So chronic pain affects millions of people and for so many it just won't go away, no matter how many scans or treatments, meds or procedures they try.
Well, what if the pain is real but the source wasn't where you've been looking, or maybe where a lot of people who are helping you out have been looking?
Today's guest, Dr Yoni Ashar.
He's a neuroscientist and clinical psychologist who studies how the brain learns pain and how it can unlearn it.
What actually helps the brain feel safe again?
And we talk about why imaging findings can make pain worse or even be totally unrelated to pain, even when they're being pointed to as the source of it.
How a powerful protocol called pain reprocessing therapy is changing the game.
And what decades of pain research are revealing about real recovery.
If you or someone you love lives with ongoing pain, this may change how you see it and what's possible.
So excited to share this conversation with you.
I'm Jonathan Fields, and this is Good Life Project.
You know, I'm excited to talk to you.
I feel like the topic of chronic pain is something that it affects so many people.
It's so poorly understood.
And we're in a moment where I feel like there's so much contributing to a mass level of suffering that maybe doesn't have to happen on at all if, or on the same level.
And you have been studying pain, specifically chronic pain, enduring pain, and we'll tease out what that actually means.
This isn't just a professional pursuit for you, though.
This has a very deeply personal origin, too.
Take me into that.
Yeah, that's right.
And I don't always talk about the personal side of it because I'm a scientist and supposed to be objective, but we're also people that have these issues as well.
By my count, I've had three chronic pain syndromes over the course of my life, actually.
The most recent one was a chronic back pain that was around for most of my 20s.
I would say it was relatively mild to moderate, never too severe.
I was never thinking about surgery or any kind of more drastic treatments.
But my wife would tell you that every day I'd come home from the lab and kind of get on this foam roller and try to stretch out my back.
And it was pretty persistent and present throughout my whole life.
So the main thing was I was having pain when I was standing still.
And I could run for miles or I could go to the gym and everything was fine.
But I was just having pain when I was standing still.
And I realized at some point that it did not make any sense that my back was injured or broken.
I had one moment where we were on a backpacking trip with some friends in the Rockies and I was hiking for miles and my back felt great.
And then we got to the summit and I stood still and my back started hurting.
And it was just like an aha moment.
Like this makes no sense.
Like how could it possibly be that you can hike for the heavy pack for miles and have no pain?
And so I realized there was something that my brain had learned to associate with standing still with back pain.
And I went on a meditation retreat to just kind of take this on and try to unlearn this connection my brain had made.
And you know how in meditation retreats, most people are sitting for the duration of the retreat.
So I was in the back of the meditation hall and I stood the whole retreat.
And I was like, I'm just going to do the thing I'm most afraid of and just stand.
And I was just watching everything, waves of fear and waves of pain and waves of anxiety, like you know, rising.
Like you know, my mind was shouting at me like sit down, bend over stretch.
And I was like, no, I'm just going to be with the fear.
I'm going to be with the pain.
Just let it rise and let it fall.
Just kind of meditating with it.
And, you know, at the end of three days, My back did not hurt any more than it did at the day one.
And so I kind of had proof that standing wasn't bad for me.
And then in the weeks that followed the whole thing just kind of unraveled and my pain basically disappeared.
And at the time, I did not understand what happened.
I was completely like... gosh, that's like really interesting.
Or I had only like a very faint understanding, is it's only you know?
Now that I've been studying this for 10 years, or more than 10 years, I can look back and see how this all actually makes good scientific sense.
Yeah.
I mean, what you're describing is not unusual.
You know, like so many people, they're able to go about a lot of different parts of their lives.
And there's a particular either position or an experience or, you know, a situation that they're in where all of a sudden, they're just riddled by pain.
And you know, it feels like, on the one hand yeah, and there are all sorts of things that we can take, that we can consume.
That will dull it for a minute of time.
But It comes back.
If we zoom the lens out here, I want to understand sort of like the state of chronic pain also.
And I know this is something that you'll we zoom the lens out and how bad is the chronic pain crisis really?
And what, you know, when we look sort of like society-wide, what are we seeing?
What's going on?
Chronic pain is the number one leading cause of disability in America and among the top three worldwide cases, meaning it's the main reason that people are not able to perform at their full function, either in their family or in their professional or social roles.
Estimates are about 50 million Americans have some chronic pain condition.
The economic impact of chronic pain due to tremendous medical imaging and procedures and days lost at work is more than heart disease and diabetes combined.
Mm-hmm.
So it is really tremendous.
And what's more Jonathan, is that if we look historically, go back a few decades, we see that the chronic pain problem is getting worse and worse.
So rates of chronic pain are going up and up over time.
On an individual level.
When somebody is living with chronic pain, what do you see on a regular basis as how it affects their lives?
It can put tremendous strain on marriages.
I know multiple people who say they nearly divorced or divorced due to their chronic pain, the stress that was causing their.
They're irritable all the time, they can't be the partner or the parent they want to be.
There's people who have to leave their jobs because they can't perform, because the pain is disabling.
It can also drive people to use alcohol or other drugs to try to manage the pain, and that creates its own set of problems.
Opioid addiction.
