Pushkin.
When you think about the pain a thousand times a day, when it's the first thing you think of when you wake up, the last thing you think of before you go to sleep, you're constantly checking in to see if it's there. When you attend to the pain, there were a lens of fear, frustration, despair that reinforces to your brain that these sensations are dangerous and it becomes this terrible cycle.
Typically, when we think about pain, we assume that something structural is causing it, like a muscle strain or a ruptured ligament. But psychotherapist Alan Gordon studies how pain can also emerge when our brains misinterpret safe signals as dangerous.
Pain is a survival mechanism. It helps us when it's working the way that it's supposed to, but sometimes the brain can make a mistake. Sometimes the brain could interpret danger where there is none and generate pain even in the absence of an injury or structural damage.
On today's episode, a novel Approach to treating chronic pain, I'm maya Shunker and this is a slight change of plans, a show about who we are and who we become in the face of a big change. Alan is an assistant professor at the University of Southern California, and he's a therapist who helps counsel patients with chronic pain. He's also the author of the book The Way Out, a revolutionary,
scientifically proven approach to healing chronic pain. The idea behind Allan's work is that a lot of the pain we experience isn't actually caused by structural issues. Instead, it's the brain misinterpreting the body's signals. In those cases, Rather than endlessly searching for medical interventions, we're better off refocusing our attention on practices that can rewire our minds and relieve
our pain. Later in the episode, you'll hear Allan guide me through his process to relieve some knee pain I've been experiencing lately. But first I wanted to learn more about what drove Allan to enter this line of work in the first place. Alan, I know that your work has very personal undertones, and I was wondering if we could first start by hearing the story of your experience with chronic back pain.
It was back in my mid twenties and I was a really active person. I was on a kickball team, I would play sports all the time, and I was in graduate school at USC at the time, and one day I woke up and I had back pain. And it was very strange because I didn't have an injury. There was no car accident, there was nothing like that, and I just thought, Okay, well, it'll pass. And by the end of the week it was still there and it was horrible. Every time I would walk, I would
have pain. Every time I would sit, I would have pain. I remember going to a movie with some of my friends. By the end of the movie, I was in so much pain. I literally didn't go to another movie for years after that because it was such a traumatizing experience. And so I started having all of this fear around the pain. Is this what my life is like? Now? What's going on? I went to the doctor, got an MRI.
I actually saw three of the best orthopedis in Los Angeles, and each one of them had a different take on what was going on with me. The first one said, this is definitely due to a discarnation. And I remember him holding up this MRIs and there's this five millimeter discreanation with partial nerve root compression. I could still see it in my mind. Then the next one I saw said, you know, I don't actually think that's what it is.
I think it's due to disc degeneration. And once again he holds up my MRI scan and shows me all of these flattened discs up and down my vertebrae. The third one that I saw just looked me up and down and said, I think you have back pained because you're just too tall. Nothing I can do about that. I just remember thinking, how did my genes even survive through evolution that I have this much wrong with my back.
When I'm in my mid twenties, and I did every treatment under the sun, everything that you could think of, acupuncture, acupressure, physical therapy, and I ended up having to move home. I'm living with my parents, and over the next couple of years, I start getting more and more symptoms. I got chronic headaches, I got wrist pain, knee pain, chronic fatigue, getting more diagnoses, more treatments, and nothing worked.
Yeah, when you experienced chronic pain, it can be so all consuming, right, and mean, it's like the only thing you think about. It comes to define who you are in this fundamental way. I mean, what eventually led you to a slightly better place.
Well, I was at home. My mom comes in to my room one day and she's holding a book and she says, I want you to read this book. My friend's son had back pain and he read this book and it helped him. I got so mad at her. It felt like an attack on the fact that, like, you know, my pain wasn't real or something like that. And I said, Mom, a book isn't going to help me get better. This isn't in my head. I have
these real structural problems in my body. I think I pulled out my MRI report and was going over all the findings with her, and she was like, all right, I'm just trying to help. And she left the book there and I think it sat on my bookshelf for maybe something like nine months, and finally one day I picked it up and I read it. And there's one thing that jumped out at me that really struck me.
