Dr. Howard Schubiner and Dr. Jen Barna explore the need for a shift in thinking in order to effectively combat chronic pain.
Dr. Schubiner and Dr. Barna focus on breakthroughs in curing chronic pain including Pain Reprocessing Therapy (PRT) and Emotional Awareness and Expression Therapy (EAET), proven to effectively retrain the brain and reduce pain in the long term.
These treatments have been backed by randomized, controlled trials and can offer lasting relief in short amounts of time.
Let’s speak about the paradigm shift that’s happening in the field of chronic pain treatment because it affects us both personally and it affects so many of our patients, regardless of our specialty.
I think the paradigm needs to shift quickly because there’s so many people suffering, aren’t they?
It’s millions of people. It’s another epidemic. And it’s a chronic one that we’ve experienced for such a long time and affects so many of our patients and so many of us as professionals.
For sure. If you take back pain, neck pain, headaches, anxiety and depression and then other musculoskeletal pain, that comprises the vast majority of the disability - not the death, not the mortality - but the morbidity in the world.
With the types of pain treatments that you have been involved in creating and testing in large randomized controlled trials, can you tell us a little bit about pain and what we’ve learned in the past? Where people are recognizing that pain originates in the brain?
What I say to all my patients is you can’t understand pain unless you understand how the brain works. I was just talking to a physician the other day, who’s a spine surgeon, and he was telling me about some of his own pains that he had.
He had headaches when he started medical school. He had neck pain when he started his residency. He has shoulder pain when he started his fellowship. They couldn’t find anything wrong with him. And he said to me, ‘Dr. Schubiner, I wouldn’t have believed that this pain, these pains that I had were due to my brain if I hadn’t experienced it myself. I was not taught that in medical school. It never made a sense to me. It’s a complete paradigm shift.’
I think we have to understand not to underestimate the power of the brain to create and generate what we feel. And so when you touch a hot stove, it’s not your finger causing pain.
Just that is a revolutionary concept because our brain works by predictive processing, which means that it generates our experience.
Our brain generates what we see. We don’t see with our eyes. We see with our visual cortex. We don’t hear with our ears. We hear with our auditory cortex and those parts of the brain have to be trained and all the impulses have to be processed within nanoseconds so that we can function in the world.
What we feel is produced by our brain and it turns out that we have this danger alarm mechanism in the brain. And it’s always there. We’re constantly on guard at the subconscious level for a bird flying or a car coming toward us or anything like that.
And this danger alarm mechanism has inputs from our body, but it also has inputs from our memory and what we’re thinking about all the time. So if somebody gets an injury, they may get pain, but they may not.
There’s millions of stories back to Henry Beecher back in World War II where all these military people were injured and had no pain at all. Then we have thousands of cases of people who have pain with no injury.
And that’s the part that messes doctors up because we try so hard to find a cause for the pain. That’s our job. You don’t want to miss anything. I mean, I feel that intensely with every patient I see - I don’t want to miss anything structural.
But on the other hand, most people with headaches don’t have a structural problem. That’s why they’re called primary headaches. Migraines, tension headaches that stick around you. There’s no disease there.
People with irritable bowel syndrome don’t have a disease in their bowel. People with fibromyalgia don’t have a disease in their muscles, and people with most pelvic pain syndromes - interstitial cystitis, so-called pelvic floor dysfunction - there’s no structural disease there.
And when it comes to back pain and neck pain, that’s where we really get messed up because everyone has an abnormal MRI. You’re a radiologist, right? You know,
Oh, my goodness. Yes.
The level of degenerative disc disease in the population rises to 90% in 60-year-olds, 80% in 50-year-olds, 40% in 40-year-olds who are healthy, who have no pain at all.
I mean, the other day, a friend of mine came up and he’s got pain all up and down his back from his lower cervical all the way down to the lumbar. There’s spinal pain when he stands, when he walks and his MRI shows foraminal narrowing at l5-S1.
So he sees a neurosurgeon and he says, ‘Yeah, we can fix that.’ Well, if you have disease due to foraminal narrowing, you’d have pain in your leg. He doesn’t have any leg pain. How does the surgery help his pain that goes all up and down his back?
Such an important question. And so often treated in a way that ultimately leads to worse pain for patients. Maybe there’s some pain that isn’t explainable by the MRI, but then the surgeon decides that they’ll try to treat it anyway because the pain is so severe that the patient is in such distress.