Chronic pain is One of the major drivers of the opioid epidemic which has taken so many lives.
It's a really vast and painful impact that it's had.
So what has been the approach?
When somebody shows up for treatment at a doctor's office or whoever their healthcare professional is, and they've been dealing with this thing, what's sort of like the typical range of approaches that have been taken over the last handful of decades, I guess.
The predominant approach in our healthcare system is what we could call biomedical.
So the understanding or the belief, the assumption is that if you have chronic back pain, well there must be something wrong with your back.
If you have chronic shoulder pain, there must be something wrong with your shoulder.
So the journey often starts with imaging.
Let's get an x-ray.
Let's get an MRI.
There's medications, there's surgeries, there's procedures.
If you go to a physical therapist, many will say oh, it's because your abs are too tight or your, you know, this other muscle is too weak.
So it's really focused on trying to find the problem somewhere below the neck.
And that's you know.
Often people are just bouncing from treatment to treatment, provider to provider and not getting relief because this approach has largely been ineffective.
So the problem is that if you do an imaging study, it's really likely you're going to find something.
So the majority of adults have degeneration in their spine.
The majority of shoulders are going to have some kind of tear in a ligament or a tendon.
And so when you do the imaging findings, you're going to find these things.
And then the next step is the real problematic one.
Then the provider or the patient will often say ah, that thing we're seeing in imaging, that's the cause of the pain.
And that's really the problematic step, because those kinds of findings, like degenerating discs and labral tears and et cetera, are highly prevalent in people who have no pain whatsoever.
Often they're incidental findings.
They just happen to be there.
They're not the cause of pain.
You might have had them for 20 years and your pain just started last year.
And so they can be very confusing.
And more than that, they can be very scary.
People say, oh my gosh, my spine is degenerating.
This is like every day is going to be worse and worse.
And they can initiate this whole cycle of fear over something that's actually a normal finding.
Having disc degeneration is normal.
If you're an adult and you don't have any dysdegeneration, that's unusual.
It's just wear and tear.
My colleague Howard Schubiner likes to describe these as gray hair and wrinkles on the inside.
Gray hair and wrinkles, those aren't painful.
They're just part of natural aging.
Same thing with all these findings.
They're typically not the cause of pain.
I mean, it's so interesting, right?
Because we like to be able to point at something and say like this.
Yes.
And I would imagine, because psychologically it's just like there's almost like a relief that says oh, like I can see, this is the source.
Now, if we just focus on the source, identify this then – and we fix whatever it is the tear, the – that then like the thing will go away and it's almost like it's a relief, like now.
I actually know what this is coming from, but i know i don't remember.
I know you're going to know the statistic a lot better than i, but you know the incidence of failed back surgery, from what i remember looking at the literature, is astonishingly high.
Where you look at, you see imaging clear as day There's compression, there's a bulge, there's herniation, whatever it may be.
You try conservative treatment, physical therapy, the different things, not getting relief.
That ends to a decision to go into surgery.
You have the surgery.
The surgery is considered quote successful, and yet the pain remains for a remarkably high number of people, if I remember correctly.
Yeah.
Yeah, it's right.
And there's been these recent studies examining all these surgeries and procedures, especially for back pain.
And when I first learned about these studies, it just blew my mind.
So to know whether these surgeries were effective, they decided to compare them in a randomized trial to fake surgeries.
So what's a fake surgery is that they put someone under anesthesia.
They just make a superficial incision on the skin, they sew the person right back up and they say great, you got it.
Let us know how you feel.
And when they compare people who got the real surgery to the illusion of surgery, they find no differences in outcomes, meaning both groups are getting better.
And this has been shown for a number.
There was just a meta-analysis published in the British Medical Journal, a prestigious medical journal, comparing 13 different surgeries and procedures for spinal pain.
And it concluded that there is no evidence that any of those 13 common procedures are better than sham, than fake versions of those procedures.
And these are happening in you know, millions annually, these surgeries.
And, you know, people might be listening and saying, well, I had that surgery and I felt better.
And yes, you did, because the brain's really powerful, because the placebo effect is real and strong and helps people feel better.
But the effect of the surgery is not due to the decompression or the fixing of the tear.
It's due to the belief that you're fixed, the feeling of being cared for.
That's a tough pill, I think, for a lot of people to swallow.
It is.
You're telling me that my brain is just causing this thing.
It's a tough pill in a lot of ways.
On the one hand, it's like we don't love the label.
I don't think anyone uses the term psychosomatic anymore because it became like this pejorative.
You're labeled, oh, that's psychosomatic.
You're, quote, making it up.
This doesn't exist.
You're making the pain and you're making the pain worse.
And, on the other hand, there's a certain amount of.
If this is true, does that mean that I'm complicit in it?
Is there shame attached to this?
There are a lot of layers here.
Yeah, there really are.
So the pain is real.
The pain is always real.
And this idea that people are making it up or exaggerating is based on a fundamental misunderstanding of what pain actually is.
We intuitively think of pain as an input to our mind, to our brain, like the body is sending pain signals to the brain.
But that's really not how pain works.
