No Stranger to Pain

Unfortunately, Rivka was no stranger to pain.

Beginning in high school, Rivka had been plagued by frequent headaches, as well as sciatica, foot pain, and lower back pain. There was always something new to try to ease the aches and pains: supplements, chiropractic, acupuncture, craniosacral therapy. Rivka had tried them all.

Each practitioner had their own theory as to the source of her pain. Each practitioner was only too happy to take her money. The chiropractor told her she was “all locked up,” and weekly adjustments were all she needed to feel great. The naturopath sent her for allergy testing and told her to start on a diet limited to beets and sweet potatoes. Rivka had tried it all, but the lack of progress left her feeling very disillusioned.

This new pain was just another in the list of agonies that had tormented her all her life.

On the phone one day with her cousin Chaya, Rivka mentioned the pain she was experiencing in her wrists.

“Oh! Let me tell you about this book my son’s neurologist told me about. She thinks it might really help him with his migraines. It’s kind of like the Sarno method, but different,” Chaya said. Chaya added that the neurologist told her she recommends the book to all of her patients, and had even sent her in-house psychotherapist to be trained in the method described in the book.

Impressed — and desperate — Rivka immediately went to Amazon and ordered The Way Out, by Dr. Alan Gordon. From the book’s description, Rivka realized that it described a mind-body approach to pain, which she was familiar with, having tried the Sarno method in seminary.

Sarno speculated that the subconscious mind diverts one’s attention from negative emotions by creating pain in the body. Rivka had tried journaling, bringing up every past grievance and misfortune, but she found it very unpleasant to dwell on past pain. She had seen improvement in her back pain at the time, but wasn’t able to sustain long-lasting results.

When The Way Out arrived, Rivka read it eagerly. Gordon’s book, she discovered, was a more updated, scientific method, built upon some of Sarno’s foundational ideas. Rivka couldn’t believe how much it resonated with her. The author described the long list of ailments that he suffered from — back pain, neck pain, toe pain, tooth pain, heel pain, itching, fatigue, leg pain, foot pain, TMJ, among others — and how he successfully rid himself of these pains using a method he called pain reprocessing therapy, or PRT.

What Is Pain?

Through a combination of real-life data, neuroscience, and brain imaging, Alan Gordon was able to study and understand chronic pain.

So what is pain? All pain starts in the brain as a response to danger signals from the body. For example, if you fall and break your arm, your brain will send you pain signals to let you know that you have injured your arm and it needs attention.

The problem begins when your brain fires these pain signals despite there being no physical or structural cause for it. Our brains learn behaviors through neural patterns that wire together, allowing us to do complex, learned tasks easily. For example, a toddler needs to learn how to walk. Once he figures it out, the brain learns the behavior and the complex motor movements become automatic. Sometimes, the brain can actually “learn” pain through repeated experiences of pain. From there, it can learn to be in pain even when there’s nothing physically wrong.

A famous article printed in the British Medical Journal in 1995 recounts the story of a construction worker who was on-site when he accidentally jumped onto a six-inch nail, which pierced straight through his shoe. Screaming in agony, he was rushed to the emergency room. Once there, the doctors removed the shoe and discovered that the nail had actually gone right through the space between two of his toes, leaving him completely unharmed. His brain, in a state of intense danger and fear, had interpreted regular sensations as pain signals, even though there was zero physical cause for his pain.

Pain without a physical or structural cause is called “neuroplastic pain.” The feelings of pain are absolutely real. But the pain that the brain creates is actually a mistake. As Gordon writes, “The good news is that just as your brain can learn pain, it can unlearn it. Pain reprocessing therapy retrains your brain to interpret signals from your body properly.”

Obviously, each patient presenting with pain must be evaluated individually to determine whether or not his pain is neuroplastic. Gordon notes that most pain caused by a physical problem will heal or respond to medical treatment. It won’t become chronic.

Since Rivka was already familiar with the concept of mind-body connection through her Sarno work, it was easier for her to accept that her wrist pain could be neuroplastic.