There was the study that I read about in the New England Journal of Medicine, and it found that the majority of people with no back pain have disc bulgess herniations distogeneration, that essentially these are just normal abnormalities and not the cause of pain in most people. I mean, I had seen probably two dozen doctors by this point.
How had I never heard this before? And so I went down the rabbit hole of learning everything I could about pain and neuroscience, and I found that very often with chronic pain, the symptoms are the result of misfiring pain circuits in the brain as opposed to structural problems
in the body. And then from there, I, you know, working with my own symptoms as well as some patients I started working with as a therapist myself, I developed a set of techniques that we now call pain reprocessing therapy, and I was able to overcome all of my own symptoms from a brain based approach.
So let's dig into the basics here. Tell me what pain is, and then tell me how you would define what you call normal pain.
So all pain is generated in the brain. If you put your hand on a hot stove, the pain is your brain's way of letting you know you need to move your hand so that you don't cause more damage. Essentially, what's happening is the nerve endings in your hand or sending danger signals to your brain. Pain is a survival mechanism. It helps us when it's working the way that it's supposed to. But sometimes the brain can make a mistake.
Sometimes the brain could interpret danger where there is none and generate pain even in the absence of an injury or structural damage. And we call this neuroplastic pain, which just means learned pain. And more and more studies are showing that many forms of chronic pain are actually neuroplastic And just like this pain can be learned, it can be unlearned.
Yeah, And I think it's so important at this point in the conversation to clarify that all pain, whether it's normal pain or neuroplastic pain, is real pain, right, because all pain originates in the brain. So there's no thing as saying like, well, this is all in your head versus this other type of pain isn't in your head. It's all in your head. So you're not in any way invalidating the existence of the pain or the intensity
of the pain. You're simply saying that the cause of the pain might vary depending on whether it's caused by a structural issue in the body versus something that's originating because your brain has made this mistake.
Yeah, all pain is real, Yeah.
You know, a foundational message of this work is that pain does not imply that there is a physical injury. And I mean that is a seismic shift in perspective. I mean, I remember growing up, I was on the cross country team. Something hurts, I instantly think, oh my god, what did I injure? I mean, it's the only question I asked myself. But there's a couple really amazing studies that show how you can experience pain in the absence
of a physical injury. So the first is this simulated car crash study, right, and I'm wondering if you could tell me a bit more about that one.
Yeah, this was brilliant. This was in Germany, and these very creative scientists created a condition where the subjects were sitting in a car on a track and they thought they were rear ended from behind by another car. And what the scientist did is they had crash sounds come up over a loudspeaker. There was an actual dent in the back of the car that was there previously that the person didn't see, and the car was on an inclined plane and so it slightly moved forward, but there
was no actual impact between the two cars. And what they found was that eighteen percent of people had neck pain after this fake placebo car accident, and a month later, ten percent of them still had neck pain. So even though there was no injury, the brain thought there was and generated pain.
You also been one of the lead researchers on a big back pain study. This is the boulder back pain study, right. Tell me a bit more about that.
All of the patients in the study had had chronic back pain for an average of ten years going into it. What the study did is we looked at three different groups. One group got pain reprocessing therapy, one group got a placebo treatment, and then one group got no treatment. There
were fifty patients in each group. We got fMRIs of everyone's brain before and after, and amazingly, in the pantiprocessing therapy group, we found that sixty six percent of the patients were either pain free or nearly pain free after four weeks, and remarkably a year later, they were still out of pain.
That's extraordinary. And you know, to clarify for listeners, there was no physical intervention like as part of pain reprocessing therapy. Alan and the other researchers never touch people's backs or gave them physical exercises to do, which is again just such a significant shift in the way that we think about pain or what we were taught for, at least for me for decades of my life.
