Overcoming chronic pain (Pain Reprocessing Therapy)

You know how so many spouses-to-be experience cool feet in movies? Forever is the scariest thing, and forever associated with pain is the bleakest thing. And yet, over 50 million adults suffer from chronic pain in the US alone. Worldwide, it's estimated to be 1.2 billion. Having chronic pain means being married to pain: waking up with pain, playing ping pong with pain, knitting scarves with pain, baking pizza with pain. It means sharing your life with a guest you never invited, nor wished to welcome into your everyday.

Over 1 in 7 people in the US are married to pain. This can't be normal. If pain is a signal of danger that the body issues when tissues get damaged, that must mean that in 1 in 7 people have something broken all the time, and that ~15% of the US population would either be in hospital at any point in time, or recovering from a recent injury. What doesn't add up is that many people get injured, which triggers pain; then the injury heals, but their pain doesn't go away. Where is the pain coming from, if the physical damage that created it has healed?

More studies and statistics make this into an even more interesting matter.

64% of people without pain have some back condition (disc herniations, disc bulges, etc). That means that there can be significant structural changes without pain.
10% of whiplash cases become permanently disabled. However, chronic whiplash syndrome doesn't exist in Lithuania: they have cars, they have car collisions, but nobody reports long-term whiplash consequences.
In an experiment with fake car collisions (where accidents were simulated with a system of levers, resulting in no real physical damage), 20% reported having neck pain, and 10% still had pain after 4 weeks. All these people suffered no physical injury at all.
Pain administered with a hot probe or induced through suggestion under hypnosis results in the same brain areas activating in brain scans (fMRIs). That means that physical and imagined pain are indistinguishable in the brain, and that the brain is capable of generating any physical sensation in any part of the body.

All pain is real. If you feel it, it's real. If you suffer from chronic pain, it doesn't mean your pain is fake, or that it's less valid than pain experienced during a trauma, or that you are making up your pain. All pain is real. But what these elements suggest is that there are some forms of pain for which focusing on fixing the body is not the right strategy. We need to target the mind.

Pain is a neutral (not a danger) signal

Pain is the brain's response to body signals. The signals the body sends are neutral: when the sensation of heat or of an impact go through the pain signature parts of the brain, the brain decides whether tissue has possibly been damaged, and whether it should trigger pain to prevent further activity from doing even more damage to tissues.

This is the way we have evolved to use pain to preserve our physical integrity. But sometimes the brain misunderstands signals from the body: signals that are neutral are processed from the brain as hints of danger. This is what gives rise to neuroplastic pain: pain that originates and feeds itself in the brain alone.

In 1995, an incredible medical case was documented. A construction worker accidentally jumped on a 6-inch nail. He was brought to the emergency room while screaming in agony. He was in such pain that the doctors had to sedate him before removing the boot. But when they took it away, they found not even a scratch in the foot: the nail had passed between his big toe and his second toe, so that no tissue had been damaged. But by the sight of it, the construction worker assumed a large deal of damage must have happened, and that he should be in great pain. The mind did everything, isn't it fascinating?

The dynamic was later replicated in an experiment where people had their heads hooked to a fake electric shock generator. Scientists explained that a handle would regulate how much current would be allowed through their head, and added a fake, increasing humming sound to make it more realistic. People reported headaches of increasing strength as the handle turned upwards, although nothing was happening to their bodies. There was no current: their brain did everything, responding to the expectation they had crafted for themselves.

In another survey, researchers followed people with a recent back injury. At first, the pain was active in normal pain regions of the brain; when it became chronic, it shifted to parts associated with learning and memory. The brain had learned to be in pain. Our brains are phenomenal at learning, and that also has a side effect: pain can get stuck. Pain leads to neurons firing together, which consolidates the neurological pattern that created pain, which leads to more pain. This is a cycle that we need to actively break.

How can you know if your pain is neuroplastic?

Not all pain is neuroplastic. Some pain is genuinely triggered, or worsened, by repeated movements that stress a body part. How you pick your granola from the cabinets impacts how you feel in your shoulders; how you pick things from the floor has repercussions in your back; how you sit at the laptop influences how you feel in your neck; how you pick vegetables from the garden can take a toll on your knees. People find that they can improve the comfort in their daily actions with Awareness Through Movement sessions, by learning to use themselves better and noticing when a pattern of movement is not serving them well.