And reading Gordon’s book, she found more evidence that her pain may be neuroplastic. There always seemed to be some sort of pain for her to focus on, yet the pain was never in more than one place at a time. Rivka frequently thought about her pain and was always scanning her body to investigate what was currently hurting. She came from a normal, healthy home, and hadn’t suffered any real trauma, but she did put a lot of pressure on herself to achieve and accomplish. She was always on the run; wasn’t every young, frum mom? Her brain was frequently on high alert, which Rivka learned, is a common factor in many patients with chronic pain. (See sidebar for additional ways to determine whether pain is neuroplastic.)

At the same time, Rivka wondered if there could be a structural cause for her pain. When she put more stress on her wrists, they hurt more. Back when she had sciatica, walking long distances would bother her. But as she thought about it, she reminded herself that she had done these same activities — nursing her baby, cutting vegetables, doing push-ups — many times without pain. She realized she was experiencing a conditioned response, where her brain had learned to send pain during certain activities.

Breaking the Cycle

To break the cycle, Gordon explains, we need to teach our brains that the pain we’re experiencing isn’t dangerous. When the brain believes that the body is damaged, it responds by producing pain. If we can accept that the pain is not due to any dangerous physical cause, the pain will disappear.

Modern medicine assumes that pain is caused by a structural problem in the body. It can be hard to break away from this belief. When doctors look for problems, they are likely to find them. But sometimes, that structural issue may not be what’s causing the pain.

Patients can start their healing journey by searching for exceptions: by trying to pinpoint the times when the pain is lessened or entirely absent. These times can serve as evidence that the pain isn’t caused by a structural or biological problem.

Gordon discusses a patient named Barry, who had his two front teeth knocked out by a drunk stranger and went on to develop chronic mouth pain. None of the treatments he tried helped. X-rays showed that his injury had healed and there was no logical reason for his pain — yet the pain persisted for six years after the accident! Then Barry attended a corporate retreat that featured an engaging and inspiring motivational speaker. The speech left Barry feeling so hopeful that his pain disappeared. Two weeks later, the pain was back — but Barry was able to use that pain-free time as evidence to himself that his pain was neuroplastic. Eventually, he was able to successfully rid himself of the pain.

People with chronic pain will often find that their pain is worse while doing certain activities — perhaps a certain chair will cause back pain or long drives leave them with hip pain. These can be “conditioned responses,” where the brain has created an association between a certain action and pain. It’s not actually the activity that causes the pain; the brain has just learned to send pain signals during this activity.

Rivka realized that the wrist pain she felt while nursing her baby or chopping vegetables was a conditioned response — and she was determined to use PRT to beat the pain. She began searching for exceptions. Rivka had blamed her wrist pain on the position in which she held her baby while nursing. But for the first four months of nursing in the exact same position, her wrists had been fine! There had also been a few days, during the previous week, when she’d been free of wrist pain while her lower back pain had started up. If there was truly something wrong with her wrists, the pain should have accompanied her back pain — not disappeared when it flared up.

One of the most important parts of pain reprocessing therapy is somatic tracking, which requires the patient to pay attention to pain sensations without fear. It’s practicing mindfulness in a nonthreatening way.

Somatic tracking comes with a few caveats that can be tricky to master. It’s most effective when you’re not focused on what the outcome might be: You need to watch the pain without trying to fix it or force it to go away. The key is to be curious and light when paying attention to it.

The second caveat is that somatic tracking is best done when the pain level is low. When the pain level is high, it’s better to do whatever it is that normally makes you feel better. In order to stop interpreting normal signals as pain signals, the brain needs to feel safe. Pushing past the pain can actually ratchet up your fear and danger level, leading to more pain.

Another important piece to solving the pain puzzle is embracing positive sensations. Many people with chronic pain will find themselves constantly scanning their bodies for pain. They become hyper-attuned to every ache and sensation. They feel like their bodies have betrayed them, that they are somehow broken or unfixable. To tackle this, tune into the positive sensations in your body: the ease with which you inhale and exhale, or the feeling of your feet hitting the pavement as you walk. This retrains you to have a positive, compassionate relationship with your body, enabling your brain to feel safe.

