at Dr. Schubiner's hospital.	Behavioral: Psychotherapy Treatment for Chronic Back Pain Twice weekly 50 minute psychotherapy sessions for 4 weeks, plus an initial medical history session
No Intervention: Waitlist Wait-listed patients will be asked not to change their treatment regime for the 4 weeks in between their two fMRI sessions. Wait-listed patients in the placebo injection arm will be offered the opportunity to receive the placebo treatment (optional). Waitlisted participants in the psychotherapy arm will be given a copy of Dr. Schubiner's book and free access to his online self-help program (optional to accept these).

Arm

Intervention/Treatment

Experimental: Placebo

The open-label placebo treatment the investigators will use is based on past open-label placebo trials (Kam-Hansen et al., 2014; Kaptchuk et al., 2010; Kelley et al., 2012). Prior to treatment administration, patients will view a brief (~3 min) video summarizing scientific findings regarding the therapeutic power of placebo treatments. The video will describe established findings regarding placebo and suggest that placebos may still work even when patients know the treatment is a placebo. The video will state that believing in the placebo is not necessary, and the investigators ask only that patients keep an open mind. Patients will then receive a subcutaneous injection of 1ml medical grade saline into the lower back. The injection will be administered near the location of the pain, as specified by the participant. The investigators will use a standard needle used in subcutaneous injections of 27 gauge with a length from 1in to 1.5in.

Other: Open-Label Placebo Treatment for Chronic Back Pain

Subcutaneous injection of 1ml medical grade saline into the lower back.

Experimental: Psychotherapy

Psychotherapy will consist of one initial medical history session with Co-I Schubiner, followed by twice weekly 50 minute psychotherapy sessions for 4 weeks with a therapist, for a total of 9 sessions maximum. The purpose of the initial medical history session is to help evaluate the likelihood that the patient's back pain is caused by structural conditions in the back. Dr. Schubiner will then speak with patients for a 1 hour session in which he collects their medical history and discusses different possible causes of their back pain with them. This session will be conducted by phone, by HIPAA-compliant Zoom, or by another HIPAA-compliant videoconferencing technology in consultation with the OIT team at Dr. Schubiner's hospital.

Behavioral: Psychotherapy Treatment for Chronic Back Pain

Twice weekly 50 minute psychotherapy sessions for 4 weeks, plus an initial medical history session

No Intervention: Waitlist

Wait-listed patients will be asked not to change their treatment regime for the 4 weeks in between their two fMRI sessions. Wait-listed patients in the placebo injection arm will be offered the opportunity to receive the placebo treatment (optional). Waitlisted participants in the psychotherapy arm will be given a copy of Dr. Schubiner's book and free access to his online self-help program (optional to accept these).

Outcome Measures

Primary Outcome Measures

Change in Brief Pain Inventory-short form (BPI-SF) [Change from pre-treatment to post-treatment (approximately 1 month later)]
Pain intensity and interference

Secondary Outcome Measures

Change in Positive and Negative Affect Scale short form (PANAS-SF) [Pre- and post-treatment (5-7 weeks after baseline) and follow up surveys (1, 2, 3, 6, and 12 months after final assessment)]
Questionnaire to rate positive and negative affect.
Change in PROMIS short forms [Pre- and post-treatment (5-7 weeks after baseline) and follow up surveys (1, 2, 3, 6, and 12 months after final assessment)]
anger (5 items), sleep disturbance (8 items), anxiety (8 items), and depression (8 items)
Change in Tampa Scale of Kinesiophobia (TSK) [Pre- and post-treatment (5-7 weeks after baseline) and follow up surveys (1, 2, 3, 6, and 12 months after final assessment)]
Questionnaire used to assess the subjective rating of kinesiophobia or fear of movement.
Change in Pain Catastrophizing Questionnaire (PCS) [Pre- and post-treatment (5-7 weeks after baseline)]
Questionnaire used to help quantify an individual's pain experience.
Change in Timeline Follow-Back Measure for alcohol and drug use (TLFB) [Pre- and post-treatment (5-7 weeks after baseline)]
Questionnaire used to assess daily drinking and drug use.
Change in Patient Global Impression of Change (PGIC) scale [Pre- and post-treatment (5-7 weeks after baseline) and follow up surveys (1, 2, 3, 6, and 12 months after final assessment)]
Post-treatment-only outcome measure depicting a patient's subjective rating of overall improvement.
Change in Treatment satisfaction questionnaire [Pre- and post-treatment (5-7 weeks after baseline) and follow up surveys (1, 2, 3, 6, and 12 months after final assessment)]
Post-treatment-only outcome measure depicting the patient's satisfaction with the treatment.
Change in Oswestry Low Back Pain Disability Questionnaire (OLBPD) [Pre- and post-treatment (5-7 weeks after baseline) and follow up surveys (1, 2, 3, 6, and 12 months after final assessment)]
Back pain disability questionnaire