However, some pains are of a different nature. A few questions that can help you figure out whether your pain is neuroplastic are:

Have medical treatments been ineffective, or have given only temporary relief?
Did the pain come during a stressful time of your life?
Have you (had) symptoms in multiple parts of your body? (i.e. is the pain moving in your body?)
Is the pain inconsistent in terms of where and when it appears and how severe it is?
Do you think about the pain often or all the time? Does it worry you throughout the day?

The most effective evidence that a pain is neuroplastic is when it deviates from its normal pattern. For example when we are enjoying an activity, and we forget the pain. Which tells us that we are paying too much attention to the pain, and that we need to learn to turn off the danger signals in our brain. Which brings us to the role of fear in chronic pain.

The drive of neuroplastic pain is fear

In another simple but very telling experiment, people looked at pictures while being administered pain with a hot probe. People reported feeling more pain when they were looking at scary pictures. They even felt pain when the probe was off. This proves that fear can create pain!

There's three habits that trigger and aggravate neuroplastic pain:

Worrying – "Will I get enough sleep?", "Is my boss mad at me?"
Self-pressure – "I must get an A", "I must meditate 20 minutes per day"
Self-criticism – "I'm not good at this", "I make stupid mistakes"

In the same way as the parents' reaction to a child falling determines how quickly the child will be up on his feet roaming happily again, our reaction to pain determines how much it blows up to debilitating proportions vs how much it deflates into nothingness. The more we worry, the more we set our nervous system into a state of high alert, the more we feel pain, and the more the cycle self-sustains.

Some people are explicitly scared that they may aggravate their pain, or that further movement may damage their bodies, so the influence of fear is clear. But some others wouldn't say they are in a fearful state. The thing is: although some emotions may feel different from fear, they belong to the same category. If an emotion makes you fell more in danger, then it's a form of fear. A staggering amount of people co-habit with high alertness: 35% of people worldwide (and 55% in USA) say they have "a lot of stress during a lot of the day".

And although negative thoughts are automatic, and we need to accept that they will come, we can choose not to buy into them and take away their power. When we feel like we are worrying, or putting pressure on ourselves, or expressing self-criticism, we can decide to let softly go of that grip and float up again. It's enough to recognize the behaviors that put us on high alert, and do them less.

However, we also need to not fall into the trap of feeling like we have to catch every negative thought: that's another form of self-criticism ("Am I doing enough? Am I catching myself all the time? I should do better."). All these forms of self-criticism boil down to the feeling of "There's something wrong with me", and we can combat that with a message of safety that says "There's nothing wrong with me. I am fine the way I am." Perfection is not required: you don't need to get to 100%. Feeling 90% better is good, and you don't need to beat yourself up because you are 10% short. Be kind with yourself.

Grandfather: "There's a terrible fight going on inside of me, and the same goes on in every person. A terrible fight between two wolves. One is evil: he is fear, envy, greed, regret, guilt, inferiority, shame, resentment, lies. The other is good: he is joy, peace, love, hope, serenity, kindness, generosity, compassion, truth."

Grand-daughter: "But grandpa, which wolf will win?"

Grandfather: "The one you feed."

Techniques to address chronic pain

Taking care of a neuroplastic kind of pain is, in practice, not that hard, because it's something you do to yourself. It's also very hard, because it's something you do to yourself. You need to get good at feeling good, and it can be a tricky walk.

There is a few strategies from Pain Reprocessing Therapy that you can try out in your daily life, which require no tools nor preparations other than your own presence and awareness. It can be easier to have a mentor supporting you, especially at the beginning, but you can also do it on your own. Somatic practices like Feldenkrais sessions can also help.

Somatic tracking

When we are in pain, the most common response is to shut it away: we think of something else, we try to dismiss it, we isolate that body part into a different room of our perception. Somatic tracking suggests instead to focus on the pain. The idea is that paying mindful attention to the pain leads to observing without fear, which results in an increased feeling of safety, which deactivates the brain's fear circuits.