Exactly. It’s so frustrating for the patients. I just feel for everybody because the doctors are frustrated. They have chronic pain patients who are needy and then they get into arguments about what pain medicine they should be giving them.
So we did a study just recently with 220 people with chronic neck and back pain. To determine using the criteria that I and others have developed to help understand how to diagnose, how to assess what I would call a neural circuit condition as opposed to structural pain.
For example, when the pain is moving from one part of the back to the other, when the pain goes away, when you’re on vacation, when it hurts when he’s sitting in certain chairs, when it’s triggered by sound or triggered by stress, we have all these criteria, right?
And so you can rule out a structural problem by the MRI not showing a tumor, infection, fractures, severe neurologic compromise like a big disc that’s causing foot drop. You don’t have any of that.
The normal findings on MRI are degenerative disease and bulging disc, but everybody has those. I do. So you can look at the MRI and rule out a structural problem. And you can rule in a neural circuit or a neuroplastic problem, which is brain generated.
And we found that 88% of the people of the 220 had non-structural pain. 88%. That’s a huge number.
Absolutely. And with patients who have structural problems, such as arthritis or a single extruded disc where you can see that there is an impingement on a nerve, but the pain is out of proportion to what you would expect. Or in addition to what you would expect, or maybe there’s pain in other locations as well, perhaps it’s mirrored in the other limb. I’d love to hear about some of the groundbreaking results that you’ve been involved in with Alan Gordon and others.
So the process that we’re using basically is to explain to people that their pain is real, that they’re not crazy, that they’re not malingering, that they’re not faking it.
Psychogenic pain or a neural circuit or no, neuroplastic pain occurs because the brain is turning on pain. It doesn’t mean that the person is crazy or that they want it.
It means that they’ve been under stress, they’ve been under emotional situations and their brain is responding to this danger signal, to emotional danger in the same way that the brain would respond to physical danger and injury.
FMRI studies show that the brain responds in the same way to emotional stress as it does the physical stress. And when you’re talking to a lot of physicians, a lot of medical professionals, a lot of them have had back pain.
What if we thought a little bit about when the back pain started? Did we actually injure ourselves or was it a time when we were feeling trapped in our job or something was going wrong in our family life, finances, or whatever, That’s an amazing way to think of this
So we explain how the brain works. We do this assessment to rule out structural problems. And then we institute two forms of therapy. One is Pain Reprocessing Therapy (PRT) and the other is Emotional Awareness and Expression Therapy (EAET) that we use in the randomized control of the program, my other study.
So the Pain Reprocessing Therapy (PRT) model relies on the diagnosis of a neuroplastic problem and lowering the fear and the worry about it. It’s very, very simple, but it’s incredibly powerful because if there’s nothing actually structurally wrong, what’s happening is these neural circuits in the brain keep firing, firing and firing and creating this real and severe pain.
But there’s a feedback loop. And what happens when you’re in pain? You start fearing it, worrying about it, focusing on it, getting frustrated by it, fixating on it, trying to figure it out. And all those things send a feedback loop to the brain, which makes it worse.
And when you stop doing that and you start realizing that you’re not actually damaged and you start living your life and you start doing things a little by little. And when the pain comes, you just smile at it and you just keep going.
It sounds so silly. It’s so simple. But in this randomized controlled trial, 75% of the people who got this treatment for chronic back pain of 10 years duration were pain-free in one month.
With that study you mentioned functional MRI prior to the treatment and after the treatment. Can you tell us about the results of that?
The changes were similar in the functional MRIs of the brain in other studies which showed when people get out of pain, their brain changes.
It had mainly to do with the anterior insula in the brain. The pain is real. The pain is reversible. That’s the message. And the treatment is fairly simple.
The hard part is getting people to buy into it. Because when you say, ‘Oh, your pain is in your brain,’ what do people hear? ‘The pain is in my head. You’re saying, I’m crazy.’
That is so difficult because there’s so much stigma against pain being psychological. It’s not psychological. It’s real. It’s a neural circuit. It’s real because all pain originates in the brain, but not everybody can hear that. And not all doctors really can grasp that, frankly, because as physicians, we’re steeped in a model where there must be something wrong in the body when there’s pain.
When I first was exposed to Dr. John Sarno’s work about the concept of pain originating in the brain, that was exactly my reaction to it - that you’re saying that you’re imagining it. But that’s not at all what you’re saying. What you’re saying is that pain is the brain’s way of interpreting whether something is critical that you need to get away from or fix.