Other Outcome Measures

Willingness to experience pain task [Pre- and post-treatment (5-7 weeks after baseline)]
Pain auction measuring willingness to experience pain, adapted from Vlaev et al
Progressive ratio task [Pre- and post-treatment (5-7 weeks after baseline)]
Participants click the mouse repeatedly to earn small amounts of money, to measure motivation
IL-1B [Pre- and post-treatment (5-7 weeks after baseline)]
Marker of inflammation
IL-6 [Pre- and post-treatment (5-7 weeks after baseline)]
Marker of inflammation
fMRI [Pre- and post-treatment (5-7 weeks after baseline)]
Patients will respond to different pain related tasks during an fMRI scan.

Eligibility Criteria

Criteria

Ages Eligible for Study:

21 Years to 70 Years

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

Yes

Inclusion Criteria:

Participants aged 21 to 70 with CBP will be enrolled.
CBP will be defined according to the criteria established by a recent NIH task force (Deyo et al., 2014). Pain duration must be at least 3 months, with back pain being an ongoing problem for at least half the days of the last 6 months. That is, patients can meet criteria by either reporting pain every day for the past 3 months, or by reporting pain on half or more of the days for the past 6+ months. This will be determined by asking patients: (1) How long has back pain has been an ongoing problem for you? (2) How often has low back pain been an ongoing problem for you over the past 6 months? A response of greater than 3 months to question 1 and a response of ''at least half the days in the past 6 months'' to question 2 would define CBP.
Patients must rate pain intensity at 40/100 or greater on the Brief Pain Inventory-Short Form (BPI-SF), in keeping with inclusion criteria from previous CBP trials (Baliki et al., 2012; Cherkin et al., 2016; Hashmi et al., 2013; Seminowicz et al., 2011).
Back pain must be elicited by our back pain device (see below).
Participants must also be comfortable and able to communicate via email or text message, as several study measures are collected in this manner (see below).

Exclusion Criteria:

Back pain associated with compensation or litigation issues as determined by self-report within the past year.
Leg pain is greater than back pain. This suggests neuropathic pain, which may be less responsive to placebo or psychotherapy.
Difficulty participating for technical/logistical issues (e.g., unable to get to assessment sessions).
Self-reported diagnoses of schizophrenia, multiple personality disorder, or dissociative identity disorder.
Self-reported use of intravenous drugs, due to concerns about infections and subject compliance with experimental protocols.
Inability to undergo MRI as determined by MRI safety screen (e.g., pregnancy, metal in body, claustrophobia, using the standard screen conducted by the MRI imaging facility).
Hypersensitive or hyposensitive to pressure pain: unable to tolerate 7kg/cm2 stimulation or reporting no pain for 4kg/cm2 stimulation; see further details below.
Current regular use of an immunosuppressant drug, such as steroids. Such drugs interfere with immunoassay results.
Self-reported history of metastasizing cancers-cancer of the breast, thyroid, lung, kidney, prostate or blood cancers.
Self-reported history of stroke, brain surgery, or brain tumor.
Self-reported diagnosis of a specific inflammatory disorder: rheumatoid arthritis, polymyalgia rheumatica, scleroderma, Lupus, or polymyositis.
Unexplained, unintended weight loss of 20 lbs. or more in the past year.
Cauda Equina syndrome, as screened for by self-reported inability to control bowel or bladder function.