How the Brain Causes Chronic Pain & How to Stop It

By changing the way you see and respond to pain you can retrain your brain to help reduce it.

 

For many patients, the primary cause of chronic pain is not a structural problem in the body but rather learned neural pathways in the brain. This might seem like a bold statement but it has been strongly supported by recent research in medicine, neuroscience, and psychology.1-5 We (the authors) developed Pain Reprocessing Therapy (PRT) based on this premise. PRT is a psychological treatment that helps people reprocess pain signals as non-dangerous in order to reduce or eliminate chronic pain.

Our research team recently completed a randomized controlled trial with 100 subjects, all living with chronic back pain. After treatment with PRT, 73% of subjects reported being pain-free or nearly pain-free. These outcomes were largely maintained 1 year later. Our team also used functional MRI (fMRI) to measure patients’ brains at pre- and post-treatment, and found that PRT changed how patients’ brains processed pain.6

This article provides an introduction to PRT, along with resources for people living with chronic pain, and their caregivers, who want to learn more. 

What Causes Chronic Pain?

Acute pain generally reflects tissue damage–for instance, touching a hot stove hurts because the stove is damaging the skin. Chronic pain, on the other hand, is more complex. Sometimes, it is caused by tissue damage in the body (eg, injuries or other pathology) but much more often, there is no structural problem in the body that is driving the pain.1-5

Let’s take chronic back pain as an example. A common view is that “structural” issues like disc herniations or bad posture cause chronic back pain. But disc herniations and similar radiological findings are present in most people–even those who have no back pain at all–and typically reflect normal, healthy aging.7-9 Similarly, studies have found no clear relationship between posture and back pain –plenty of people with “good” posture have intense back pain, while many with “bad” posture have no pain at all.10 In other chronic pain conditions as well, there is often no identifiable structural cause of pain.1,4

Clinicians and diagnostic tests can help rule in or rule out causes of chronic pain, but the way that pain is viewed by the person experiencing it matters most. (iStock)

 

Where Pain Exists in the Brain

Pain functions as a danger signal generated by our brains to alert us to bodily threats. And sometimes, we can be in pain even when there is no actual threat to the body.11-14

There was a startling demonstration of this in a case report.15 A construction worker had jumped down from a scaffolding, landing on a large nail that pierced his boot. He was in agony and was rushed to the hospital. But when doctors removed his boot, they found that the nail had passed between two of his toes, without even causing a scratch. When the construction worker saw this, the pain faded and disappeared.

His brain had generated the pain because it believed he was in danger. But once it had become clear that there was no threat, his brain stopped generating the pain.

In this article, we call brain-generated pain “neuroplastic pain” because changes (plasticity) in neural pathways are the primary cause of pain. Even though neuroplastic pain is generated by the brain, it is not imaginary. All pain is real.

Fear, Avoidance, and Chronic Pain

When the brain experiences pain over and over, neural pathways get strengthened and sensitized.12,16 Over time, the brain learns the pain and it can become chronic.13,17

How does the brain learn pain? It is driven by fear and avoidance.18,19 When we fear and avoid pain, we reinforce that the pain is actually dangerous. This reinforcement can create a vicious cycle: the pain leads to fear and avoidance, and the fear and avoidance lead to more pain.

 

What Is Pain Reprocessing Therapy (PRT)?

Pain Reprocessing Therapy (PRT) is a set of techniques aimed at breaking the pain-fear cycle. PRT is appropriate for patients with neuroplastic pain. In the next two sections, we describe the assessment process for neuroplastic pain and the central techniques of PRT.

Could Your Pain Be Neuroplastic Pain?  

Pain not caused by injury is neuroplastic pain. There are two ways to assess whether chronic pain is neuroplastic.2,20 First, a doctor can help rule out any structural/medical causes of pain, such as tumors, fractures, infections, and auto-immune diseases. Medical tests like X-rays or MRIs can help, although they also often reveal incidental findings that are not the cause of pain.9,21,22

Second, a clinician can help rule in neuroplastic pain. There are several indicators that the pain may be neuroplastic, including:

  • Pain originating without injury
  • Pain originating during a time of stress
  • Pain that is inconsistent (eg, back hurts while standing but not while running)
  • Pain that spreads or moves around the body
  • History of a wide range of symptoms (eg, stomach pain, migraine, knee pain, etc.)
  • Childhood adversity or trauma history
  • Personality tendencies towards anxiety, hypervigilance, and perfectionism

None of these on its own is definitive. Each is suggestive. And the more indicators that are present, the more likely it is that the pain is neuroplastic.