Yeah, everything we've ever known about cause and effect is telling us if you have pain when you walk, if you have pain when you sit, then it's the walking or the sitting that's causing the pain. Really, so it's counterintuitive to really wrap your mind around the fact that, like, I have pain, but there's nothing wrong with my body. So I was even shocked by how regenerative of the body is and how such a high percentage of chronic pain could actually be neuroplastic.
Yeah, what about for people bull for whom this chronic pain is instigated by an acute injury, what's going on in the brain in that case.
Yeah, that's a great question. So the injury is real, there's maybe a lot of fear or preoccupation around the symptoms. The brain learns and remembers the pain, and the pain persists even after the injury heals. There was another study where they looked at a lot of patients who had initial episodes of back pain and they took scans of their brains, and they found that the pain was present in the areas of the brain that are normally associated
with pain. And then they followed the patients who went on to develop chronic pain, and they took brain scans again, and they found that the pain had actually moved to the parts of the brain associated with learning and memory, so that even after the symptoms heal, it could still be chronic. You know, I had knee pain for a while and I ended up getting imaging on it, and I had a severely torn meniscus tear and there's no blood flow to the meniscus, and I ended up needing
to get surgery to fix that injury. So I don't want to be so black and white about it and say that all chronic pain is neuroplastic.
So, Alan, you've established that neuroplastic pain is very, very prominent.
Right.
It is responsible for so much of our chronic pain, for so much suffering in the world. Right, how do we get rid of the damn thing? What is your process for getting rid of neuroplastic pain?
This is the exciting thing is that it's very treatable. Even in the Bolder Back Pain study, there were some patients who had had chronic back pain for forty years and they were able to overcome their symptoms in just a few weeks. So it doesn't matter how long you've had the pain. If you have neuroplastic pain, then you are able to overcome it. So the first thing that you want to do is determine whether or not you have neuroplastic pain or structurally caused pain. And there are
twelve or thirteen different criteria that we look for. I'm not going to go over all of them right now, but a few of them are did the pain come on during a time of stress. Another thing we look for is does the pain spread or move around right Sometimes it's on the left side of your back, sometimes
it's on the right side of your back. Another thing we look for is inconsistency of symptoms, so you know, maybe it is really bad during the week, but on the weekends or when you're on vacation it's a lot better. Or you know, maybe it's there in certain positions but not other positions, and it's not really consistent. All of these things are indicative of the fact that it's neuroplastic pain.
But even if you're able to wrap your mind around the idea that you have neuroplastic pain on an intellectual level. It's really hard to embrace on a gut level because it's it's counterintuitive, and so it actually involves embracing a reality where your senses are lying to you. So it can be very tricky to do, even if you have
all the evidence in the world. So sometimes it can be helpful to create an evidence sheet so that you know, you can put up on your fridge and constantly look at it to reinforce.
This is neuroplastic.
There was a patient that I saw a while ago, and she came into my office and she had chronic back pain. Every time she sat. She sits down and she says, I know that you're going to tell me that the pain is being caused by my brain, but I don't believe it. I just don't believe it. And I go, okay, we'll see what happens. And halfway through the session I did a meditation with her, and by the end of it, her pain was completely gone. She opened her eyes and I said to her, well, now
what do you think? And she looked at me for a few moments and she said, I still don't believe it. It was so funny that even in the face of overwhelming evidence that the pain went away.
Yeah, it's really really hard.
It's hard to wrap your mind around. And so the main technique that we use for pain reprocessing therapy is something we call somatic tracking. So normally when we pay attention to the pain, it's with a sense of fear, preoccupation, worry, despair, and all of these negative emotions. When we're attending to the pain through that lens reinforces our brain that the
pain is actually dangerous and keeps the pain alive. So somatic tracking is is it's a way to try to break that pain fear cycle, where you're attending to the pain in a new way to show your brain that the signals that are coming from your body are actually safe and not dangerous.