And when there’s no structural problem that is going to harm you, your brain just has that feedback loop on to constantly be reinterpreting or misinterpreting the signal as a warning that it needs to warn you that there’s something that you need to change.
Our brain has a smoke alarm in it that gets activated when you’re in physical danger, like if you get a cut,. But it also activates in the same way if you’re in an emotionally difficult situation.
Good doctrine can really help to explain this to people and help people figure out that they’re not as damaged and crippled and as broken as they think they are, and that there’s hope for recovery.
So it helps us as physicians to be able to know what to do with this large swath of people who have chronic symptoms, which include chronic fatigue and anxiety and depression, and insomnia.
Medications are great when they work, but we’re spending incredible amounts of money on invasive and sometimes risky procedures. You know, we could do better.
Even with such severe pain syndromes as complex regional pain syndrome. You can see somebody’s foot. It might be swollen, purple, red. And yet there’s no damage. This is an autonomic nervous system dysfunction, but what controls the autonomic nervous system? You’re brain.
When you do this therapy with patients is part of the therapy teaching people to calm their minds and to retrain their brains to interpret safety where they were previously misinterpreting danger?
Absolutely. When a kid falls off a bike, they look to you to see if they should cry or not. So there’s a natural tendency to freak out that the kid fell. But if you step back and you’re the parent, what do you want to teach that kid?
You want to teach the kid it’s okay to fall. So when the kid falls, you smile and say, ‘Oops, that was fun. You’re okay, buddy. Let’s do it again.’
And that’s what you’re doing to your brain because your brain is looking to you. You’re brain is giving you pain and you’re either freaking out or you’re going, ‘Oops, that’s silly. You know, I’m okay.’
A huge difference when a kid has a temper tantrum if you freak out and worry. But if you know there’s nothing, they don’t have something in their eye, the best thing to do is to ignore them, right?
But it’s hard to do because you’re the parent and you love them and you want them to be happy. But you have to step back, say, ‘Hey, I’ll just wait.’
And that’s what you have to do when you’re having pain or these other symptoms. If you can’t sleep, the harder you try to fix your sleeping problem, the worse it’s going to get. The harder you try to fall asleep, the worse it’s going to get.
You have to step back and say, ‘Yeah, I’ll fall asleep if I don’t fall asleep tonight. I’ll fall asleep tomorrow.’
It’s so simple. The other thing is you have to do it. And this sounds silly coming from an internist, but you have to do it with love.
It’s like we love our kids. So we let them cry out. We love our kids so we don’t freak out when they fall. And when the kid is lying in bed, fearful of a monster in the closet, we don’t give mad at him because we know they’re afraid.
And that’s what the brain is. The brain is basically operating under fear. So with kids we open the closet door and say, ‘Look, there’s no monster.’ And with our brain, we say, ‘Hey, there’s no damage. My back’s not broken. My stomach’s okay. And then we soothe and we calm. And we engage in our life.
Most people are going to get better. I tell patients that you’re going to have to realize it’s going to be way too simple. It’s going to be way too silly. And we’re going to laugh and have fun.
Like this doctor I was telling you about, fine surgeon, friend of mine. He’s having all these symptoms. And then when he realized that it was not his body and it was his brain, he just started living his life. And the pain just went away.
There’s another story you tell about a woman who actually was experiencing terrible pain. And when she understood this type of treatment, she wrote a letter to her brain.
There’s all sorts of techniques. What we’ve been talking about now is Pain Reprocessing Therapy (PRT). It’s changing your relationship to the pain.
If you’re having trouble walking more than two blocks, you start walking five steps without fear. And then you do 10 steps and then 20. That’s a kind of behavioral approach.
It’s based on the idea that you’re going to get better. You can get better. There’s nothing wrong with it.
But some people need a little bit more. Because it is well known that higher rates of migraine headaches, fibromyalgia, interstitial cystitis, irritable bowel, pelvic pain syndromes, back pain syndromes is much higher in people with childhood trauma.
And so some people have not only their pain, but they have tremendous anxiety and fear and histories of trauma. For those folks, we’ve designed other models that have to do with dealing with the emotions and dealing with the trauma.
Cognitive-based therapy and other therapies have been used prior to this to help people to deal with pain, whereas this helps people treat pain and make it go away. Can you explain what the differences are in the results between those two?
We think of it as a curing model versus a coping model. Cognitive Behavioral Therapy (CBT) works. It’s been studied in thousands of studies for all sorts of things. It works but it doesn’t work that much.
