Boulder Back Pain Study: Results, Limits & 5-Year Follow-Up

Last updated August 23, 2026 · 10 min read

By Tauri Urbanik, research writer and PainApp founder

Why this trial matters

The trial supplied randomized evidence for a new psychological treatment model in a selected primary chronic back-pain population. Its effect was large enough to justify close attention and further replication, but not broad claims about all chronic pain.

The study was published in JAMA Psychiatry, one of the most respected medical journals in the world (Ashar et al., JAMA Psychiatry, 2022↗). It was funded by the NIH. And it used the gold standard of medical research: a randomized controlled trial.

Here's everything you need to know about it.

Study design: how they tested it

The researchers recruited 151 adults with chronic back pain. Not mild discomfort. These were people who'd been hurting for an average of several years. Real, persistent, life-disrupting pain.

Participants were randomly assigned to one of three groups:

Pain Reprocessing Therapy (PRT): 50 patients received 8 sessions over 4 weeks. The treatment taught them to reinterpret their pain as a brain-generated signal rather than evidence of body damage. Core techniques included somatic tracking, safety reappraisal, and education about neuroplastic pain.

Open-label placebo: 51 patients received a subcutaneous saline injection in their backs. They were told it was a placebo. This controlled for the general effects of receiving treatment and medical attention.

Usual care: 50 patients continued whatever they were already doing for their pain. No new intervention.

The design was rigorous. Randomized. Controlled. Blinded assessors. Published in a top-tier journal with full peer review.

The results

At the primary endpoint, 33 of 50 people in the PRT group were pain-free or nearly pain-free. The corresponding proportions were 20% in the open-label saline group and 10% in usual care.

This wasn't a 10% improvement. It wasn't a modest effect. It was a fundamental shift. People who had been in pain for years walked out of 4 weeks of treatment without it.

What the brain scans revealed

Here's what makes this study special beyond the clinical outcomes. The researchers didn't just ask people how they felt. They looked inside their brains.

Every participant received fMRI brain scans before and after treatment. The PRT group showed measurable changes in brain regions involved in pain processing. Specifically, activity decreased in areas that evaluate the emotional significance of pain, like the anterior insula and anterior midcingulate cortex.

In plain language, group-level pain-related brain responses changed alongside reported pain. The imaging supports an association with altered pain processing, but it is not a diagnostic scan and cannot by itself establish why an individual improved.

Why does PRT work so well?

The treatment is based on a specific model of chronic pain. Some persistent pain, the researchers argue, is neuroplastic. The brain learned to produce pain independently of tissue damage. The original cause may have been real, an injury, a strain, a disc issue. But the brain got stuck in a pain pattern even after the body healed.

PRT targets this directly. It teaches people three things:

First, that their pain is real but not dangerous. The brain is sending a false alarm. Understanding this reduces fear, and fear is the fuel that keeps neuroplastic pain burning.

Second, to observe pain sensations with curiosity instead of threat. This is somatic tracking. When you attend to pain without panic, you send your brain a safety signal. Over time, this recalibrates the pain response.

Third, to gather evidence of safety from daily life. Movements that don't hurt. Days that are better than expected. Pain that shifts or disappears during distraction. Each of these corrective experiences teaches the brain that the danger signal is wrong.

The 5-year follow-up

Clinical trials often show impressive short-term results that fade over time. So the durability question is critical. Do people stay pain-free?

A five-year secondary analysis was published in 2025 and reported persistent group differences in pain intensity. It strengthens the durability case while adding important considerations: not every original participant contributed five-year data, the analysis was not a new randomized trial, and several authors disclosed professional or commercial relationships related to mind-body pain treatment.

Limitations worth knowing

No study is perfect, and being honest about limitations is important.

Sample size. 151 participants is solid for a clinical trial but not massive. Larger studies would strengthen the findings.

