Using Functional MRI to Evaluate Cognitive Behavioral Therapy Treatment Response in Adults With Chronic Pain

Many recent studies have suggested that there is an overlap between pain and emotion-related
neurophysiological processes. Several modern pain theories also advocate that pain should be
considered as a complex sensory and emotional experience, rather than as an isolated sensory
event. In accordance with these theories, it is reasonable to expect that an intervention
such as CBT, which teaches patients to understand and control both the emotional and sensory
aspects of pain, could alter the brain's responses to both pain and emotionally provocative
stimuli and, consequently, change the underlying neural circuitry.

To date, there are no published studies that explore the neurobiological effects of
psychotherapeutic approaches, such as CBT, on chronic pain. A previous pilot study showed
that the exaggerated amygdala response to negative emotional stimuli in chronic pain
patients was normalized after 12 weeks of group CBT, suggesting that CBT may affect at least
the emotional component of the pain process. Using functional magnetic resonance imaging
(fMRI), which creates a three-dimensional picture of the brain, this study will determine
the following: (1) whether CBT treatment changes the function of brain neural circuitry in
response to acute noxious physical stimuli and to fearful emotional stimuli; and (2) how
altered activation in brain areas associated with the attentional, affective, and sensory
aspects of chronic pain relate to measurable improvement in someone's clinical response to
group CBT. Directly measuring the effects of CBT on brain function could ultimately improve
clinical decision making and contribute to the development of individualized treatment for
patients with chronic pain.

Participants will be randomly assigned to receive 12 weeks of either CBT or pain education,
which will act as an attention control condition. Each CBT session will last for 90 minutes
and will teach participants specific skills to better cope with chronic pain. These skills
will include breathing exercises, distraction, and relaxation techniques. Each weekly pain
education session, also lasting 90 minutes, will be structured as a group discussion and led
by a health care counselor. During the session, participants will receive information about
the nature of chronic back pain, talk about treatment options, learn exercises and
stretching techniques for maintaining strength and flexibility, and learn how to protect
their backs. Every participant will undergo two fMRI examinations: one before treatment and
one after treatment.

Inclusion Criteria:

- At least 6 months of musculoskeletal non-neuropathic pain confined to lumbar or
thoracic back

- Meets study threshold for severity of typical pain of 4 or more on a 10-point scale
adapted from the McGill Pain Questionnaire

- Has ongoing standard pain management from a physician

- Agrees to participate in this research study

Exclusion Criteria:

- Malignancy

- Reflex sympathetic dystrophy and/or naturopathic pain

- Opioid medication use

- Substance use disorder

- Neurological disorder, such as epilepsy, stroke, or other medical condition that
could confound or interfere with the current study

- Major depression or/and dysthymia

- Post traumatic stress disorder or panic disorder

- Left-handedness

- Pregnancy

- History of illicit drug use (cocaine, cannabis, heroin) that can result in altered
cognition

- Exceeding the weight limit on the MRI scanner

- Suffering from claustrophobia

- Any of the following: cardiac pacemakers, auto defibrillators, neural stimulators,
aneurysm clips, metallic prostheses, cochlear implants, any implanted devices (pumps,
infusion devices, stents), permanent eye make-up, intrauterine devices, shrapnel
injuries