Pain is an output, not an input, meaning that the brain creates pain based on its understanding of the situation that the person is in, combined with input from the body.
But pain signals don't really reach the brain.
It's just input from the body and the brain has to make sense of them and interpret them to create pain.
And so no one is ever, you know, making it up or exaggerating it.
Except for my kids when they want to miss school.
Besides them.
Who will later admit that they were making it up.
But in the real situations, pain is real.
And one of the terms we're using is neuroplastic.
And Jonathan, you talked about people feeling shame or such.
And it's really... I'd like people to understand that...
If you have neuroplastic pain, it's because your brain is smart.
It's because your brain is doing what it's supposed to do.
Our brain's job is to try to protect us and keep us safe from threats.
And sometimes it does that job almost too well of trying to keep us safe.
And that pain is here to keep us safe.
So the brain is learning and it's smart. trying to keep us safe.
And it can try to.
Sometimes it's doing that job a bit too well and creating pain even when it doesn't need to, because the level of threat we perceive is not the actual level of threat.
So then in an acute situation, you break a leg or, you know, like you sprain an ankle.
There's inflammation.
If I understand this right, there's circuitry that basically, from that point of acute injury you're getting signals that are being sent up through the nervous system into the brain saying injury.
And then your brain then takes that and interprets it in a way where it says injury equals pain.
So I'm going to create the experience of pain.
But actually, the pain part of it is generated in the brain.
Yeah, that's right.
So that's the typical situation.
But let's say you're a soldier in a battlefield and there's an injury and your brain might say not a good time for pain.
And it just turns that pain off.
And that's why soldiers will come home and find bullets in their body and have no memory of getting shot.
There's reports of people having their legs bitten off in shark attacks and they describe it as kind of a dull thud, but not really painful.
So the brain, even in acute dramatic situations, the brain rules about whether there's pain or not.
Yeah.
So it's not obvious what the response is going to be.
It's almost like what's the highest likelihood option here to keep the person safe or moving towards safety.
And that's the experience of pain, either non or extreme that I'm going to create.
Exactly.
And we'll be right back after a word from our sponsors.
So when we move into the world of chronic pain, then maybe you did have an injury or an illness and there was this immediate, acute thing and it was a good and rational response for the brain.
It lets you seek help and care and treatment.
And that thing is now resolved.
Or maybe you had COVID and now, like two years later, and there was a lot of pain during the original thing and your body needed to repair and recover and, like you, kick in the immune system.
And years later, you're still feeling what a lot of people describe as long COVID and there's pain associated.
I'm curious about this distinction between an important and necessary reaction to help take care of whatever healing needs to happen in an acute phase, and then chronic pain.
Or maybe there was never an acute phase.
Maybe people experience these quote syndromes which get diagnosed not because you can actually test something and see it, but it's a collection of symptoms.
Fibromyalgia, I think, still falls under that.
Ehlers-Danlos syndrome falls under that.
They're sort of like a category of things where it's just chronic, often migrating, varying levels of pain.
What's going on there?
Yeah, you just brought up a lot of really good, really rich material to talk about.
This is spot on.
So first, the transition from acute to chronic pain is really important to understand.
Very often not always, but very often chronic pain will start with some kind of injury, or Sometimes we can't even remember what it is, though
And then over time, just like you said, the injury will heal.
And that is the typical course.
Typically injuries heal within days to weeks to months, depending on the nature of the injury.
It's rarely longer than that.
But often...
Pain persists for years or even decades.
What's happening there is that the underlying mechanisms of what's causing the pain are shifting.
In the post-injury phase, the pain is what we would call bottom-up.
It's driven mostly by signals coming in from the body that the brain is accurately interpreting as injury.
But as time passes the pain becomes top down, meaning the pain is now being driven mostly by signals from the brain going down to the body.
That's causing the pain to persist afterwards.
So there's a learning process that happens.
Basically, the brain has learned the pain, and There's this amazing study from about 10 years ago where they took people who had recently injured their backs and put them in the brain scanner.
And they found that brain activity after the injury that was related to the pain was in areas like the insula and the thalamus and somatomotor cortex.
And basically exactly what you'd expect, like typical pain processing areas.
But when they brought the same people back in a year later for those who still had back pain a year later, the pain had shifted to a different set of brain regions.
It was now associated with the medial prefrontal cortex and the amygdala.
And these are brain regions that are related to emotion learning memory, narratives.
We could call them meaning-making brain regions.
Us in the field, we're looking at these results and we're saying, what the heck?
What's the pain doing up in the medial prefrontal cortex?
It doesn't belong there.
That's like a storytelling emotion region.
That's not a pain processing region.
And the study was amazing because we caught on camera this transition from acute to chronic, as the pain shifting to different brain regions.
And then you know, once it's reached that phase, the pain can live on loop in these brain regions relatively independent of what's happening in the body.
So it starts in one way and then it literally shifts into a different part of the brain.
And that part of the brain it sounds like what you're describing is.
It just keeps cycling it and like looping through and looping through and looping through, unless and until at some point, something breaks the cycle.
Exactly.
Yes.
