Science

The Pain Science

Since the advent of sophisticated imaging techniques like MRI, doctors have believed that what they can see on scans must be causing pain. However, in the last ten years researchers began imaging asymptomatic individuals, and realized these so-called abnormalities observed on MRI are found in nearly everyone they scanned. These “normal abnormalities” are as likely seen in completely healthy, pain free people as those coming to doctors’ offices in pain. What doctors assumed to be the source of pain – degeneration of internal tissues – is actually a completely normal sign of aging; like grey hairs on the inside.

This explains the 2% rate of success with back surgeries, sham knee trials showing the benefit of such procedures is only placebo, and that cortisol injections are proven to be no better than saline. In short, doctors and other therapists have been unsuccessful in treating chronic pain because they are trying to fix things that are not the true source of patients’ pain. If nearly everyone – pain patient or not – has the same MRI findings, then it is impossible these “normal abnormalities” are causing pain; There must be another reason.

Around the same time as researchers were discovering physical degeneration we can see on MRI is common to all people, imaging technology improved to allow functional MRI (fMRI). This incredible machine gave neuroscientists the ability to watch the brain in action, as the body and mind are also active. fMRI led to quick breakthroughs in understanding – in actually watching – the brain learning pain. Landmark studies showed pain moving from physical regions of the brain to those associated with learning, habit, and emotion over time. Researchers were also able to predict who would develop chronic pain, and whose pain would fade away, by observing what brain regions were active at the outset of pain. These are only two of hundreds of studies convincingly linking our experience of chronic pain to activity in the brain, not degeneration in the body.

The Pioneers

For the last 50 years, there have been doctors and researchers – even at eminent universities and hospitals – who observed that emotions – like stress, trauma, repressed anger, grief – played an enormous role in patients’ pain syndromes. One of them, Dr John Sarno at NYU, called this phenomenon Tension Myositis Syndrome (TMS). Dr Sarno helped many thousands of patients out of pain, wrote a handful of wildly successful books, and trained many doctors still continuing his work. However, as the brain imaging techniques to prove his theories did not exist in his lifetime, and it was very out of vogue to mix discussions of mental health with medicine at that time, his theories did not gain mainstream traction.

Fast forward to ten years ago, when a group of doctors from across medical specialties – who were familiar with Sarno’s work – came together to discuss their observations. Their interactions with pain patients over decades of medical practice bore out Sarno’s basic concept that unhelpful central nervous system functioning – the brain turning on false danger alarms as the result of stress, trauma, etc – and not physical degeneration, was the cause of chronic pain. This rare interdisciplinary meeting, with doctors from across medical specialties sharing the similar patterns they’d noted in pain syndromes appearing in many different places in patients’ bodies, convinced the attendees that central sensitization – a hyper vigilant central nervous system – was responsible for chronic pain, no matter where that pain was seemingly located in the body.

These doctors founded an organization called the Psychophysiologic Disorders Association to pool their intellectual and scientific resources. Over the next decade, the PPDA published books, educated other doctors and their patients, and designed research studies to prove these concepts beyond a shadow of a doubt.

Pain Reprocessing Therapy – The New Way to Treat Chronic Pain

The most groundbreaking of these research studies – The Boulder Back Pain Study (out of the University of Boulder, Colorado) – was published in October of 2021 in the prestigious Journal of the American Medical Association (JAMA), Psychiatry. It was the first published example of positively curing chronic pain – even in participants who had suffered for decades. You can read this research, and many more published papers, if you keep scrolling down. The researchers – crucially an interdisciplinary mix of neuroscientists, doctors, and psychiatrists – in this incredibly successful study only used one intervention with the participants: Pain Reprocessing Therapy (PRT).

My Mind Body Program is synonymous with Pain Reprocessing Therapy – the only therapy scientifically proven way to defeat chronic pain. PRT was designed by neuroscientists and psychiatrists and is a completely non-invasive therapy for ending chronic pain and other unpleasant chronic symptoms.

Research:

There has been an explosion of paradigm shifting research on the brain’s role in the chronification of pain in the last two decades. 

• If I could point everyone to a single randomized clinical trial, it would be Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain In the Journal of the American Medical Association, Psychiatry. This landmark study on chronic back pain, funded and organized by the Psychophysiologic Disorders Association, was the first study ever to produce complete pain recovery, and the only intervention used was Pain Reprocessing Therapy. 

Remarkably, not only one or two people completely recovered, but more than half of those treated with PRT were still pain-free one year later. This incredible result in the PRT group was notably a huge improvement on the placebo and usual care groups. Additionally, a high percentage of study participants who did not get to “pain free” over the course of the study, still registered significant improvement and continued to get better following the study’s conclusion. The researchers also used fMRI (functional magnetic resonance imaging) to track changes in the brains of chronic pain patients before and after treatment with PRT. 

This is a fascinating, well designed, landmark study that will forever change what we accept as fact about the origins of chronic pain and what treatments are proven to work. I am so proud to have received training directly from several of the doctors, psychiatrists, and researchers responsible for it.

• Washington Post article about these findings: Chronic pain is surprisingly treatable – when patients focus on the brain. An unexpected therapy shows results.
• Times of London articles about these findings: Is this a cure for chronic back pain? A new study has reported a remarkable success rate using only psychological methods.; and Retrain your brain: is it the cure for back pain? Recent research suggests the key to chronic back pain is not drugs.