After the break, I asked Alan if you could coach me through somatic tracking. I've never tried it before, but I've had this annoying knee pain for a while and I really wanted to see if it could help me. We'll be back in a moment with a slight change of plans. I have a personal story that really error is yours, So probably at this point eight or nine years ago, I was taking a one of those bar classes and I remember during the ab part of the workout,
I kind of just strain lightly my lower back. A week goes by, two weeks goes by, it's not quite getting better. And the more time that passes, the more stressed out and freaked out I am that I've done something terrible to my lower back. Fast forward a year and a half, I'm struggling with chronic lower back pain. I was not able to sit without pain for a year and a half. I became terrified of sitting. It
was just like it was a stressful. And so the moment it was unlocked for me as I remember seeing the head of orthopedics at George Washington University and he looked at my MRI scan and he said, Maya, there's nothing structurally wrong in your back.
Wow.
He just said that to me. He's like, there is nothing wrong with your back. This is logical pain. And it's so interesting because in that moment, because I'm trained in neuroscience, I was so thrilled by this news. It did not feel like he was invalidating my pain at all.
Yeah.
I mean, it's so empowering to learn that. However, to your point, knowing it intellectually is very different from intuiting this emotionally. So it took me still years to unwind the pain. And there are still times now where I'm sitting on a chair that's at a not appropriate angle given what I'm comfortable with, and I start to feel that pain return. So it is definitely a process. It's really hard to buy into because you still feel really
threatened by it. So this is to say, I know one thing that you've discovered in all of your work is that fear is a huge reason why neuroplastic pain is so sticky, right, like why it sticks around for so long. And I think that's what happened. The more it stuck around, the more fearful I got, and it was this negative vicious cycle.
It's the pain fear cycle. So when you think about the pain a thousand times a day, when it's the first thing you think of when you wake up, the last thing you think of before you go to sleep, you're constantly checking in to see if it's there. When you attend to the pain, there were lens of fear, frustration, despair that reinforces to your brain that these sensations are dangerous and it becomes this terrible cycle.
So, Allen, I've never tried somatic tracking before, and I would absolutely love to give it a shot. Do you think it's something you can coach me through right now?
Do you have pain right now?
Yes? I'm aching in my knees right.
And so are you still struggling to determine whether or not this pain is structural or neuroplastic?
Yeah, it's like I'm not totally convinced that it's neuroplastic. That's part of the problem.
Yeah, and so this is like it's real. Yeah, this is I mean again, all pain is real.
I know, I know, I know, but here I am it feels structural, really feel structural.
Let's let's go through the evidence. Well, we know that you're very prone to neural plastic pain. That is a big piece of evidence in and of itself, but that's not definitive. So you know, even if you're prone to neural plastic pain, you want to be scientific about this. You never want to make assumptions, and so, you know, we want to gather as much evidence as possible. What other evidence do you have about your knee let's do an investigation.
Okay. I think another is that I've had this history. Okay, I have had long periods of time in which this right knee of mine was so achy it put me out of working out for a while. I had a lot of anxiety around it.
So we know that those neural pathways are already laid down, right, So maybe sometimes when you feel stressed out, that kind of may be your go.
To, And it's worth mentioning that in this particular case, this episode of knee pain transpired following a legitimate physical injury. So I had a swollen bursa and I'm still stuck with this deep aching of my knee.
Okay, quick question. When the burso was swollen, was your knee hurting in the way that it's currently hurting or was it hurting in a different way.
My knee actually was not hurting at all when the bursa was swollen, So the verse is a few inches from my knee that I was not feeling any aching in my knee. As the burso was resolving, I started to develop this aching in my right knee.