It's a bit I think of, like PTSD, like someone is in a really unsafe environment and they learn an appropriate threat response to that environment because that environment's really unsafe.
Then time passes, they're now in a new context.
They're now safe, but their brain still feels and perceives threat like it used to be.
And what we have to do is help the brain update and learn that the threat has now resolved.
The body is now safe.
Yeah.
And so when it transitions into that second phase, the different parts of the brain is that where you describe that pain as more of the neuroplastic pain.
Yes.
So that's the term we use.
It's neuroplastic.
The pain is caused by plasticity in the nervous system.
These changes in the nervous system are causing the pain.
And that pain is just as real and just as miserable as any other kind of pain.
So now I'm going to return to I guess it was.
I gave you a very long run on question to lead to this but maybe the second part here, which is, you know, for people who are experiencing chronic pain that is often diagnosed as one of these sort of like just an ongoing syndrome fibromyalgia EDS, long COVID, like there are probably a whole bunch of others.
Is this a similar process where you can't identify an initial acute phase of something?
All of a sudden, you start feeling these things in your body that persist and persist and persist.
Yeah, it is the same.
Those are neuroplastic pain conditions.
And a lot of the most common chronic pain conditions like chronic headaches, chronic migraines fibromyalgia, chronic pelvic pain, chronic back pain and more.
These are predominantly neuroplastic in most cases.
We believe they're driven predominantly, primarily by changes in the brain.
Not by an injury in the body is the main cause.
And in those cases, I would imagine we may have no conscious awareness of what may have led to those changes in the brain.
That's right.
No, it's beyond, we're not so aware of it.
I mean the one other piece here that's really important to bring in.
That people are sometimes more aware of is stress and emotion.
People will look back and say, like gosh, this pain started during my divorce or during a really tough time in my marriage.
And through pathways that we're still unpacking and unraveling.
We know that these kind of like really difficult emotions and highly stressful periods can create conditions that are ripe for chronic pain and can cause chronic pain to continue as well.
Right.
So I guess if we determine that pain that we're experiencing is neuroplastic, it's kind of a good news, bad news situation, right?
Bad news is we still have it.
It's real.
It's there.
And I want to keep reinforcing this.
We're not saying it's not real.
You are feeling it.
You are experiencing it, and it can be brutal.
The good news is, if it's being caused by this almost like misfiring loop in a different part of the brain, well then, maybe there's something we can do about it.
And that's where a lot of your focus has been.
But before we get to some of the what we can do about it and the protocols that you've explored, I am curious if somebody is joining us now and they've been experiencing some version of what we're talking about and they want to know like.
Is this neuroplastic pain that I'm experiencing?
Are there a set of questions they can ask themselves or things to look for that might help them tease us out?
Yeah, that's great.
And this whole treatment approach, or this whole approach that we're studying, really begins with identifying whether a person has neuroplastic pain or whether their pain has a substantial neuroplastic component.
And that's very important to figure that out and see if this is the right approach.
So there's some telltale signs that we look for.
If pain is tends to move around the body, like sometimes it's on the left, sometimes it's on the right, that's an indicator that's neuroplastic injuries don't move.
If pain tends to fluctuate substantially from one day to the next, like good days are uh, you know bad days are seven out of ten and good days are two out of ten, that's not really consistent with an injury.
You know, if you have a broken foot, every time you step on it, it's going to hurt pretty similarly.
It's not going to be a one day and a seven the next day.
If you look back at your life and realize that wow, there was a lot going on in my life when this pain started, you know that's another indicator as well.
If there's a number of different chronic pain conditions that you either have right now or have had historically, Like oh, I had some stomach stuff when I was a teenager, back pain in my 20s and then headaches in my 30s.
These kind of multiple conditions make it really increasingly likely that they're neuroplastic.
Because what are the chances that you have a stomach problem and then a back injury and then some kind of head injury?
It's much more plausible and likely that your brain's really good at learning about symptoms and amplifying them.
That there's one explanation which is in the brain about how the brain's interpreting input from the body and how it's amplifying input from the body.
So those are just some of the things we look for.
Yeah.
And you also.
It sounds like we're careful to use the phrase like this helps determine whether the pain is neuroplastic or, like part of the pain is neuroplastic, whether it's contributing to it.
Yeah, that's right.
And you know, sometimes it's not completely clear from the get-go whether it's fully neuroplastic or mostly neuroplastic.
But that can become clear if you try treating it as neuroplastic pain and see how it responds.
Then that can also be clarifying.
Yeah.
And some people start, you know, thinking a part of it is neuroplastic.
And then later on they look back and they're like all right, I can now see it was fully neuroplastic, even if that's kind of hard to wrap your mind around at the beginning.
Yeah.
So let's talk about that treatment a bit.
There's a whole protocol pain reprocessing therapy that you've been deeply involved in developing, along with Alan Gordon and some others.
Walk me into what this is.
What is pain reprocessing therapy and what's the fundamental approach here?
So the fundamental approach is helping people unlearn pain that's been learned by the brain.
And it's really centers on the pain threat cycle.
So pain is an opinion.
I know that's kind of strong say, but it's our brain's opinion or perception of threat.