Below is a list of my personal favorite research studies to share with clients and friends. However, for a comprehensive, annotated list of major research by type, I highly recommend you visit the Psychophysiologic Disorders Association Bibliography.

• Predicting transition to chronic pain. Properties of the brain’s emotional learning circuitry predict the transition to chronic pain.: Researchers tracked patients for one year following an initial episode of back pain, including taking brain scans of emotion-related circuitry to assess emotional activity at the outset of their acute pain. Researchers were able to predict with 85% accuracy who would develop chronic pain based on the early brain scans, representing the patients’ emotional mindset, alone.
• Chronic Pain and the Emotional Brain: Specific Brain Activity Associated with Spontaneous Fluctuations of Intensity of Chronic Back Pain: Researchers scanned the brains of patients experiencing chronic back pain in different environments in the lab and found that spontaneous chronic back pain is observed in brain regions known to be involved in negative emotions, response conflict, and detection of unfavorable outcomes, especially in relation to the self. These findings suggest the emotional brain, especially regions pertaining to ideas of the self, is a key player in chronic low back pain.
  • From the conclusion of the study: “The current study is the latest of a series we have been conducting to examine the brain in CBP. Together, how do these studies impact the current viewpoint regarding CBP? The common clinical approach to CBP is to relate its behavioral manifestations to the site of injury. Although some CBP patients have identifiable structural or mechanical cause for their pain, most do not (Cavanaugh and Weinstein, 1994; Boos et al., 1995; Deyo, 1998). Given the poor association between structural abnormalities to pain, other nonspecific variables have been proposed as predictors of clinical outcome, like demographics including age, gender, and education (Boos et al., 1995), psychosocial factors such as level of depression, anxiety, pain catastrophizing, fear and/or helplessness, job satisfaction, and environmental reinforcers such as compensation and litigation (Greenough, 1993; Keefe et al., 2004).

• Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits: Researchers compared the brains of back pain patients who had symptoms for two months (with no history of pain) and patients who had suffered back pain for at least 10 years. They also tracked and scanned the acute back pain patients for one year, and continued to examine the brains of patients whose pain went on to become chronic. The researchers clearly observed that acute pain was seen on scans in areas of the brain limited to physical pain sensation, while chronic pain was seen in regions limited to emotion-related circuitry.
  • Science Magazine article about these findings: Blaming the Brain for Chronic Back Pain. A brain scan may be able to predict whether a patient with back pain will recover or develop persistent pain.
• A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee: Double Blinded study on 180 patients randomly assigned to undergo arthroscopic debridement, arthroscopic lavage, or placebo surgery. Neither of the intervention groups reported less pain or better function than the placebo groups.
  • Scientific American article about these findings: Study Suggests Common Knee Surgery’s Effect Is Purely Placebo

• Failed Back Surgery Syndrome: Pain Medicine Journal Article; Research confirms many of the most common back surgeries are no more effective than “sham” surgeries, and less effective than interdisciplinary, moderately invasive interventions.
• Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations: Radiological findings in people with NO back pain prove spinal degeneration is incredibly common and is very often observed on MRI in the absence of any pain. 
  • From the conclusion of the study: “Many imaging-based degenerative features are likely part of normal aging and unassociated with pain.”

• No stress–no whiplash? Prevalence of “whiplash” symptoms following exposure to a placebo rear-end collision: 51 participants experienced a simulated crash. Three days later, 20% of them had neck pain that they attributed to the crash, and one month later 10% of them still suffered from symptom, even though there was no way they suffered an actual injury from the “crash.”

• Situational and psychophysiological factors in psychologically induced pain: “To investigate pain that occurs in the absence of painful stimulation, normal subjects were connected to a sham stimulator and were told that a headache could occur as a result of the electrical current they would receive. Half of the subjects who received this suggestion reported pain. Pain ratings increased as the settings of the sham stimulator were increased.” The results show that pain can be reliably induced solely by psychological suggestion, and in the absence of tissue stimulation or damage. Simply put: Belief in pain causes pain.
• Cerebral activation during hypnotically induced and imagined pain: Subjects were placed in an fMRI machine as pain was administered with a hot probe, and watched the pain regions of their brain light up. The same subjects were again monitored via fMRI as they were hypnotized and pain was induced via suggestion – in the absence of any physical stimulation. When subjects were hypnotized the suggested pain lit up the same brain regions as the pain from the hot probe did. The subjects’ brains reacted the same to physically and hypnotically induced pain. This study provides “the first direct experimental evidence in humans linking specific neural activity with the immediate generation of a pain experience.”
• Increased bias to report fear or pain following emotional priming of pain-related fear: Participants received random but equally hot pulses on their skin while looking at images that were either scary or neutral. Subjects reported much more pain while looking at the scary photos; sometimes the subjects reported pain while looking at the scary photos, even when the hot pulses were off. This study shows that fear alone can produce pain, and that fear intensifies sensitivity to physical sensation – potentially turning a neutral sensation into a painful one.

• Human brain mechanisms of pain perception and regulation in health and disease: Review of Research, “The nociceptive system (pain sensing system) is now recognized as a sensory system in its own right.” Reviewers found that the brains of people experiencing acute pain were fundamentally different from those experiencing acute pain, in that chronic pain activates regions associated with emotions and cognitive function. Thus this component of pain might be a specifically distinctive attribute of chronic pain. They also conclude that an understanding of how the pain sensing system in the brain transmits information to the body – instead of a focus on information traveling the other way around – is crucial to understanding human perception of pain and suffering.