Okay, yeah, this is neuroplastic. Okay, this is the evidence that we needed. Whenever you have pain that is delayed from the onset of the actual injury, that is like the holy grail of evidence that your pain is neuroplastic. If the pain that you feel right now was caused by this bursa swelling, you would have had it while the burso was swollen. It wouldn't happen days later. What it did is it refocused this level of attention and preoccupation you had around this already scary part of your body.
And so you know, your brain was like, yay, we have a way we could bring her back into fear preoccupation mode.
Yeah.
So now all we need to do is show your brain, get your brain experiential evidence that there's nothing wrong with you.
You want to try, I really do. I'm so excited. I've never done this before, so I'm really excited.
So all you're doing right now is you're trying to give your brain the experience of attending to this pain in a new way. So close your eyes and just bring your attention and maybe just take like a couple breaths at first, just to calm your system down. Good.
And it's so interesting, Alan, Like, as I'm taking these deep breaths. My brain is constantly trying to redirect attention to the knee.
That's okay, I mean it's hard not to. Your brain is trying to help you. It's just misreading the signs okay. So let's so indulge in in the messages that your brain is giving you. See if you could bring your attention to your And what I want you to do is just see if you can be a little bit of an investigator. And the first thing we want to do is just explore where you feel it. Is it a widespread sensation? Is it localized? How do you experience this sensation?
I feel it. It's fully under my kneecap and right below my knee cap.
Okay, And how would you describe the quality of this sensation? Is it a burning sensation? Is it tingling? Is it a little throbby? Is it a pressury sensation?
Yeah? I would say a combination of throbbing with a little bit of pressure.
Good. Good. Just even the fact that you're able to describe it as good. Oftentimes people think pressure means bad, but I imagine getting a massage, right There's all this pressure putting on you, but it feels good. So we don't need to get rid of this sensation. So this is the first thing that is important for you to wrap your mind around. You don't need it to go away, you don't need to get rid of it. All we need to do is help your brain wrap your mind
around the fact that it's safe. I would not tell you this was neuroplastic pain if I had any doubt. What's going on right now is your knee is sending safe sensations to your brain. But because you have so much fear, so much preoccupation around these signals, your brain is making a mistake and it's interpreting these sensations as if they're dangerous and generating this kind of unpleasant pressury throbby sensation. So we don't need to lower the intensity
of it. But I want you just to lean into the sensation and just breathe into it, knowing that it's safe. It's just your brain overreacting to a perfectly safe, perfectly neutral sensation, and breathe into the sensation and just let it go. And what do you notice happening to the sensations as you're paying attention to them. Does the intensity increase, does a decrease?
What do you notice, Yeah, I feel kind of lightness in the area, So I still feel that throbbing.
That's okay, but I feel that.
There's like a little lightness and a little tingly.
Okay, good now, so just ride it out.
Just jumping into say that. Alan and I did this exercise for far longer than what you're hearing, but we wanted to just share the highlights with you.
Really breathe into it with each in breath and h out breath. See if you could actually feel what happens to the sensation as you breathe in and out. Bring your attention back to that sensation, your need, and I want you to just let it go away.
This is really extraordinary. I really feel a significant reduction in the throbbing. Yeah, under my cat.
And here's the thing we're so tempted to say, like I'm feeling a reduction and intensity, that's a good thing. I'm jumping for joy and celebration in a totally neutral way.
Neutral way. Yeah, I understand, I understand. I very much could have not had that response and it would have been totally fine. And this is a practice that I would do exactly do.
Yeah, when your attention goes back to the sensation through a lens of fear, of preoccupation or hyper vigilance. It's going to be there, but that's okay, And this is the point of all of it. We don't want it to go away. We just want to teach your brain to attend to it.
And right now I'm feeling that aching just as much as I did before. Yeah, so I have to be okay with that. So to summarize this pain reprocessing therapy approach, step one is gather evidence around whether it's neuroplastic or not. Right. The second is to do the exercise we just did, which is to attend to the sensation simp so that your brain learns this is safe.
Right.