And our brain will create pain when it feels threatened or when it perceives threat.
And conversely, when it feels safe, it won't create pain, because the function of pain is to protect us.
And so if there's a need for protection, it'll create pain.
If there's no need for protection, then there's no need to create pain.
And so PRT, pain reprocessing therapy, is really trying to target this pain-threat loop.
And the problem is so.
The brain perceives threat, it creates pain, but now you're in pain, so that's going to amplify the perception of threat and it's going to cycle.
Pain creates a sense of threat, a sense of threat creates pain, and it cycles.
So basically it's like a doom spiral.
A doom spiral, exactly.
Yeah.
Yeah.
And we're trying to intervene.
And the main, the way you break the pain threat cycle is by bringing in safety.
That's what neutral, that's the antidote to threat is safety.
And so, and there's a few ways we try to do that.
Before you get to those ways also.
I just want to tease out the word threat a little bit, because there may be a tendency to hear the word threat and think, oh well, this is a perception or something from the outside that's causing a threat to me.
But I sense you have a different way of looking at it.
Yeah, thanks for helping me clarify that.
What we mean is that there's something about the sensations that you really don't like and wish they weren't there.
They're a threat in some way.
Maybe they're annoying, maybe you're afraid of them, maybe you're really frustrated with it because you've had it forever, maybe this, the pain, means to you that you'll never be able to walk again on the beach uh, into the sunset, and you know all these ways that pain is a threat, it threatens your future, it threatens um, what you think, you know what you can do, and and just like you want it to go away, and then that makes it a threat too.
So these are all aspects of in other language you could say resistance, that you're resisting it, you're opposed to it, you dislike it, you're averse to it.
In all those ways, it's really relating to it as a threat.
So, if I remember back to Sarno's original work, which I think started introducing a lot of people to this notion of pain may not be what we think it is.
The thing that he focused on more than anything else was and tell me if I'm getting this right if I remember correctly, this was a long time ago was rage repressed rage.
Would that qualify in some way, shape or form as under the category of threat for you?
Yes.
So that's a slightly different understanding and complementary understanding, where other things going on in our life can create a general sense of threat.
So if we have an emotion that we think we should not be feeling like let's say, I grew up in a home or a culture where I was not allowed to be angry you shouldn't be angry.
But hey, someone just really crossed me and I am angry, but now I've got a problem because I am angry, but I shouldn't be angry.
So there's a threat happening inside.
Or I have a lot of shame or sadness, but I'm not okay with feeling sad or feeling ashamed.
And so now there's a threat happening inside.
And that sense of threat, you know, things are not okay.
There's things happening inside me that are a problem, are threatening my idea of who I am and my relationships.
So that's going to drive pain as well.
Yeah, no, that makes a lot of sense.
Okay, so then you were about to share a bit more about PRT.
So is it possible in this conversation to sort of walk through the basic steps of what this protocol is about?
I think so, yeah.
Maybe not the steps, but like the main principles.
Yeah, that'd be great.
I'm thinking about it recently as like three main domains that we would work in.
So in the cognitive domain, we try to help people feel safe by mainly by thinking differently about their, by understanding their pain through a new lens.
And so if you know someone who has back pain, they may be used to being like Oh, like it's degenerative disc disease.
This is really scary.
My back is feeling the best it's ever going to feel because it's degenerating every day.
So changing that narrative around the pain to a narrative of this is neuroplastic and It's real.
My brain has learned this.
There's really no injury in my back.
So there's nothing to be afraid of.
It's a false alarm.
The alarm is really going off, but there's really not a threat to my back.
So trying to kind of even rehearsing these thoughts and just saying there's like my body is not injured.
My brain has learned this pain.
So that kind of cognitive aspect can create a lot of safety for people who are, or someone who like, has been very confused about their pain.
Understandably, it doesn't know what the cause is.
They're like, oh, my gosh, is it happening again?
Another headache.
Why is this happening?
I've seen three doctors.
They don't have an answer.
So you can hear there's a lot of threat and fear and worry in that narrative.
So shifting to a narrative where there's a lot more safety of like.
This is neuroplastic.
I'm not in any danger.
In the behavioral domain, it's really helpful to start re-engaging in activities that have been feared and avoided.
So someone who maybe they hurt their back playing tennis and now they're not playing tennis anymore.
Well, let's slowly, very gradually, very slowly start to play tennis again.
It could start with just like stand in your living room, hold a tennis racket and just do some practice swings, and do that every day for a week.
And then the week after that, You know, just go out by yourself and just hit some balls against the wall.
And then a week after that, maybe just a rally or, you know, with a friend.
And then, you know, gradually getting back into it.
Or someone who hasn't been walking because of their pain.
Start walking.
Start 15 minutes a day.
So this kind of reengaging in these spirit activities has many, many benefits.
One of them is it's one of the most compelling ways to prove to your brain that your body is safe and strong and healthy.
Like your brain just like starts to see like, oh, I can do this stuff.
And so your brain starts to realize that the body is safe and strong and healthy.
And so it doesn't need to protect as much.
It's kind of like exposure therapy.
It's exposure therapy.
That's exactly what it is.
Right.
