Brain and Behavioral Correlates of the Patient-Clinician Relationship: A longitudinal fMRI hyper-scanning study of chronic pain patients

Research suggests that a good patient-clinician therapeutic alliance can improve clinical outcomes. In this ongoing, longitudinal study, we applied fMRI hyper-scanning to determine whether behavioral, neural, and clinical variables associated with the therapeutic relationship between chronic pain patients and their clinicians influences clinical outcomes. Ten women with fibromyalgia (mean age=40, SD=10.71, each group N=5) were randomly assigned to either an Augmented (warm/attentive) or Limited (neutral/business-like) interaction style, and were treated with electro-acupuncture for 6 biweekly sessions. Before and after acupuncture therapy, each patient-clinician dyad underwent a simultaneously recorded fMRI hyper-scanning procedure with video connection between two scanners and an evoked cuff pressure pain/treatment paradigm. Clinical outcomes and the quality of the patient-clinician relationship were assessed by questionnaires targeting treatment-related changes in clinical pain levels, therapeutic alliance, trust, and the clinician's warmth and competence. Pooled therapeutic alliance (assessed after treatment sessions 1, 3, and 6; scale 0-50) in the Augmented group (mean=43.17, SD=2.97) was significantly higher than in the Limited group (mean=27.27, SD=10.44; t(8)=3.28, p=0.011). Similarly, clinicians’ warmth, as rated by patients, was significantly higher in the Augmented (mean=4.00, SD=0.0) than in the Limited group (3.02, SD=0.73; t(8)=3.00; p=0.017). Preliminary results show that over all 6 acupuncture treatment sessions, irrespective of group assignments, most patients experienced post-treatment clinical pain relief (p<0.001). Brain imaging data analysis focused on social mirroring areas such as the temporo-parietal junction (TPJ), as we found stronger dynamic coupling in dyads with stronger therapeutic alliance in our previous hyperscan fMRI study (Ellingsen et al. 2020). This study focuses on patient-clinician interaction during longitudinal clinical treatment, and highlights the influence that the therapeutic relationship can have on brain processing of nociceptive signaling and clinical outcomes. Moreover, we hope that our results will inform future chronic pain treatment approaches, especially how to harness the positive effects of the patient-clinician relationship. 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.