The groundbreaking Boulder Back Pain study (JAMA Psychiatry. 2022) indicated that PRT is the most effective treatment for chronic pain. The randomized and controlled study assessed 150 people with chronic back pain (some of whom had actual diagnoses based on MRIs or X-rays). Fifty of the study participants continued with their usual treatment, 50 received a placebo injection, and 50 received PRT twice a week for four weeks. In the PRT group, 98 percent of the patients showed improvement, and 66 percent reported that they were pain-free after the treatment. Studying fMRI imaging that showed before-and-after images of the patients’ brains, Gordon and his colleagues were able to see that the patients’ brains had actually changed in the process, with the fMRI showing a reduced response to an evoked pain stimulus.

Intrigued, Rivka googled PRT and found a host of other people who said that Gordon’s book had given them their life back. Tziporah Hait, a clinical social worker based in Israel, shared one such story. On Get Help Israel, she relates how at 32 years old, she began suffering from terrible foot pain. She was subsequently diagnosed with Plantar Fibroma, inflammation of the TP and FHL, pelvic misalignment, and other diagnoses. Tzipora was treated by podiatrists, an osteopath, physical therapists, a reflexologist, and general practitioners, who tried cortisone shots, massage and physical therapy, acupuncture, and pain killers. Nothing worked. After discovering PRT, she was nearly pain-free in two months. Tzipora now incorporates these techniques in her own therapy practice to help others.

Reading all of this, Rivka felt a new hope that she hadn’t felt in years. The next time she felt slight pain in her wrists while nursing her baby, she took the opportunity to practice somatic tracking. She closed her eyes and turned inward toward the pain. It was a slight, warm throbbing. She visualized it in her mind’s eye, and told herself, “There is nothing wrong with my wrists. My brain is making a mistake and sending me pain signals, but there is no reason to be afraid.” She even made a little mental joke to keep her feelings around the pain light and nonthreatening.

After a few days, Rivka began to notice that when she would do somatic tracking, the pain would actually disappear.

After a few weeks, Rivka’s wrists felt great. She was able to return to doing all the things she needed to do. She even got back to push-ups in her weekly workout class. She was on top of the world — until one morning, she bent down to pick up a sock and her lower back began to spasm. I’ll never break free from the pain. I’ll always hurt. Her thoughts continued their negative spiral.

After a few hours, Rivka realized she was experiencing what Gordon referred to as a setback. She sent herself messages of safety, used a heating pad, and kept reminding herself that there was nothing wrong with her back. Her brain was just sending her mistaken pain signals.

By morning, the pain was gone.

Back in her workout class a couple of months later, her friend Dini watched Rivka doing push-ups on the next mat.

“Feeling better?” she asked.

“Yeah, baruch Hashem,” Rivka answered. “So much better.”

They both got into position for lunges. Dini grumbled, “My knees have been really bothering me lately.”

Rivka looked at her wrists and smiled. “I have a great book for you.”

Is My Pain Neuroplastic?

When you’re in pain, your pain is very real — no matter what its cause. So how can you tell if your pain is a real danger signal of some physical problem or just mistaken neural messaging?

There are usually some clues:

• Have most treatments been ineffective or only provided temporary relief?
• Does the pain move around to different parts of your body?
• Do you focus on the pain throughout the day?
• Did the pain come during a stressful time?
• Are symptoms better or worse depending on the time of day?
• Is the pain symmetrical (both hands, both feet, etc)?

Answering yes to most of these questions is a pretty sure sign that the pain may be neuroplastic.

The three habits most associated with patients who have neuroplastic pain are worrying, self-imposed pressure, and self-criticism. These patients’ brains are in a state of high alert, which can reinforce the pain cycle.

When we respond to pain with fear, our brains keep interpreting normal signals as an alarm — reinforcing that the pain is dangerous, and making it persist. This causes a feedback loop. The pain triggers fear, fear reinforces the pain, which leads to more fear, which leads to more pain. Realizing that the pain is neuroplastic, and using PRT to fight it, can help break the painful cycle.

(Originally featured in Family First, Issue 928)