Sometimes the diagnosis is fairly clear. In other cases, a process of evidence gathering is needed. This process can be like detective work, requiring curiosity and attention to detail (eg, noticing variations in the location and intensity of the pain at different times or across different social contexts). 

Pain Reprocessing Therapy (PRT) and How it Works

In cases of neuroplastic pain, the brain is interpreting safe signals from the body as if they were dangerous. The primary goal of PRT is to correct that misinterpretation and teach the brain that these sensations are in fact safe. 

The central technique of PRT is somatic tracking. Somatic tracking involves a particular way of thinking about and paying attention to the pain. Typically, when we pay attention to pain, we are bracing ourselves: How bad is it now? Will it get worse? How will I be able to do X or Y with this pain? And while these are perfectly natural responses, all that fear reinforces messages of danger to the brain, keeping the pain signals activated.

Somatic tracking allows us to flip the script. Instead of attending to the pain through a lens of danger, we do so through a lens of safety.

Somatic tracking has three elements:

  • Mindfulness
  • Reappraising sensations as safe
  • Generating positive emotions

With mindfulness, we attend to the painful sensation without fear or judgment, and without trying to get rid of it. We reappraise the painful sensation as safe by reminding ourselves that the pain is a “false alarm” that does not indicate bodily injury. And we generate positive emotions, allowing us to more easily attend to the sensation with a lighthearted, easy-going attitude.23

The goal of somatic tracking is to pay attention to the pain with a sense of safety and ease, viewing the sensation as fundamentally non-dangerous. This neutralizes the perceived threat, allowing our brains to “reprocess” the sensation as safe. As this happens, the pain will eventually fade.

The pain may not immediately disappear the first time trying somatic tracking. That is OK. While the long-term goal of somatic tracking is to eliminate pain, the short-term goal is to overcome fear of the pain. Fear is the driving force behind neuroplastic pain, and if you reduce that fear, pain reduction will follow.

Somatic Tracking in Motion

For many with neuroplastic pain, it is common to have symptoms during particular activities (eg, wrist pain while typing, back pain while bending, etc.). Though it may seem like the activity is causing the pain, it can actually be a learned association – whereby the brain has created a link between the activity and the onset of pain.11,19,24

In PRT, we engage in somatic tracking during feared activities. Somatic tracking helps us create a new association that links the activity to positive feelings of safety.25As this new association gets strengthened, we will be able to engage in these activities with little to no pain. 

Other Threats that Amplify Pain

When we are in a state of high alert, we are more likely to interpret everything through a lens of danger. Loud noises will make us jump, light touches will cause us to recoil, and sensations in our body are more likely to be experienced as painful.26,27

PRT thus aims to lower a person’s overall threat level. This can include helping someone process threatening emotions, a history of trauma, difficult relationships, and more. As overall levels of fear and stress decrease, the brain is more likely to interpret signals from the body as safe, leading to a reduction in pain. Any relevant therapeutic approach can be used for this component of PRT, such as Emotional Awareness and Expression Therapy,28 Eye Movement Desensitization and Reprocessing(EMDR),29 expressive writing,30 and more. 

 In PRT, we typically focus on the pain sensations first, using somatic tracking. We then address non-pain threats as needed, returning to the pain sensations when appropriate. This order of treatment may be most efficient.31  

Treating Pain By Healing Emotions

Today, psychological treatments are not widely used for chronic pain. Few patients consider it, and even fewer have actually tried it or have access to it. We hope that recognizing the central role of the brain in many chronic pain conditions —along with the development of new brain-based treatments like PRT—will usher in pain relief for many.

To learn more about PRT, consider checking out the new book, The Way Out: A Revolutionary, Scientifically Proven Approach to Healing Chronic Pain.

Updated on: 03/25/21
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Chronic Pain and Mental Health: The Empowered Patient's Guide
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