The average decrease in pain is about one half of one point on a 10-point Lickert pain scale. And it’s no better than acceptance and commitment therapy or mindfulness-based therapies.
These therapies are designed to help people cope better with the pain because they’re not designed to evaluate the cause of the pain and say, is it neuroplastic versus structural?
They’re designed to take pain and help you cope with it better, which is what they do, but they don’t do it that much.
And so our model is distinctly different because of the assessment, because of the diagnosis, because of the understanding and the brain science, and because of the treatment designed to eliminate the pain, not to cope with it.
It’s really important because the techniques we use sound so simple, like anybody could do them, but they’re based on a different underlying assumption.
Does someone need to have formal treatment or is this something that you’ve seen people have very good results just on their own? I know you have the book, “Unlearn Your Pain.” What kind of feedback have you gotten from people who are using that?
Some people, when they read about it or they read my book or one of Dr. Sarno’s books can say, ‘Oh, that’s me. I can see it. That’s obvious.
And then they just start to do the exercises and they get better. Other people are like, ‘Are you sure it’s me? I’m not sure it’s me. I really need to know if it’s me.’
And so then they need to seek care and then they’re emailing me and they’re trying to find doctors who can make sure that they’re not structurally damaged.
That’s where physicians can come in because any good physician can evaluate somebody to say, “Yeah, the diagnosis is fibromyalgia. That’s not a structural disease. It’s real. It’s not a structural disease.’
So some people need counseling. They need somebody to coach them and help them lower their danger signal and help them stop fearing the pain so much because they get so wrapped up in it. Any doctor can just see somebody who’s so on edge about their pain they needs help.
One that I see among physicians is certain common character traits like perfectionism and being very harsh on oneself. There’s an overlap. What about people who have traumatic events that happened during childhood, versus someone who is just a sensitive person who is very hard on themselves?
That’s a great question. I mean, I have neural circuit or neuroplastic pain. When I started my internship, I had diarrhea for six months.
Why? Because I was scared shitless about killing somebody on a young doctor, right? So my sensitivity or my perfectionism or my people-pleasing and my worry about making a mistake were high enough to cause my brain to cause me to have diarrhea.
That went away in about six or eight months as I kind of got used to being a doctor. But when I was in my 30s and 40s and I was starting a career as a faculty member, you’re teaching. Oh, there’s research. Oh, there’s clinical practice. Oh, there’s administration.
There was so much going on, right? And I started to get neck pain. And I was just trying to please everybody. I was trying to be the best that I could possibly be.
And I’d wake up with this horrible neck thing. And then an MRI would show a bulging disc and arthritis. Then I’d get PT and then I’d get better and then I’d get worse again and get better and get worse again.
Now I don’t have any neck pain. I still have all those MRI findings. But I’m, you know, I’m more at peace with myself.
It’s the external pressures that get put on us. And it’s the internal pressures that we put on ourselves on top of it. And that can be a recipe for the brain’s alarm system to go like, ‘Hello. Something’s going wrong.’
The brain can’t tap me on the shoulder and say, ‘You’re a doctor, you know, heal thyself.’
The brain just gives you a headache or stomachache.
You mentioned mindfulness therapy. And I know that’s different from mindfulness tying into the treatments that you recommend. What’s the difference between mindfulness therapy and using mindfulness to help you to calm your brain?
I’ve been teaching mindfulness since 1999. Everyone should learn it. Children should learn it. Doctors should learn it. These sorts of patients should learn it.
It’s a great way to have skills to navigate life. But if it’s so great, how come the research using mindfulness for chronic pain has not shown it to be very effective? The effects are small and they wane over time.
This is different than our study where the effects were large and didn’t wane over time. So why is that? The reason is that mindfulness is a way to accept what is and separate from it and let it go.
And that works great with thoughts because if you have a thought, okay, well, you know the thoughts coming from your brain is just the thought. So you can notice the thought, accept the thought, notice the next thought. And you can learn to deal with thoughts, which everyone has because you know they’re just thoughts.
But when you’re using mindfulness for pain, if you assume the pain is due to a structural problem, you’re not going to just kind of let it go. You’re going to notice it and try to separate from it, but there’s a ceiling effect.
When you recategorize the pain into a thought, a brain-generated phenomenon, a sensation, and now you do mindfulness with it - that can be incredibly effective.
We use mindfulness in our treatments, but we use it by first recategorizing the symptom from a structural one to a neuroplastic one. And that makes all the difference in the world.