Let me ask sort of like a wrinkle here.
Let's say somebody's doing this and they're like, oh, like I'm just swinging a racket.
It feels kind of good.
And then they're swinging a little bit more and then they go to their local high school and they're just hitting balls against the wall, really gently and not really moving around a whole lot.
Right.
And then they're like, oh, this feels really good.
I'm going to go do a game.
And then they go play a game you know like the next weekend with a friend and all of a sudden the back seizes up again.
Right.
Yeah, exactly.
It's a classic, classic story happens for many people.
And it's a classic challenge and exposure therapy for all kinds of conditions that you can have what we'd call like a setback.
So you got to go gradual, you got to go slow and not to get disheartened by setbacks.
If you have a setback. it's completely normal.
Just give yourself a few days, or you know a little more to recover and let the flare die down, and then just get right back on the horse and go back to it again, but maybe a little more slowly.
But there's, you know, symptoms will flare.
You know, you might have a flare, but don't let that scare you.
Don't let that make you think this treatment isn't working.
It's kind of part of the approach.
You know, it takes a bit of trust, a bit of faith to be like, even though yeah, my back seized up, there's still nothing wrong with my back.
In a situation like that, do you have an understanding of what would cause the body to then say I'm going to set you down temporarily again?
Yeah, there's a brain-body feedback loop.
So neuroplastic pain is kind of pain.
We're talking a lot about the brain, but the brain is in the body.
And there's a lot of communication between the brain and the body in both directions.
And so I think almost everyone's experienced like when you feel stressed, your shoulders get knots.
At least I do.
And so what's happening?
There doesn't yeah, the knot really is in your shoulder muscle, but it's driven by your brain telling your shoulder to clench and to tense, because your brain isn't, you know, perceiving stress and threat, so it's creating that.
So likewise, if your brain's really worried about your back, it can tell your back muscles to clench and to seize up as well, and that can happen.
And once they clench and seize, it can be harder for them to unclench and see it might take a few days, even if it is neuroplastic.
So So neuroplastic pain is not, it's not all in your head in the sense of you're making it up, and it's not all in your brain.
There can be changes in your body as well, but those are driven by the brain sending signals down to the body.
Yeah, I mean, that's, I think, so helpful to understand.
So it's like okay.
So if your back does spasm, you literally feel the muscles in your back just contract sharply and lock you down.
That's real.
There's a physiological response happening.
But whereas your initial thought might be well, there's a compression happening here or something else going on.
What you're saying is there may be another explanation, which is that your brain for some reason has perceived threat again and sent a signal to those muscles to say lock it down, not safe.
So just understanding that going into it and maybe even expecting at some point along the way.
Some version of this is probably going to happen.
Maybe helps us, if and when it does happen, move through it with more understanding.
Does that make sense?
100%.
Completely agree.
Yeah.
Yeah.
And we'll be right back after a word from our sponsors.
Those are the first two phases.
I think there was a third one.
Yeah.
So the third one is the realm of emotions and you could say spirituality, purpose, meaning.
And that's where the pain might be pointing us to something deeper going on in our life, where we've mostly been talking about pain up until now as kind of like false alarm.
The brain's learned it kind of like a misfiring of the nervous system.
And that's true.
And that can often, it's often the case.
There's another, almost another kind of neuroplastic pain, where the pain is, instead of it being a false alarm, It's a life message alarm.
The pain's coming to wake you up and tell you like there's something going on in your life that you really need to pay attention to.
And often it's a relationship.
It could be a sense of something in the spiritual realm or meaning related and purpose.
And to resolve the pain.
You want to address that deeper, that relationship problem or whatever it is.
And doing so is going to really let your system feel safe again and let the pain down.
And so that's this.
Third domain that PRT works in is how do we help someone feel globally more safe?
What else is happening in their life?
And how do we help them align that with their meaning and purpose and values?
So now we're talking about often bigger life issues, right?
And I would imagine also this might be something that people would look at.
And if you suggest that, well, this needs to be on the table if you're still experiencing pain.
Let's look at your relationships.
Let's look at your work.
Let's look at different aspects of your life.
You're going to get a lot of resistance.
Because somebody may have that voice deep down that says look, this has been really off for a long time.
And I've been, quote, okay, just keeping on, keeping on.
And if I actually really do address this, it may substantially blow up central relationships in my life, the work that I'm doing, things like that.
And I don't know if I want to endure that level of disruption anymore.
But not realizing that by continually saying yes to whatever is off, they're basically feeding the pain to continue to sustain.
Is that right?
That's right.
People might have to make a choice.
Is it worth rocking the boat to relieve the pain?
Or am I just going to keep getting headaches every time?
I see this relative.
Or am I going to keep having back pain every day at the office because I just don't want to rock the boat?
My heartfelt wish for people listening would be that, when the time is right, they have the courage to try to align those things in their life.
But there's always risks in doing that.
And I think it's also probably important to note at this point that we don't want to judge people for the choices that they make, even if they realize okay, this pain very likely is neuroplastic.
I'm actually starting to be able to see a likely source of this and I'm making a choice to stay where I am, to basically endure this, because
In my mind, the fallout from the level of disruption would be more painful to me than what I'm enduring now.
I think everyone probably needs to land at their own decision in moments like that.
I feel like we have a tendency from the outside looking in saying, how can you do that?
How can you keep once you know, how can you sustain that?
And everyone has different life circumstance.
Everyone has different history.
Everyone has different values.
And do you see sort of like judgment layering in at this moment?
So one of the risks that I worry about sometimes with this work is that we could judge someone like oh, they have neuroplastic pain.
Why don't they get over it?
Why don't they fix it?
Why don't they like do the deep work they need to?
And then, you know, it's just more complicated than that.
And it's not that simple.
And everyone's got their own journey.
And I would never hold it against someone for, you know, the demons that they're wrestling with.
So just try to offer compassion and support to people.
Yeah, that makes sense.
You were part of a group that investigated this methodology pain reprocessing therapy and the outcome was kind of astonishing.
Yeah.
Yeah, so we ran a randomized controlled trial 150 people with chronic back pain and a third of them got PRT.
It was nine sessions.
Treatment followed the principles that we just outlined about twice a week helping people think more safety and act in ways to help their brain function.
See, you know exposure therapy, see that the brain is out of the body, is intact and healthy, and this emotional work as well.
And then another group was that there was a placebo arm and the usual care arm.
And what we found was large and lasting reductions in the PRT group relative to the other groups.
So people started around four out of 10.
In the control groups, they went down to about a three out of 10.
And in the PRT group, they went down to about a one out of 10.
So really large reductions.
We recently completed a five-year follow-up study and we found that people's pain was still low.
So this is like a one-month treatment and for five years later at least five years they're still reporting large reductions in pain.
We had brain imaging before and after treatment and we saw changes in their brains, particularly in the anterior cingulate and interior insula that correspond to less of a threat response to sensations from the back, supporting our model of how we think this works.
And we saw that what really explained when we looked at the data, like explain, like what explained these pain reductions?
It was reductions in fear of pain and reductions in avoiding activities.
Hmm.
So I want to make sure I'm wrapping my head around this.
You basically, you have 150 people who show up who've been experiencing chronic back pain.
Was there an average duration that somebody had been experiencing pain?
10 years.
So this is not a new thing for these people.
They've been on average, you have 150 people have been experiencing back pain for a decade.
And if that's the average, some are going to be a lot longer than that, I'm guessing also.
You divide them up.
Some people get the control, which is, well, I guess the control would be nothing, right?
In this first study, it was a placebo control.
Okay, so they think they're getting some sort of treatment.
Right.
And they have a mild reduction in pain which is kind of consistent with placebo-based results in almost all experiments, right?
Yes.
And then you actually do the PRT right, the pain reprocessing therapy, with another third or so of these people.
And they experienced pretty huge reductions in pain, like down to a one out of 10.
On average.
And so two thirds of people in the PRT arm reported a zero or one of 10 after treatment.
So it was really dramatic.
Right.
And then, five years later on follow up, was the pain still at around a zero to one, or had it like slowly crept up?
It's crept up a bit.
I think it was around like one and a half on average.
Okay.
So that's not a lot.
That's still pretty low.
Yeah.
Right.
And probably substantially below what they had been experiencing before they showed up for the initial trial five years earlier.
Yes.
And then you look at brains and you notice you can literally see this reduction, while actually watching the brains to back it up.
Yeah, yeah.
We had people in the scanner and we basically inflated this kind of pillow under their back that causes this painful extension of the back.
And so we did this kind of back pain challenge during brain imaging before and after treatment.
And what we saw was that people in the PRT group, relative to control's, had less of a response in the interior insula and cingulate to this back pain challenge.
And those are brain regions that do many things, but one of the things they do is respond to threats.
So seeing less activity there is consistent with this model of less of a threat response to a back pain challenge.
Right.
So how do those outcomes compare to other, more common or typical approaches to trying to treat the same kind of pain?
So they really seemed a lot better and had a lot of typical approaches.
But it's always a bit of a challenge to compare across studies because you could say well, you know, the ideal thing is to line up two treatments and compare them head to head in the randomized trial.
And so we actually just finished... a second study where we did that.
And so in this study people were randomized to either PRT or to another treatment called cognitive behavioral therapy.
And the results aren't published yet so I can't share too many details.
But our findings this is another 150 people with chronic back pain and the findings basically the same as the first study really support our findings.
And now we have a direct comparison to a current leading treatment and seeing that PRT leads to large reductions, substantially larger than other current leading treatments, which is pretty incredible, also because you know if you zoom the lens out here, right.
And you sort of say okay, so what is the cost to an individual or to a system, a health system, you know of somebody doing PRT?
It's pretty minimal.
And it's also not something that well.
I'm going to have to keep taking something or paying for something for life.
Like this is, it almost sounds too good to be true, right?
The reason that this seems to be working so well is because it's the fundamentally different model.
PRT is saying that the causes of pain are in the brain and therefore the solutions are there as well.
And most or all other treatments really don't have that starting place.
And so I think for me that helps explain why we're getting such good results, because it is such a different treatment in many ways than what other people have tried.
So it's quite new in that sense.
I mean, it's so exciting to see.
I'm excited to see the new study when it comes out also, but thanks for the sneak peek.
For somebody who's joining us right now, who is in chronic pain and maybe really curious about this.
What are a few concrete steps that they might take, starting today, even that would be sort of like rooted in your research or starting them in exploring this approach?
Yeah, there's a nonprofit that's put together some great resources.
The website is symptomatic.me.
We should also say a lot of what we're.
We may not have time to fully unpack this, but a lot of what we're talking about for pain is also applicable to other symptoms like nausea dizziness, tinnitus and such.
These kind of chronic symptoms, unexplained somatic sensory symptoms.
So so this website symptomaticme, has a great collection of resources from a non-profit and as a starting point, it would be starting to like just ask yourself the question what if part of my pain is neuroplastic, and what would that mean?
And that that question is a is a.
You know, what if my pain is not as threatening as i've been thinking it is?
And slowly starting to like think of something you haven't done for a while or you're kind of avoiding doing and that's not too scary, and start doing it and see, you know, see what you learn, kind of self-guided exposure therapy.
I mean it's interesting also that you were sharing that.
We're talking largely about the circuitry around pain here, but there may be a wide range of other symptoms of varying levels of intensity, or discomfort or concern, that the same underlying mechanism sort of like your brain creating a loop and then spinning it to sustain those symptoms.
Long after and sort of like an inciting injury or illness, or even if that never happened and that the same approach may be effective with those as well.
It kind of makes sense that it would extend beyond just pain.
Yeah.
All these symptoms are processed by neural pathways and neural pathways are plastic.
They can change and adapt and respond to their environments.
And now you mentioned long COVID earlier.
We really have a lot of good reasons to think that most cases of long COVID are this kind of symptom learning pathways that happen.
And, you know, we know that the brain can turn on inflammation in the body.
There's been a series of studies over the past couple of years have really traced the pathways, starting with the insula anterior to posterior insula, that can create.
You know, you stimulate those brain pathways and the body starts to mount an inflammatory response.
So the brain can create inflammation in the body if it thinks that there is an infection or if it thinks that it should be creating an inflammation, for whatever reason.
So So these brain-body feedback loops are powerful and can drive a range of physiological changes and a range of symptoms.
Yeah, and if the brain can create inflammation and we know inflammation is implicated in so many things in the body, including illness, disease risk it's fascinating to think about what the potential implications of the core approach here is across all systems and all the different things that we experience over time.
Can I share one amazing study published earlier this year?
They put people in a VR environment, virtual reality, and they had an avatar, someone who's like red in the face and the nose is dripping.
And in VR, the person comes really close to you and sneezes right on your face.
And what they found was an increased immune response in the body in response to this virtual infection.
Which is brilliant.
And it makes so much sense.
Your brain now thinks that there's some infectious agent coming in, so it should mount an immune response.
But there was no infection.
This was all virtual.
Nothing actually happened.
But if your brain's anticipating infection, if it thinks it needs to be anticipating infection, it will mount an immune response.
Yeah.
And while on the one hand, you think well, that's great, my body's managing an immune response, if it becomes an overly aggressive immune response and it becomes chronically elevated, then we have all of these symptoms that appear in the body.
Exactly.
Fascinating.
So interesting.
Thank you so much.
I really appreciate this very different lens.
And I think maybe also important to wrap up with one notion that if you're joining us and you're thinking, this sounds really interesting.
I'm very interested.
I want to explore this.
You're not saying avoid going to a doctor or a qualified healthcare provider in the first place to get checked out, to have whatever you need done in the early days done to make sure that they're.
I guess what I'm concerned about is people avoiding things where maybe there is something acute that does need to be addressed that they should actually go and talk to their healthcare provider about.
Yeah, so you want to do due diligence while staying reasonable and not spinning out into doing 10 different specialists and providers.
So kind of basic due diligence, by not going overboard with Current guidelines for multiple bodies.
Multiple medical bodies say not to do x-rays or MRIs for chronic back pain unless there's a red flag.
So due diligence for chronic back pain does not mean you have to get an MRI or an x-ray.
So if you're seeing a provider, really check with them, like, do I really need this?
Is this what the guidelines say that I should be getting these testing and these imaging?
So you just might want to confirm that with providers.
Got it.
Feels like a good place for us to come full circle.
So always wrapping with the same question, in this container of Good Life Project, the phrase to live a good life.
What comes up?
To live a good life is to be honest with yourself, with what you're feeling, and to embrace your own ability and agency to be an agent of healing in your own life.
Thank you.
Hey, before you go, next week we're sharing a really meaningful conversation with Harry Reid about why love doesn't always land, even when it's real.
Be sure to follow the show in your favorite listening app so it shows up for you.
Thank you so much for having me do me a personal favor.
A seven second favor share it with just one person.
I mean, if you want to share it with more, that's awesome too, but just one person even then invite them to talk with you about what you've both discovered, to reconnect and explore ideas that really matter, because that's how we all come alive together.
Until next time, I'm Jonathan Fields signing off for Good Life Project.