So tell me about what step three is of this reprocessing therapy.
Yeah, so step three is really addressing the psychological issues that may have made you more prone to developing neuroplastic
pain in the first place. Some of the personality traits that we find that make people prone to developing neuroplastic pain, along with anxiety, along with depression, chronic fatigue is the tendency to put a lot of pressure on yourself, tendency to beat yourself up a lot, and the tendency to worry yep, because these are really all things that are going to bombard your brain with messages of danger and make you more prone to eventually attending to these sensations through a lens of danger.
So those are working to identify internal stressors putting pressure on yourself worrying. What about external stressors, of which there are an abundance in modern society.
I think there's two different of external stressors. One is the type of thing that you can't control, Like if you have a ton of kids, they're always running around and a really tough job, tough job. What you do in those situations is you increase your capacity to regulate your system on more of a moment to moment basis so that those stressors affect you less. But a lot
of this external stuff we bring on ourselves. You know, there was a time when I was reading the news on my phone every day, two hours a day, every different outlet. I was reading it, and you know, I was bombarding my brain with danger signals because they're not putting like happy, fuzzy stories on the news. It's the kind of thing that's going to stress your brain out. I mean, you're either communicating messages of danger to your brain or messages of safety to your brain, like all
throughout the day. So what you want to do is shift that balance.
It's so interesting, Alan, because I feel like the work you're doing is so important, and I can imagine how challenging it is to tell people about pain might not be the results of an underlying injury because you're running up against, you know, billion dollar healthcare industry. You're running up against all of these pharmaceutical companies. Like ye, what you're offering is a free technique that is available to every person in the world. It's not like you're hiding
the ball. You just went through the process with me, and it can be really hard to convey science that cuts against other people's financial interests or like industry financial interests.
Yeah, it's really the biggest inefficiency in all of medicine.
You know.
They found that chronic pain is actually costing the US economy over six hundred billion dollars every year. So one of the things we're working on right now is partnering with health insurance companies so that this treatment can be provided to people for free and everybody wins they get better health insurance companies are saving money and it could eventually lead to this paradigm shift in the way that chronic pain is treated and understood.
Yeah, such a hopeful message. And it is true that for whatever reason, pain reprocessing therapy might not work for you, like we really hope it does, and it works for a ton of people, but there was no downside to giving it a try, even for the biggest skeptic out there.
Yeah. I mean, the saddest thing in the world is when we did this boulder back pain study. These patients had had pretty debilitating chronic back pain for an average of ten years before learning about this study, and they all said the same thing to me, why didn't I
learn about this sooner? So that's really what we're hoping that we're in the beginning of a paradigm shift, so that in the future this is going to be a frontline treatment for chronic pain and not just the thing that you try after everything else failed.
Hey, thanks so much for listening. Join me next week for a two part conversation with my friend Kelsey Snow. When Kelsey first met her husband, Chris, she fell hard. They soon fell in love, got married, and had two kids, but then Chris received a devastating diagnosis of ALS, a progressive neurodegenerative disease, and Kelsey's identity had to shift from
wife to caregiver. If you enjoyed my conversation with Alan, we on, the Slight Change team would be so grateful if you could share the episode with someone you know, it helps us get the word out so we can keep making more episodes for you. And if you're looking for more stories of Change, you can always check out our back catalog. Thanks so much and see you next week. A Slight Change of Plans is created, written, and executive
produced by me Maya Shunker. The Slight Change family includes our showrunner Tyler Green, our senior editor Kate Parkinson Morgan, our senior producer Trisha Bobida, and our engineer Eric o'huang. Louis Scara wrote our delightful theme song and Ginger Smith helped arrange the vocals. A Slight Change of Plans is a production of Pushkin Industries, so a big thanks to everyone there, and of course a very special thanks to Jimmy Lee. You can follow A Slight Change of Plans
on Instagram at doctor Maya Shunker. See you next week to