Back pain only. The study specifically tested chronic back pain. While the neuroplastic pain mechanism is shared across conditions, this trial didn't directly test migraines, fibromyalgia, IBS, or other pain conditions. Separate studies have shown brain-based approaches work for those conditions too, but this particular trial focused on backs.

Self-selected participants. People who volunteer for a study about brain-based pain treatment may already be open to the idea. The results might look different in people who are firmly convinced their pain is structural.

Therapist-delivered. PRT in the study was delivered by trained therapists. The book "The Way Out" adapted the approach for self-help, but the exact protocol in the trial involved professional guidance.

Comparator and blinding. Participants knew their treatment assignment, and the saline injection was explicitly described as a placebo. Expectancy and therapist-contact effects cannot be fully separated from the PRT-specific techniques.

Conflicts of interest. The five-year paper disclosed professional, publishing, training, consulting, and advisory relationships among several authors. Disclosure does not invalidate the results, but readers should know it when weighing the evidence.

These limitations matter when interpreting the result. The trial provides promising evidence for therapist-led PRT in a selected primary chronic back-pain population; it does not establish the same outcome for other pain conditions, self-guided programs, or routine clinical practice.

What this means for chronic pain treatment

The Boulder study matters beyond its specific numbers. It validates a fundamentally different model of chronic pain. For decades, the dominant approach has been structural: find the damage, fix the damage. When that doesn't work, manage the symptoms.

The study tested whether changing beliefs about pain causes and threat could improve primary chronic back pain. It supports central pain-processing mechanisms as a treatment target for selected patients, without showing that most back pain is exclusively neuroplastic or that physical and medical care are unnecessary.

M

Mark, 45

back pain for 9 years

Mark read about the Boulder study after his third round of physical therapy failed. Nine years of pain. Two MRIs showing "mild disc degeneration," a finding also found in some pain-free people his age. He had always assumed the scan fully explained his pain. Learning that pain can have several contributors gave him a new question to discuss with his care team. He added pain education and psychological skills to his rehabilitation, and over time his pain became less disruptive.

Composite story based on common patient patterns. Not a specific individual.

From research to your experience

The Boulder study is powerful evidence. But evidence only matters if it leads somewhere for you. The question isn't whether PRT works in a clinical trial. It's whether the neuroplastic pain model applies to your situation.

If pain has lasted beyond expected healing, moves, fluctuates with stress, or does not match imaging, central pain processing may be worth discussing with a clinician. These patterns are not diagnostic, and the trial's eligibility criteria should not be treated as a self-test.

Frequently asked questions

What is the Boulder back pain study?

The Boulder study is a 2022 randomized controlled trial published in JAMA Psychiatry. Led by Yoni Ashar at the University of Colorado Boulder, it tested Pain Reprocessing Therapy on 151 chronic back pain patients and found 33 of 50 people assigned to PRT were pain-free or nearly pain-free in 4 weeks.

How long did the Boulder study results last?

A 2025 secondary analysis reported that group differences in pain remained at 5 years. Follow-up attrition, the secondary-analysis design, and author conflict disclosures should be considered when interpreting durability.

What did the brain scans show in the Boulder study?

Task-based fMRI showed changes in pain-related responses and connectivity after PRT. These group-level associations complement the clinical outcome but do not independently prove the mechanism or diagnose an individual's pain.

Does the Boulder study apply to conditions other than back pain?

No direct conclusion can be drawn for other conditions. The trial enrolled selected adults with primary chronic back pain; evidence for other diagnoses and other treatment formats must be evaluated separately.

References

1. Ashar YK, et al. Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial. JAMA Psychiatry. 2022;79(1):13-23.DOI: 10.1001/jamapsychiatry.2021.2669
2. Brinjikji W, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR Am J Neuroradiol. 2015;36(4):811-816.DOI: 10.3174/ajnr.A4173
3. Ashar YK, et al. Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: 5-Year Follow-Up of a Randomized Clinical Trial. JAMA Psychiatry. 2025.DOI: 10.1001/jamapsychiatry.2025.1844