Reprogramming Chronic Pain

Sarah is one of nearly 60 million Americans living with chronic pain. Unlike acute pain, which warns of danger, chronic pain can persist long after tissues have recovered. Stress, poor sleep, inactivity, and trauma can sensitize the nervous system, amplifying pain and someone’s reactions to it.

Desperate for relief, Sarah enrolled in an early study testing SpinePal, a digital therapy designed at Dartmouth to help patients recover after spine surgery. The program reflects a growing recognition that chronic pain isn’t sustained by damaged biology alone, but by interactions among the brain, body, behavior, and lived experience.

Interrupting the Cycle

SpinePal was developed by psychologist Madelyn Frumkin, PhD, assistant professor of biomedical data science and of psychiatry at the Geisel School of Medicine at Dartmouth, and neurosurgeon Murray Echt, MD, assistant professor of surgery at Dartmouth Health’s Dartmouth Hitchcock Medical Center (DHMC). Delivered through a smartphone app, SpinePal combines cognitive behavioral therapy, mindfulness, relaxation training, and recovery coaching before and after surgery to reduce the fear, stress, and opioid reliance that can keep patients trapped in pain.

“People really vary in how they experience pain,” Frumkin notes. Some patients with extensive tissue damage may recover quickly, while others experience debilitating pain despite few visible signs of ongoing injury. Two patients may undergo the same surgery and exhibit nearly identical MRI scans, yet report dramatically different levels of pain.

That variability has stymied physicians and patients alike. For example, of the million-plus Americans who undergo spine surgery each year, 10 to 40% develop persistent pain, disability, or prolonged opioid use, according to studies published in Pain Medicine and Anesthesia & Analgesia. Roughly half of patients taking opioids before surgery continue using them afterward.

The missing piece isn’t always another procedure or prescription. Standard post-operative care rarely addresses psychosocial factors like depression, anxiety, fear of movement, and “catastrophizing”—the tendency to fixate on worst-case outcomes. But, Echt says, in clinical settings, “we see all the time that factors such as depression and anxiety lead to disability, and they predict outcomes after spine surgery more consistently than surgical or imaging factors.”

Tracking Pain in Real Life

Built to intervene during that window, SpinePal combines wearable biosensors with brief smartphone check-ins that ask patients about their pain, mood, activity, sleep, and recovery throughout the day. Together, those data create a much more detailed picture of healing than occasional clinic visits weeks or months after surgery.

To determine whether patients would use the program, Frumkin’s team interviewed 10 people (including Sarah) who continued using opioids for pain management months after spine surgery, walking them through SpinePal’s design and content to understand what resonated, what didn’t, and what they needed most during surgery.

At its core, the therapy works by targeting the thought patterns that can unintentionally keep pain cycling. “As cognitive behavioral therapists, we’re often helping people put thoughts on trial,” Frumkin says. “What evidence supports this fear? What evidence doesn’t? What happens if we respond differently?”