How the Patient-clinician Relationship Influences Treatment Experiences and Outcomes in Chronic Pain Patients: an Fmri Hyperscan Study

The patient-clinician therapeutic alliance is a powerful modulator shaping patients’ treatment experience and clinical outcomes. Before and after a 3-week electro-acupuncture intervention (6 sessions), fMRI hyper-scanning was applied to investigate the influence of either an Augmented (warm/attentive) or a Limited (neutral/business-like) clinician interaction style. Eighteen women with fibromyalgia (mean age=41.41, SD=12.20, each group N=9), randomly assigned to an Augmented or Limited patient-clinician dyadic interaction style (trained acupuncturists), underwent a simultaneously recorded fMRI hyper-scanning procedure with a video connection between two scanners and an evoked cuff pressure pain/treatment paradigm. Questionnaires were used to assess the patients’ experience by targeting treatment-related changes such as clinical pain levels, therapeutic alliance, trust, the clinician's warmth and competence, and the probability of continuing the treatment with this clinician after study participation. As rated by patients, pooled therapeutic alliance and clinicians’ warmth in the Augmented (mean_alliance=43.21, SD=2.40; mean_warmth=4.00, SD=0.0) were significantly higher than in the Limited group (mean_alliance=22.79, SD=13.15; mean_warmth=2.54, SD=1.10; t_alliance(16)=4.31, p<0.001; t_warmth(16)=3.74; p=0.002). Additionally, over the course of all 6 acupuncture treatment sessions, most patients experienced immediate clinical pain relief after each treatment session (p<0.001), irrespective of augmented or limited group assignment. Pain catastrophizing was significantly reduced after the intervention (t(16)=3.79; p=0.002) in the Augmented (∆-7.88) but not the Limited group (∆1.44). Importantly, only the Augmented group reported a high probability to continue with the treatment after the study as well as a high pain relief expectation for future acupuncture treatments even though both groups experienced similar pain relief treatment outcomes over the course of the study intervention. Brain imaging data analysis focused on social mirroring areas such as the temporo-parietal junction (TPJ). In summary, this study highlights the importance of investigating variable interaction quality during longitudinal clinical therapies and its influence on clinical outcomes, treatment compliance, and brain processing of nociceptive signaling. Grant support from NIH - National Center for Complementary and Integrative Health (NCCIH: R61-AT009306, R33-AT009306), Neuroimaging Pilot Funding Initiative at the Martinos Center for Biomedical imaging (MGH R90DA023427), Korea Institute of Oriental Medicine (KIOM), Foundation for the Science of the Therapeutic Encounter, National Center for Research Resources (P41RR14075; CRC 1 UL1 RR025758), Harvard Clinical and Translational Science Center, Martinos Computing facilities, and National Institutes of Health (Grant Nos. S10RR023401, S10RR019307, S10RR019254, and S10RR023043). The funders had no role in study design, data collection and/or interpretation of the results. Also, all authors declare no existence of competing conflicts of interest. The patient-clinician therapeutic alliance is a powerful modulator shaping patients’ treatment experience and clinical outcomes. Before and after a 3-week electro-acupuncture intervention (6 sessions), fMRI hyper-scanning was applied to investigate the influence of either an Augmented (warm/attentive) or a Limited (neutral/business-like) clinician interaction style. Eighteen women with fibromyalgia (mean age=41.41, SD=12.20, each group N=9), randomly assigned to an Augmented or Limited patient-clinician dyadic interaction style (trained acupuncturists), underwent a simultaneously recorded fMRI hyper-scanning procedure with a video connection between two scanners and an evoked cuff pressure pain/treatment paradigm. Questionnaires were used to assess the patients’ experience by targeting treatment-related changes such as clinical pain levels, therapeutic alliance, trust, the clinician's warmth and competence, and the probability of continuing the treatment with this clinician after study participation. As rated by patients, pooled therapeutic alliance and clinicians’ warmth in the Augmented (mean_alliance=43.21, SD=2.40; mean_warmth=4.00, SD=0.0) were significantly higher than in the Limited group (mean_alliance=22.79, SD=13.15; mean_warmth=2.54, SD=1.10; t_alliance(16)=4.31, p<0.001; t_warmth(16)=3.74; p=0.002). Additionally, over the course of all 6 acupuncture treatment sessions, most patients experienced immediate clinical pain relief after each treatment session (p<0.001), irrespective of augmented or limited group assignment. Pain catastrophizing was significantly reduced after the intervention (t(16)=3.79; p=0.002) in the Augmented (∆-7.88) but not the Limited group (∆1.44). Importantly, only the Augmented group reported a high probability to continue with the treatment after the study as well as a high pain relief expectation for future acupuncture treatments even though both groups experienced similar pain relief treatment outcomes over the course of the study intervention. Brain imaging data analysis focused on social mirroring areas such as the temporo-parietal junction (TPJ). In summary, this study highlights the importance of investigating variable interaction quality during longitudinal clinical therapies and its influence on clinical outcomes, treatment compliance, and brain processing of nociceptive signaling. Grant support from NIH - National Center for Complementary and Integrative Health (NCCIH: R61-AT009306, R33-AT009306), Neuroimaging Pilot Funding Initiative at the Martinos Center for Biomedical imaging (MGH R90DA023427), Korea Institute of Oriental Medicine (KIOM), Foundation for the Science of the Therapeutic Encounter, National Center for Research Resources (P41RR14075; CRC 1 UL1 RR025758), Harvard Clinical and Translational Science Center, Martinos Computing facilities, and National Institutes of Health (Grant Nos. S10RR023401, S10RR019307, S10RR019254, and S10RR023043). The funders had no role in study design, data collection and/or interpretation of the results. Also, all authors declare no existence of competing conflicts of interest.