The key to somatic tracking is not just looking at the pain, but how you do it. It is not going to help to look at it with eagle eyes: nothing about a laser-focused burning gaze says "you're safe". Rather, observe it like a sunset, with effortlessness and curiosity. Another good image is to imagine you are scuba-diving and you see a school of fish: you don't try to catch the fish; you just watch them: how they move, how they glitter, how they change direction. There's no outcome to achieve. It's fascinating how we can do all the right things, with the wrong attitude – a bit like the young student complaining about his recurring test failures: "I'm studying all afternoon, every afternoon!"; and then it turns out he constantly multi-tasks, thinks of football games, snacks, and endures math exercises without his mental presence.

How long should you be doing this for? It depends. If the pain is so unbearable that you can only tolerate a few seconds, set yourself a timer and do a few seconds. If you can bear to look at it for longer, you can do a few minutes. It doesn't need to be long – in fact, 2 minutes will do fine. You don't even need to be in a special position, you can do it while standing at the checkout line. In that time, there's only your pain. Try to describe it for yourself: what shape does it have, what color, where does it go. Maybe it feels like it has a spike downwards, or inwards, or it feels itchy, or burning, or maybe it feels like having a weight resting there. Collect all the sensations that come from that area. And then – and this is as important as the observing part – stop paying attention to it. Allow yourself to look at the pain for some time, and then stop. And you do it with some consistency: don't wait until it's unbearable; do it when it's also just a discomfort. Even when your pain is gone, keep taking care of yourself.

Lack of expectations and outcome independence

Many people report feeling better by practicing somatic tracking. That's great, but remember that it's not the goal. If you go in with the expectation that the pain will diminish, it probably won't work. Whatever happens to the pain, happens. You just observe, and feel successful regardless of the result. The harder we try to get rid of the pain, the more we reinforce the belief that it's dangerous, which drives up the brain's fear circuits and puts us back into the fear-induced pain positive feedback loop.

When we practice somatic tracking without expectations, we also stop feeling like everything needs to be fixed. And that transposes beautifully to life, to an attitude of "it is what it is". Some people feel like they are losing control over their life, but I prefer to frame it as liberating. We get into this feeling that things are not major obstacles to be surmounted; they are just transient events in our life.

Exposure to fear

When we expose ourselves to fear with a sense of safety, we create a corrective experience. If you pay attention to your pain, you may notice it is linked to certain actions, or thoughts, or contexts. If family dinners make you feel stiff, you can imagine being in the dinner, and feel your response. If that's still too much, you can imagine being with a subset of the people that are normally present to dinner, and feel your response. Whatever it is that triggers your fear, you can backtrack enough so that you feel safe and distant enough that your nervous system doesn't feel in danger, and work from there. If getting into a car makes your neck hurt, keep your distance and look at the car from outside. Take your time to get in, over multiple days, and don't rush to drive. Gradually expose yourself to fear and let you nervous system know that you are safe.

On the other hand, when exposure triggers danger, the fear is reinforced and we experience a setback. Setbacks do happen, and they are temporary. There's two main contexts in which they happen:

when we push through pain and fear, thinking we'll get through it. When you feel in danger, you don't need to be pushed further into the fire; you need soothing. You can soothe yourself saying things like "This is temporary, I'll be okay", "I'm safe, and my body is fine", "My brain thinks I'm in danger, but I know it's a false alarm".
when we are un-learning our pain. When un-learning a behavior, laboratory rats showed extinction bursts before finally giving up on the behavior, meaning they would play out that behavior like crazy in the last stage. Habits don't give up without a fight. If this happens, just acknowledge it and treat your pain as you did from the beginning.

Avoid hyper-vigilance

You can become paranoid about every little sensation and wonder: "is this some kind of quasi-pain that's not pain just yet, but might turn into actual pain later?". You can get so caught up in the negative sensations (or in scanning for them – and if you really want to find something, your brain will give you something) that you get cut off from the positive ones. You enter into this territory where you are either in pain, or waiting for the pain. Your body becomes your enemy.

You don't need to constantly check on your posture, nor to constantly tune into the feelings arising from the painful area. Pay attention to it when you do somatic tracking, and then go on with your life.

Next steps

If any of this has resonated with you, you may want to take a peek at the original resources that inspired this article. Feel also free to contact me, either for questions or for arranging a session – if I can help you, I'll be glad to.

Alan Gordon - The Way Out: A Revolutionary, Scientifically Proven Approach to Healing Chronic Pain
Norman Doidge - The Brain that Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science
Ellen J. Langer - The Mindful Body: Thinking Our Way to Chronic Health
Job Kabat-Zinn - Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness