Episode 60 | Dr. Yoni K. Ashar, PhD – PAIN REPROCESSING THERAPY - RETHINKING CHRONIC PAIN

Yoni K. Ashar, PhD is an assistant professor and director of the Pain and Emotion Research Lab at the University of Colorado Anschutz Medical Campus. He completed his doctorate in clinical psychology and neuroscience at the University of Colorado Boulder and an NIH-funded postdoctoral fellowship at Weill Cornell Medicine. Yoni’s research uses functional MRI brain imaging, natural language processing, and other clinical and computational tools to understand how mind and brain processes influence health, especially chronic pain. A main research focus is investigating a new class of psychological and neuroscience-based treatments aiming for recovery from chronic pain. 

See Dr. Ashar links below:

Featured research on NBC’s Today Show, Washington Post, WSJ, NPR

https://www.symptomatic.me/

https://www.painreprocessingtherapy.com/

 https://unlearnyourpain.com/

 https://painpsychologycenter.com/the-book  

Transcript

SPEAKER_03 0:01

You can help people reduce their fear and avoidance of pain by talking about pain acceptance and trying to help them understand that resisting the pain isn't helpful and such. And that will have some, that will lead to less fear of pain or help people understand that we know pain isn't a reliable indicator of tissue damage. And that's going to reduce fear and avoidance of pain. But if you tell someone, you know, your body's healthy and strong, your brain has learned the pain, and that's true for them. So if you're being honest, that's going to really bring down the fear much more powerfully.

unknown 0:39

Dr.

SPEAKER_05 0:40

Yoni Ashar is an assistant professor and director of the Pain and Emotional Research Lab at the University of Colorado Anschutz Medical Campus. He completed his doctorate in clinical psychology and neuroscience at the University of Colorado Boulder and an NIH-funded postdoctoral fellowship at Weill Cornell Medicine. Yoni's research uses functional MRI brain imaging, natural language processing, and other clinical and computational tools to understand how mind and brain process and influence health, especially chronic pain. A main research interest of his is investigating a new class of psychological and neuroscience-based treatments aiming for recovery from chronic pain.

SPEAKER_04 1:26

As always, I can be reached at Afton at AftonHasset.com.

SPEAKER_05 1:35

Hi, Yoni. I tell you, interest in pain reprocessing therapy is like at a fever pitch. I'm so excited to have you on to talk about this. You've really been at the center of this, and um, either as a principal investigator or certainly directing us. I know you've done a lot to help keep Drew and I on track as we're looking at a brief form of pain reprocessing therapy. So um again, welcome.

SPEAKER_03 2:01

It's such a pleasure to be here, Afton. I've really enjoyed your show, hearing other episodes and honored to be on it.

SPEAKER_05 2:08

Well, we're we're so happy to have you. So I was thinking just as we were even just talking here, I don't know much about your story. And I think it'd be really interesting to kind of hear a little bit of what kind of brought you up to the point of where you took part in the infamous Boulder Back study. So a little bit about what kind of led up to that.

SPEAKER_03 2:30

It's a winding journey.

SPEAKER_05 2:32

Yeah.

SPEAKER_03 2:33

I started my career in you know, studying computer science as an undergrad and then working for a high-tech company for a couple of years before realizing that software development was not my passion. And it took some couple years to travel the world and um, you know, broadened my interests and uh developed a pretty serious meditation practice during that time, and then found this whole field of contemplative neuroscience, which is a wonderful name, but like studying how meditation changes the brain. And I thought that was the coolest thing I'd ever encountered. And I uh looked for a job working uh in this field, and gratefully Tor Weger, my doctor who ended up being my doctoral mentor, offered me a position in his laboratory studying the effects of meditation in the brain. And uh that ended up being a you know a side project in Tor's lab. Tor is notorious for side projects. Uh, you know, the the the main uh I mean them the best possible way. Um and you know, the main focus in Tor's lab was really a lot of work on pain and placebo effects. And I thought placebo effects were just incredible, the way our beliefs and our relationships and our emotional state can shape our experience of even something as physical as pain.

SPEAKER_04 3:56

Yeah.

SPEAKER_03 3:57

And I was really wanting to take that in a more clinical direction. I was doing uh also uh a PhD in clinical psychology. And and just about the same time as Tor and I were developing these dissertation ideas related to placebo effects in a more clinical context, like chronic back pain, uh, these two wonderful clinicians reached out to Tor, Howard Schubiner and Alan Gordon, and they basically told Tor, um, we have this amazing new treatment and we need to test it. And I didn't have a name yet. Um and Tor said, Oh, great, I know just the person to do it. I have this PhD student, Yoni, he'd be perfect. And Tor comes to me with the idea, and I I say, obviously, I say, no way, this is madness. What are you talking about? So I'm like, two clinicians call you up and say they have something they want to test. And now it's my like doctoral dissertation. Like, I want to graduate here. I'm not gonna follow this down. But Tor is very persuasive and very optimistic. And so we ended up uh ultimately saying yes. And the more time I spent with these two clinicians, and the more time I spent going to the research on chronic pain and neuroscience and the psychology, um, the more everything started clicking for me. And um and that's the backstory to to the Boulder Back pain study, and also you know, some of my own backstory and how I got to this field and how I now am a pain scientist.

SPEAKER_05 5:30

Yes. Isn't it interesting? Every once in a while I do talk to somebody who this is what they wanted to do since Drew Sturgeon. This is he wanted to be a pain psychologist since he was like a kid. So figure that, but most of us end up on these really kind of interesting paths where the people that we meet, our circumstances kind of take us new directions. And so here you are, a former kind of coder sort of guy in the psych world, in the brain world, approached by these two clinicians who say, we've got something that's like lightning in a bottle.

SPEAKER_03 6:03

We want to. Exactly. Yeah. And I'm kind of like, it sounds like snake oil.

SPEAKER_06 6:09

Yeah, yeah.

SPEAKER_03 6:10

But uh, but it you know, ultimately it was worth testing. It really was worth testing, and uh I'm sure glad I did. And you know, from from where I'm sitting now and what I now know, it all makes a lot of sense to me. Yeah.

SPEAKER_05 6:26

Um yeah, it does to me too. So I was not a believer either. So I met Howard probably 17 years ago or so. We were at the Mayo Clinic together doing a uh visiting professor, and and he was sweet and fascinating and fun. But it's like, I don't know. I don't know what this thing is you're talking about. Um in some ways it was intuitive and kind of made sense, but in other ways it's like, yeah, we'll we'll see. Let's let's do the data. Let's get let's get the data.

SPEAKER_03 6:54

So we do, you know, Afton, we do have to do the data, and and you kind of, you know, in your opening mentioned that the you know, this kind of work on PRT, there's a lot of hype around it now. There's and it's um yeah, it's really important uh to not get swept up in the hype and to try to separate fact from fiction and and and keep our noses in the science uh to best serve the patients. I I do think we have something here that's you know new and valuable, and we'll talk about that. But it's absolutely not a silver bullet or a panacea or anything like that. So we gotta, you know, the research will continue and and you know, clinical clinicians will keep experimenting and uh we'll we'll find our way forward.

SPEAKER_05 7:39

Yeah. And I think where we're so excited is for the people in whom it works, it's like a light switch for some people. So that's the exciting piece of it. So we'll get there a little bit, but let's let's give some background. So you're a brain guy, and so I could see how this intervention would be interesting to you because it is kind of all about the brain, right? It kind of starts in the brain. So, what is the basic premise, kind of the neuroscience of how we think PRT works?

SPEAKER_03 8:09

Uh the basic premise is that there is a subtype of people who have of cry who have chronic pain that we would call uh nociplastic chronic pain, or a term we often use clinically is neuroplastic chronic pain. We don't have to get into the terminological details. Uh I'll probably use those interchangeably here. And for those people, the pain is driven much more by how the brain is processing input from the body than any injury in the body itself. And when I say brain here, uh, I'm speaking a little colloquially, uh central nervous system, including the spinal cord. How the central nervous system or the brain is processing input from the body, and that there are functional changes here, meaning they're not pathological, there's no disease. It's just the way the neurons are getting wired together in this moment in this nervous system is causing some amplification of sensory input or uh causing the pain system to activate really in the absence of physics tissue damage.

unknown 9:18

Yeah.

SPEAKER_05 9:19

We talk about nosoplastic pain frequently here because you know it is kind of where most of us in research are kind of toiling and thinking about how it is that the brain and central nervous system can amplify pain or even create pain where there is no stimulation, right? So it's it's uh uh not clear how that's happening. And in some places, we think about you know the role that threat plays and kind of presumption. And I feel like that's kind of a cornerstone concept.

SPEAKER_03 9:54

It really is. We have to start by understanding the function of pain, really what pain is, and you know, the very old view, which none of us in the field um subscribe to, but there may still be, you know, it's a very intuitive view that maybe some of the listeners would have, is that pain reflects pain is an accurate indicator of tissue damage in the body. And we now know that's not the case. You can have pain with no tissue damage, you can have tissue damage with no pain. So then that leaves us wondering, well, okay, so so what is pain if it doesn't indicate tissue damage? And one one idea that's been very influential for me, and I'm uh thinking especially of papers from Ben Seymour here, is that pain is uh the brain's best guess as to whether there's an injury in the body, or you'd say an optimal inference whether there's an injury or not. And so the brain is getting sensory input from the body, you know, these sensations, these signals that come up from the body to the brain. Uh, we also have social input. So, what providers or other people have told us about what we've read online from other people. Um, we have memories uh that we've had in the past, and all these streams of information are integrated to make a best guess about whether there is an injury present. And if there's if there's an inference made that an injury is present, then pain is generated. Uh, and that has, of course, you know, multiple functions, including to protect ourselves from further injury and damage. And so so so in this model, pain is the inference. And you know, inference is a is a challenging problem. And uh sometimes the brain's kind of like playing detective, and sometimes you can make a mistake. You can make a mistake, it can infer that an injury is present when perhaps it isn't.

SPEAKER_05 11:45

Yeah.

unknown 11:46

Yeah.

SPEAKER_05 11:46

So the brain kind of functions like a prediction machine, right? It's gonna it acts fast and it makes its best guess. And sometimes that guess is wrong, but it would rather default to danger to protect you rather than default to I don't think it's all right. So better safe than sorry. Yeah.

SPEAKER_03 12:07

Right. Then that's the evolutionary pressure there that you know, better to have some false alarms than to miss the true alarm because you could be dead if you miss a true alarm. Right. And and like you said, after threat is at is at the center here. And so that's one aspect of neuroplastic pain as I understand it. And the there's a second aspect where a general sense of where other processes that are threat related can amplify pain. So there's we know there's a lot of uh interactions, interactions between stress and pain and emotions and pain. And these are also things that can amplify pain. So if there's something happening in your life, in your emotional world that is threatening, and now you feel generally unsafe, yeah, uh, that seems to, although we still have to do more work on this, that seems to also amplify the pain experience as well.

unknown 13:04

Yeah.

SPEAKER_05 13:04

And it makes sense. You know, the brain's not sure, you know, whether an embarrassing social situation is life-threatening, but somehow that threat signal is tweaked, right?

SPEAKER_03 13:16

And yeah. One way I think about it is that there's a uh like a threshold function in the brain. And uh, you know, this is a work from Vanya Apkarian who wrote about this kind of and sensory input is coming in from the body, and there's a threshold function to say if that input from the body is above a certain threshold, then create pain. And and like a high threat state, like an embracing situation, could cause that threshold to drop. And now all this sensory input that's typically kind of tuned out and suppressed by the brain is now passing the threshold and and pain is being generated.

SPEAKER_05 13:49

Yeah, yeah. These are such important concepts. And I think for interventions like PRT to work well, it really helps if the person with chronic pain, if the patient, understands the nature of how we see their pain potentially as being processed. So, I mean, there are these key ideas are at the heart of PRT. What in what ways do you convey these ideas to patients? Do you use analogies or you know, are there some case stories, or how do you help convey this so that patients have a better understanding of how pain is functioning or dysfunctioning in their lives?

SPEAKER_03 14:26

Yeah, there's two metaphors I'd love to share.

SPEAKER_05 14:28

Yeah.

SPEAKER_03 14:29

But before we share any metaphor, we always make sure people understand your pain is real.

SPEAKER_06 14:34

Oh, yeah.

SPEAKER_03 14:34

Neuroplastic pain is real, nosoplastic pain is real, no one's making it up, no one's exaggerating. We just have to understand the causes. Because if we understand the cause, we can we can guide the treatment.

SPEAKER_06 14:45

Yeah, yeah.

SPEAKER_03 14:46

So the two metaphors, uh, these are my two go-to metaphors. One is um, so say Afton, that you turn on your car and the check engine light is on the dashboard, and you take the car into the garage, and the mechanic comes back to you and says, Hey, Afton, good news. I checked out the whole car, the whole engine. Turns out the engine is fine. The issue is that the wiring from the engine to the dashboard got sensitive, got sensitized.

SPEAKER_06 15:15

Yeah.

SPEAKER_03 15:15

And so now the check engine light is going off on the dashboard, even though that the engine is fine. And that's good news because it's much easier to fix that wiring than it is to like replace your engine or something like that.

unknown 15:26

Yeah. Yeah.

SPEAKER_06 15:28

I like it.

SPEAKER_05 15:28

It's good. I experienced that not too long ago with our car. It was the exact thing. It was like, oh my gosh, we were traveling across country. I was like, oh my God, we got to find a dealer in somewhere out of nowhere. And same exact thing. It was just a sensitive light. So he that that feels very coherent.

SPEAKER_03 15:44

Great. So your car just needed some PRT. It just needed some PRT.

SPEAKER_05 15:50

Between the wiring.

SPEAKER_03 15:52

Exactly. The the second more we the second metaphor we love using is of uh like guitar playing. So uh say, you know, someone, many of our patients have been in pain for years, even decades, and we say, so let's imagine you've been playing guitar for years or even decades. Whether you try to or not, those guitar-playing neural pathways get more and more efficient over time. It just that's how the brain works, neurons that fire together, wire together. So these neural guitar-playing neural pathways get more efficient. And the same thing has happened with your pain pathways. You've been in pain for years or decades. Without you even trying or choosing it, those pathways have become more efficient and are more easily activated. So the brain's been learning. And um, you know, unfortunately, it's been learning pain, but we can help you kind of unlearn the pain and try to change some of those neural pathways.

SPEAKER_05 16:43

I like both of those too. And I I think when I talk to patients too, we we talk about um the notion of phantom limb pain. I think that's also kind of a useful way to think about it. The people who have phantom limb pain, this is once you've lost a you've lost a leg or an arm and and still experience intense pain where that leg should be. Nobody's making anything up. The brain is actually experiencing pain.

SPEAKER_03 17:10

Yes, exactly. And it's clearly, or I shouldn't say clearly, but we we know that in phantom limb pain, a large part of it is due to changes in in you know how the brain is processing sensory input that's actually no longer there.

SPEAKER_05 17:23

Yeah, yeah. So that that's that's really powerful. So um before we get too deep into PRT, um what do you think is kind of the key ingredient?

SPEAKER_03 17:38

Uh PRT is a integrative treatment that includes many elements, and they seem to work in synergy to help people. That's my sense of it. Yeah, it's a difficult question. I can tell you what the research data show. Uh the research data would show that what they support is that uh reductions and fear and avoidance of pain are at the heart of PRT.

SPEAKER_05 18:03

Yeah, that's what I was going for. Thank you, Yoni.

SPEAKER_03 18:05

Yes, exactly.

SPEAKER_05 18:06

I mean, that that is my sense. That that's the that is kind of the mechanism, that's the piece we're tweaking. And how we get there is kind of through these um elements of PRT. So let's talk about that.

SPEAKER_03 18:19

And that and can I can I just add one thing there that's really important, which is that reducing fear and avoidance of pain, I mean, that's something that psychological treatments have been doing for decades. That's something that you know pain exposure therapy does, CBT Act, right? So there's nothing, in the sense we're not coming to say there's a whole new mechanism here, but it's possible, and and our evidence now supports that PRT may engage these old mechanisms in more powerful ways than than you know other treatments do.

SPEAKER_05 18:52

So talk about that a little bit.

SPEAKER_03 18:55

Yeah, so you can you can help people reduce their fear and avoidance of pain by talking about pain acceptance and trying to help them understand that resisting the pain isn't helpful and such, and that will have some that will lead to you know less fear of pain or help people understand that we know pain isn't a reliable indicator of tissue damage, and that's gonna reduce fear and avoidance of pain. But if you tell someone your body's healthy and strong, your brain has learned the pain, and that's true for them. Yeah, so you're being honest, that's gonna really bring down the fear much more powerfully.

SPEAKER_05 19:34

Yeah, right. And actually start to extinguish the fear. Okay. Exactly. Perfect. Okay, so let's talk about what are some of the parts. We talked a little bit about pain education. Pain education is really critical just to understand because so I think generally people think that you know pain is purely stimulus responses. We were talking about before, right? You have some damage, you hurt your knee, you hurt your ankle, you got you know bad MRI findings on your back. Yeah, that's causing my pain. But not necessarily so. And there's multiple studies that show that the damage that we see on MRIs do does not often tidally map onto the experience of pain. So when we kind of get beyond pain education, what are kind of the pieces of PRT, just for maybe someone who's never really heard about what is involved in the treatment?

SPEAKER_03 20:25

PRT has four components. One of them is pain education, like you just noted, like we've been talking about. A second piece is this somatic work that we do where we help people uh pay attention to sensations in their body in a different way. Uh this looks like some mix of guided meditation, cognitive work, like changing your thinking, a bit of hypnotic sort of element to it. People's eyes are often closed, their attention is inward, and they're learning a new way of paying attention to the sensations in their body as non-dangerous, as safe, paying attention to curiosity and compassion and warmth and tenderness, uh, and not trying this kind of like this default pattern we all have, because we're human, of pushing away unpleasant sensations and trying to shift that pattern and instead welcoming or at least being curious about these unpleasant sensations. And that's this somatic work in PRT. We could think about it as a form of interoceptive exposure. So doing an exposure but to sensations that are inside the body.

unknown 21:37

Yeah.

SPEAKER_03 21:38

And doing that's um, yeah.

SPEAKER_05 21:40

And doing a way that kind of takes out all of that fear and can you know, you know, that that is often when people are experiencing their pain and they get into the thoughts, oh my god, what does this mean? It's gonna get worse. And no, so all of that kind of gets diminished.

SPEAKER_03 21:57

That's the goal. And there's an art to dismatter. Tracking, and sometimes you know, I'll be leading someone in it, and I feel they are still relating to these sensations from a place of fear and avoidance and threat. And try as I might, I'm not able to shift them. Maybe I'm cracking jokes or I'm using different metaphors, but for them in that moment, the way I'm presenting it, it's not clicking.

unknown 22:20

Yeah.

SPEAKER_03 22:20

And um, but that's the goal is that in this moment, they're they have a new relationship with these sensations. And what we we observe often happens is that the sensations start to shift, they start to move, they start to get louder, quieter. And and that can be a powerful feedback signal where people start to see, like, wow, these sensations are really brain-generated. Like, I'm just sitting here not doing anything, and sensations moving from the left to the right, or it's going from the top to the bottom. And these things have to happen. And and uh there's a growing understanding that people have of how directly and immediately their state of mind can impact this uh somatic experience.

unknown 23:01

Yeah.

SPEAKER_05 23:01

And then when people have that kind of a moment of panic and it gets worse, it's like, whoa.

SPEAKER_03 23:06

Yeah.

SPEAKER_05 23:06

They kind of have that. I saw what happened there.

SPEAKER_03 23:10

Exactly. They see the fear and avoidance in their own system happening, and and and then they could start to sometimes they can start to release that and relax that and and not have the same fear and avoidance.

SPEAKER_05 23:22

Yeah, no, that can be incredibly powerful. So no, we talk about kind of safety reappraisal. What what does that mean?

SPEAKER_03 23:30

Uh it means so reappraisal in the sense of uh thinking differently about something.

SPEAKER_06 23:39

Yeah.

SPEAKER_03 23:40

And here, instead of thinking about the pain as a threat, thinking about it as a non-threat.

SPEAKER_06 23:45

Yeah.

SPEAKER_03 23:46

That's the hardest safety reappraisal.

SPEAKER_06 23:48

Yeah.

SPEAKER_03 23:48

Um, this pain is not a threat. It's not an indicator of damage. My body is safe, my body is strong.

unknown 23:54

Yeah.

SPEAKER_03 23:54

Uh and this is again, this is with people with nosoplastic pain, where we are reasonably confident that there is a pain is nosoplastic or it's predominantly nosoplastic.

SPEAKER_05 24:05

Yeah. And you hit on something important too. People can have pain that is generated by, say, a bad knee, you have bad osteoarthritis, but it's also to some degree the pain has also become nosoplastic. So it's also twofold things going on there. And you can probably dial back that nosoplastic element pain.

SPEAKER_03 24:25

Exactly. Exactly. Some pain is mostly or completely neuroplastic, nosoplastic, and some pain is more of a mixed where there is some um you know severe osteoarthritis, like in the knee, uh, but there's also a layer of sensitization that's on top of that as well.

SPEAKER_05 24:43

And and you know, and just helping people step away from the notion that pain equals danger. Pain is danger. Instead of pain is like the fire alarm. Pain is telling there there might be danger somewhere, but the pain itself is not the danger. Just like a fire alarm on the wall that's blaring is not dangerous. It's telling you about something out there might be dangerous.

SPEAKER_03 25:05

So exactly. It's unpleasant, like a false alarm, like the fire alarm's going a fire drill. Unpleasant, but not dangerous.

SPEAKER_05 25:12

Exactly. Great, great, great analogy. So um there's a lot of discussion about what this thing is, is pain reprocessing therapy. Is it really? Yeah, go ahead.

SPEAKER_03 25:25

Well, let me just briefly mention the other two components of PRT. We talked about pain education, yeah. We talked about um somatic tracking. There's also a behavioral piece where we get people to re-engage in the activities they've been fearing and avoiding. So someone who's you know, stop playing tennis, let's start playing tennis again. Someone who's not bending or kneeling, let's start bending or kneeling again. And then the the fourth piece here is emotional work here. Uh this is really taken um with permission from emotional awareness and expression therapy. And um where PRT and and EAET, I know you had Mark Lumley on the show recently, and he talked about EAT and stuff. PRT and EAT have been becoming you know, moving closer and closer to each other. And and that's this fourth piece of PRT is this emotional work and where it because we know emotions can contribute to and amplify pain and uh reducing emotional avoidance also can reduce pain.

SPEAKER_05 26:29

Yes. And then I think that is a place that we weren't initially with these very behavioral approaches, but it's important because people will tell you when I'm angry, my pain is much worse. When I'm afraid, my pain is much worse.

SPEAKER_03 26:44

Yeah. So we just compared to the uh data collection for a little study. Yeah. Uh is really very simple. We took a sample of close to 200 people with migraine, and we asked them, uh, tell me in your own words, what causes your migraines.

SPEAKER_06 26:58

Yeah.

SPEAKER_03 26:59

And you know what the number one answer we got? What's that? Stress. Yes.

SPEAKER_05 27:04

Isn't that powerful?

SPEAKER_03 27:05

This is what people, this is just what the patients, this is an unselected group of close to patients. This is what they told us. Yeah. And so I think a lot of patients know, certainly these migraine patients really recognize that like stress, and we can include in that difficult emotions are are causing pain. So we can't ignore that, you know, what what these patients are telling us.

SPEAKER_05 27:24

Yeah. And difficult emotions drive stress. So that's so powerful. Good, good. I'm glad I'm glad you came to it. Okay. So um, and then positive emotion, that's also a piece of what is another piece of purity. Yeah, yeah. And and when we're feeling more positive emotions, we it's almost it's very hard to have both fear and and positive emotions at the same time. It really does help buffer or offset.

SPEAKER_03 27:51

Exactly.

SPEAKER_05 27:52

Okay, so the question that I'm um often arguing with people about, which is what side are you on though? What side are you on? So people say, hey, there's nothing new under the sun. PRT is behavioral therapy, cognitive behavioral therapy, some hybrid there. Or is it something different?

SPEAKER_03 28:13

Um I can argue both sides of this.

SPEAKER_06 28:15

Yeah.

SPEAKER_03 28:16

Um, you really you could say this is so similar to things we've done before. And I would say, yeah, in a sense it is. The the pain, you know, the education you give, it looks a lot like pain neuroscience education that we've been doing for decades.

SPEAKER_06 28:31

Yeah.

SPEAKER_03 28:31

Getting people re-engaged with with these feared activities. Well, we've been doing pain exposure therapy for decades. Emotional work. I mean, that's been a part of you know, many cognitive behavioral treatments when one way or another, usually not the center, but it has been a part. Yeah. So there's a lot of pieces here that are really building on prior work. Um at the same, you know, and also if we look at things like CBT for panic disorder, actually, PRT looks a lot like CBT for panic disorder as well. Yeah. So there's a lot of connections to things that are existing. With all that being said, there are some really important distinctions as well. Um, I'll just name a few of them, conceptual distinctions, which is most or almost all current leading treatments don't tell people, don't try to assess whether a person has no syplastic pain and then tell them that they have no syplastic pain. Um, so that seems a that's a really important starting point in PRT. Um, in PRT, we explicitly have the perspective and attitude that the pain was, you know, learned, quote unquote was learned and can be unlearned. It's due to functional changes in brain pathways that can that are modifiable and some cases reversible. And the goal is is pain recovery. Uh that's pretty different. A lot of the current treatments really come from a gate control model where you have sensory input from the body and the brain gates it. So it's more or less, the gates more or less open or closed depending on how much you catastrophize or how much you resist the pain. But um, we really we for us in PRT, the brain is not a gate as much as a generator of pain. Yes. So it really has a more expanded role for for that.

unknown 30:20

Yeah.

SPEAKER_03 30:20

Um, and so there's some some important conceptual differences. Uh, we also now have empirical evidence, actually, that this isn't published yet, but that that PRT leads to greater pain reduction than cognitive behavior therapy.

SPEAKER_05 30:35

Okay, good cheese and a good segue to where I wanted to go next.

SPEAKER_01 30:40

There are 86 billion neurons in the human brain. Complex networks connect these remarkable cells so we can breathe, move, think, communicate, and feel pleasure, and pain. Changes in some of these brain networks are likely to underline my pain. But these networks are not underlined. Stress, sadness, fear, and loneliness can affect brain networks and make your pain worse. But healthy eating, sleep, and exercise can help your brain make new connections, and so can mindfulness, joy, friendship, and love. Because this is true, the power to create a new tomorrow with less pain and a more rewarding life already resides within you.

SPEAKER_00 32:00

Dr. Hassett's book, Chronic Pain Reset, can be found on Amazon and independent bookstores everywhere.

SPEAKER_05 32:08

You've done a beautiful job kind of laying the foundation for what this thing is. Let's talk about its effectiveness and why we're pretty excited. So you alluded to this study that you did with Torwagger. Um, gosh, has it been six years? Six years ago.

SPEAKER_03 32:25

Um Yeah, we started working on it a decade ago. I think it's been published for five years.

SPEAKER_05 32:30

Okay. Okay, so we refer to it colloquially across researchers as the Boulder Back Pain Study. So talk a little bit about that. You gave us a little sense of kind of the events leading up to it. But what exactly was the study?

SPEAKER_03 32:44

So it was 150 people, 151 with chronic back pain. And they we were, you know, people were we selected people who are more likely to have nosoplastic chronic back pain, and I can talk about how we did that.

SPEAKER_02 32:59

Yeah.

SPEAKER_03 33:00

And we randomly assigned people to either usual tear, this uh placebo injection control condition, and or PRT. And PRT here was nine sessions. It was one session with a physician, followed by, and that was Howard Schubner, followed by eight sessions with a therapist, and that was either Alan Gordon or Christy Weedby. And uh and they were the developers of PRT. And then we also and we scanned people's brains before and after treatment, and we collected patient-reported outcomes and measured like how much pain are you in, and how much of the pain interfere with your life, anxiety, depression, right? Before and after treatment. And um, I was a graduate student at the time, I was leaving the study, and the the results were really remarkable. Like I started saying earlier, when I started the study, I was a healthy dose of skepticism to say the least. If anything, I was even reluctantly working on it.

SPEAKER_06 33:57

Yeah.

SPEAKER_03 33:58

Um, but even before like we unblinded and saw the results, you know, I would kind of hear stories from the therapist about what was happening, and I'd even hear, watch some of the recordings, and uh bump into patients in the hallway who'd be like, I'm out of pain. And I'm like, huh? What's going on here? This is not supposed to happen. So what we what we found really briefly is that quite large reductions in PRT uh in pain intensity. People went from about a four to about a one out of ten pain intensity. A substantial portion of people reported uh being out of pain uh post-treatment, just saying, I don't have pain anymore. Uh the brain scans showed that there was less of a response in the interior insula and interior cingulate to this kind of back stimulation device we did during brain imaging, which is consistent with this model of less processing of sensory input from the body, less interoceptive amplification that's happening. And um and we also just completed last year a five-year follow-up on these people. These are people we hadn't had any contact with them, you know, besides these nine sessions they got five years ago, no further contact. And and we saw lasting benefits appear at T even five years later, including still a meaningful number of people who were reporting zero pain. Yeah. Uh, you know, so very encouraging and um kind of amazing.

SPEAKER_05 35:29

No, no, it was stunning beyond belief, is kind of what it was. We all looked at this and said, no way. That was kind of the reaction, no way. Come on, what happened here? And you know, it's interesting that we've gotten bits and pieces of data sense that make us feel comfortable with the you know, with the effectiveness of these treatments. And so there was one piece of the boulderback pain study that I wish we could use in our studies, and that was the role of Dr. Howard Schubiner as the physician, who did what during that first session? Talk a little bit about what he did.

SPEAKER_03 36:08

That's an important part here, and that was you you're right, Afton, to pick up on this. This was not traditional in the sense of most studies you see a therapist for eight to twelve, maybe sixteen sessions. And yeah. And this was in the first study with Howard.

SPEAKER_06 36:25

Yeah.

SPEAKER_03 36:26

And the the role here was assessment and education. So Howard looked through, and let me emphasize this was a phone call. So this wasn't an in-person physical exam.

SPEAKER_05 36:36

I didn't know that.

SPEAKER_03 36:37

Yeah, okay. Yeah, it's kind of amazing. But people sent Howard their whole medical records, any pre-existing spinal imaging that they had, and Howard, you know, looked through it all, talked with them, uh, got to hear their pain story, um, understood how the symptoms present. Are they do they move around? Uh, how widespread is the pain, how variable is it from one day to the other? All these clues that can help point towards a centralized brain mechanism. And then Howard said, you know, basically, I'm a doctor and uh I think you have neuroplastic pain. And let me tell you what that means. And and Howard's quite clear and compelling and compassionate. Um, and we never try to like convince anyone or bulldoze them. It's really about educating and sharing a new perspective for people to consider and to try on.

SPEAKER_02 37:27

Yeah.

SPEAKER_03 37:28

And uh that really set the stage, I think, for the therapist to work effectively.

SPEAKER_05 37:33

Yeah. And there's something so powerful about the physician acknowledging this, I do believe is going to be helpful for you, and this is a reason why. So I thought that was such a secret sauce. And I wish we had many Howards that can take place in our studies that you know can provide that reassurance. You know, we have patients think about, you know, if you have pain that's due to structural damage, it's pretty much in that spot, a similar level of severity, and it doesn't do too much, except for you, maybe worse if you ex you know, if you exert it. Um, it doesn't move, it doesn't, you know, go to the other side of the body, it doesn't change, it doesn't go away forever to come back at the end of the day. You know, it's you know exactly.

SPEAKER_03 38:16

And it doesn't get worse when you show up at your in-laws. Yes.

SPEAKER_05 38:20

So predictable. And it's what's so interesting is that people who undergo this therapy say, oh my God, I so see it now. This is so interesting.

SPEAKER_03 38:28

That's really the goal. And provide us education, we really are hoping that people have a light bulb moment where they're like, oh, I've gotten so many explanations from so many different doctors about this torn labrum or this degenerating or whatever. And none of that really ever made sense. And now everything you're saying, this makes sense. Now I understand why my pain is worse at the in-laws and why my pain started during the you know, the stressful breakup. And yeah. So so we're hoping that this really helps people make sense of their pain.

SPEAKER_05 38:57

Yeah, it it it's incredibly powerful. So, okay, so one really big cool study. Other studies supportive of PRT. What's out there now?

SPEAKER_03 39:07

Yeah. So one study is never enough.

SPEAKER_05 39:10

Uh-huh.

SPEAKER_03 39:11

Um, there's been a few um studies published.

SPEAKER_06 39:15

Yeah.

SPEAKER_03 39:16

Uh so you and and me, together with Drew Sturgeon, recently published uh some findings on a abbreviate, a brief format of PRT for fibromyalgia with some encouraging results there as well. Uh, there's a migraine case series published by Joel Fishbein, showing uh in a case series, some patients having really remarkable uh reductions in migraine severity with PRT. And um there's other studies that are ongoing uh that I'm aware of as well. And perhaps most uh one of the most stands out is one I won't be able to talk too much about because it's not published yet. We're just working on getting it submitted now. But we compared PRT to CBT in a sample of 150 people with chronic back pain. And uh we're really pleased with the results. Um you know, what we're finding is that the proportion of people who attain this recovery status is going to be really variable across studies. Yeah. But large reductions in pain is very consistent across the across both of our trials that we've conducted.

SPEAKER_05 40:23

It's super exciting. And you know, and just I we we we certainly cannot scoop your your findings, but I think you guys did a beautiful job addressing any of the concerns from previous days. Hey, we methodologically, we've done some different things to you know to really help us zero in on what's happening, and it remains encouraging. And you know, we certainly see the same thing in our pilots today. We're just finishing a one in veterans and Drew Sturgeon's leading, and that we know you and I are uh is co-eyes on it. And the same thing with our veterans with chronic back pain. Every once in a while it's like, oh, it was a six, now it's a two. And it's like 25 years later, how is that possible? Because you know, if if people aren't pain researchers, um we don't see pain reduction much more than a point often. We get very excited if we see a point and a half of pain reduction, a really good intervention. Even some of our medications, we get very excited about that. We just don't see the needle in pain move. And that's why it's right here.

SPEAKER_03 41:21

And well, I think what we're learning is that for some people, more is possible, more pain reduction is possible. We can get there.

SPEAKER_05 41:28

Yeah, yeah.

SPEAKER_03 41:29

And I think we have to understand that.

SPEAKER_05 41:31

Yeah, and I and I think it's also a skill. This becomes a skill that people who actually click onto it, they practice it, they do it. I think that you know, people can get better at it if they don't immediately respond. That exactly, yeah, that they that there's definitely room to grow and improve the skill and have a better effect.

SPEAKER_03 41:49

Yeah, and there's, I mean, there are these cases where people have a very rapid, large response. And those cases I think generate a lot of interest and even hype. And that's you know, it's not the typical course. The typical course of treatment is, you know, kind of you just it takes more time. I don't want to put any numbers out there, but it takes more time. You stick at it and you see over time uh things are trending in the right direction. And then, you know, one day, a few months later, you look back and you're like, wow, I'm actually doing a lot better.

SPEAKER_05 42:20

Yeah, yeah. So you've talked to a lot of patients who have undergone the therapy. What's it like for them? Can you give us a sense of what the experience might be undergoing PRT?

SPEAKER_03 42:31

It's gonna be really variable for different people. I would say for some people, it's gonna be challenging in the sense of challenging their beliefs. Like some people will really this will really rub against what they think, you know, some people uh really believe, and they may be right that it is like the misalignment of their spine that is driving the pain. And yes, maybe. Uh or some people really think it's the scoliosis or something. Um but so PRT will be, you know, we'll do an assessment. And if the pain isn't neuroplastic, then it will challenge those beliefs.

unknown 43:09

Yeah.

SPEAKER_03 43:10

Um, but and along with that, PRT also aims to be quite gentle and compassionate, and it's really a lot of paying attention to sensations inside your body in a new way. And you know, for some people it's really deep and beautiful, and for some people, um, it's very intense to actually really stop and feel what's happening inside. Yeah. There can be a lot of emotions, a lot of feelings that are kind of bubbling just below the surface that people have been pushing out of awareness. And uh you stop and you pay attention to your body, and and somebody's, you know, some of this starts to come up. So it can also be intense, uh, even though we we work with a lot of gentleness, it can be intense.

SPEAKER_05 43:50

Yeah. But often that's the start of another level of recovery, too. So that can be a launching point for a much deeper, wide. Or broader recovery. So yeah, exactly.

SPEAKER_03 44:02

Exactly. It is. It's part of the healing.

SPEAKER_05 44:05

Yeah.

SPEAKER_03 44:06

It's part of the healing.

SPEAKER_05 44:07

Oh, that's beautiful. So our time went very fast. Where can people go to learn more about PRT and the work that you're doing and you know other useful? We we can link things in our in our uh in our show notes. But what do you where do you what do you have some good go-tos?

SPEAKER_03 44:22

Uh my first recommendation would be to the website for an association that's called the ATNS Association for the Treatment of Neuroplastic Symptoms. Okay. And the website is very catchy. It's www.symptomatic.me.

SPEAKER_06 44:36

Okay.

SPEAKER_03 44:37

Um and that's a really nice kind of one-stop shop with a lot of resources there for different um related to PRT, EAET, and other related approaches. Um, I would say for now, there is an online training for providers who are interested in learning how to deliver PRT. That's pain reprocessing therapy.com. Uh disclosure, I'm one of their trainers. So there's a I just want to put out my conflict of interest there. Uh but we've heard great things about people, you know, from people taking a training come back with great feedback. And um there's there's a book that Alan Gordon wrote called The Way Out. And Howard Schumanner has a book called Unlearn Your Pain. Yeah. And those will be two great books. And um and this podcast is just a great way to keep learning about pain in the brain and different psychological treatments. There's so many wonderful episodes here.

SPEAKER_05 45:31

Oh, thank you, Yo. No, that this is just such a cool topic, and I'm so excited that we got to dive into it. And we're gonna definitely have to have you back on once your results are out with from your new study. You'll come join us again. Maybe we'll do a little results roundup.

SPEAKER_03 45:43

I'd be delighted. I'd be delighted.

SPEAKER_05 45:45

That would be awesome. So um before we go, um I often ask my my um podcast guests, um, what did I not ask you that you had wished I might have asked you?

SPEAKER_03 46:03

Another time we'll have to talk about my own uh journeys with my own chronic pain uh conditions over time.

SPEAKER_02 46:08

Wow.

SPEAKER_03 46:09

Nothing too severe or intense, but you know, more kind of mild to moderate chronic pain conditions that also uh gave me a lot of insight into uh into how this all works as well. Or, you know, insights that ideas to say test in the laboratory.

SPEAKER_05 46:24

Yes.

SPEAKER_03 46:24

Uh that you can generate hypotheses from your own experience.

SPEAKER_05 46:28

Which is incredibly powerful. You know, you understand the process at a different level. I I my my my sweet husband is very open about this too, but he has he's had neuroplastic pain for years. And when we first took kind of a Sarno approach, it was the first time he just went away. And so every once in a while it kind of comes and goes. And for and for me, it's always been a reason why I've been very passionate about this and learning more and wanting to be, you know, to to to you know play a role in the you know assessment of the uh uh of of interventions and and the validation because it's made all the difference in the world in his life. So, like you said, for you it's powerful, you know, for my family members. So that's that's really key. Okay, good. Well, maybe when we have you back on, you could talk a little bit about that. Okay, okay. Last question I'll ask you what brings you joy?

SPEAKER_03 47:22

You know, I knew you were gonna ask me this, so I did some thinking about it. I love singing. I love, and I'm not a good singer, so I'm not gonna sing, but I love like singing with friends and with community. Uh uh like joyous and spiritual uh song is it really you know lifts my spirits pretty reliably.

SPEAKER_05 47:41

Oh, that's good. That's that's beautiful. Yeah. I I can't sing a notebook boy, I enjoy it too.

SPEAKER_03 47:47

Exactly, exactly. It's so neat, it's good exposure therapy. Do something you're not great at.

SPEAKER_05 47:54

Well, someday maybe you'll sing.

SPEAKER_03 47:58

I sing all the time, but just not on uh not on podcasts.

unknown 48:02

Okay.

SPEAKER_05 48:03

Well, Yoni, thank you again. It's really been a treat.

SPEAKER_03 48:07

Yeah, it has Afton. Thank you so much. It's a pleasure to get to uh discuss and think through all these important issues and to have you as our colleague in the field.

SPEAKER_05 48:16

Oh, thank you. We'll be well.

SPEAKER_03 48:18

Great. Take care.

SPEAKER_00 48:20

If the Chronic Pain Reset Podcast series has brought you some inspiration and hope, please consider joining the community of listeners who have helped fund our production. Your support is important for us to keep creating content for those impacted by chronic pain. Look for the Support the Show link in our show notes in each episode. Today's episode was produced and edited by William Hassett, made possible by listeners like you, Son of a Books, and the team at Venue by 4M. Our music score, Just Being, was produced by Bohemian Roosters. That's it for today. Join us in two weeks for another episode of Chronic Pain Reset.