Transforming Pain Management: Pain Reprocessing Therapy with Howard Schubiner

[00:00:00] Howard Schubiner is a physician who moved from a career in academia to a medical practice where he faced the challenges of pain like many of us. It was the work of John Sarno that started his journey to approach pain in a different way.

[00:00:11] He didn't have all the science and neuroscience to back up what he was saying, and you made a few mistakes along the way, but his general thesis turned out to be great, and he began over years to expand it to other things besides back pain.

[00:00:22] I went to work with him for a few days and I came back to our hospital and I said to my boss, hey, I want to start a little practice. It became clear to him that getting to know his patients at a deeper level than lab tests

[00:00:32] and imaging studies was key. As he started to utilize and hone his approach, he started to see some pretty impressive results. Her headaches completely went away after 17 years of chronic daily headaches, and we see the same thing with back pain and irritable bowel and fibromyalgia and…

[00:00:48] It is clear that many healthcare professionals are hesitant to delve into psychology and emotions in their practice. I know I for certainly was. He had some thoughts on this and why it's probably important for us all to incorporate some psychologically informed principles into our practice.

[00:01:01] What are you going to do? You're going to just ignore that when you know that's the thing? I could turn off the pain like that and your patient or client would be eternally grateful to you? What are you going to do?

[00:01:14] Pain reprocessing therapy was the main focus of his practice, and it was rooted in helping people make sense of their pain and helping them gain skills to move back into the life they wanted. We reversed it in PRT by helping people be more empowered, less afraid, and sometimes

[00:01:29] it's hard to do. Obviously, how do you make yourself not afraid of pain? Not easy, but gradually over time we teach them how to change the neural circuits in their brain by… Physical medicine and rehabilitation clinics have a tendency to be biased towards structural diagnosis.

[00:01:44] Howard discussed studies that have been published showing that many of the conditions seen in PimaNar practices are non-structural or nociplastic in nature. If you have 222 people coming to a regular usual PimaNar practice, like all of his

[00:01:58] partners in his own practice, 95% of them would be diagnosed as having a structural problem. He also discusses how we need to take our current methods further to develop more comprehensive approaches to better manage pain.

[00:02:10] More research is on the horizon and it is hoped that it will continue to help us shed light on better ways to manage and treat pain and help people reclaim their lives. We will talk to the next level beyond the pain education, beyond the CBT and ACT type

[00:02:23] stuff to the level of pain. And I'm only saying this because the data, that's what the data is showing us. And we'll follow the data. In this week's episode we will talk with Dr. Schubner about this and much more.

[00:02:34] Don't forget to check out our community at modernpaincare.com. forward slash community to go deep on these topics and more to better help you in your practice. Now, onto the episode. This is the Modern Pain Podcast with Mark Karjula. Welcome to the podcast, Howard. Hey, Mark.

[00:02:50] Good to see you. Thanks so much for having me. It's great to have you on. I think there's been a lot of buzz in the research world and really enjoyed reading your work around pain reprocessing therapy. I know you do more than just that.

[00:03:00] There's other components of your practice that touch upon today. But I think there's been some exciting developments with research of the study that came out in JAMA Psychiatry in 2022 was a real kind of landmark study that showed we could make some longstanding changes in pain.

[00:03:14] You've seen some other methods that have been encouraging that have similar yet differing perspectives around kind of dealing with some persistent pain issues, but excited to have you on today. And I was wondering for the audience who may not be aware of you, if you

[00:03:27] could introduce yourself and then maybe interested in how people get to where they are working with persistent pain and their story because often it's one lace with frustration of maybe traditional methods of pain. And how did you get to where you are today? Well, it's come all, Mark.

[00:03:43] Kind of a long story. But basically, in my undergraduate years, I had some questions about the medical profession. We had a pamphlet called Billions for Band-Aids back when I was in undergraduate school. Now it's Trillions for Band-Aids.

[00:03:57] But so there were some questioning of how the medical profession was working and whether we were getting to the underlying cause of illnesses or we're just kind of treating symptoms. And anyway, but I spent first 18 years of my career at Wayne State University as a full-time faculty member.

[00:04:14] And I did research in a variety of different topics and et cetera. I became a full professor there in 2002. And then I left, which is not the usual academic pathway, but I was just tired of the academic grand race.

[00:04:27] And I moved to a really nice community hospital in the Detroit area called Providence Hospital. And they let me do whatever I wanted. And if so happened that next year, somebody, a good buddy of mine,

[00:04:39] gave me this book by John Sarno, Dr. Sarno, who, where he was saying, he's been writing this since the 80s that a lot of people with back pain, it's not because of their back. It's because of stress and trauma and emotions that are going on

[00:04:54] in their mind and in their brain. He didn't have all the science and neuroscience to back up what he was saying. And he made a few mistakes along the way. But his general thesis turned out to be right.

[00:05:04] And he began over years to expand it to other things besides back pain. Anyway, I went to work with him for a few days and I came back to our hospital and I said to my boss, hey, I want to start a little practice in this.

[00:05:14] He says, OK, go ahead. So I just started talking to people and I took time. And I literally just started talking to people about their lives and their pain and looking more and more closely at what are the

[00:05:28] characteristics of pain that allow us to determine if it's actually structural pain as our first job as a physician or a PT or whatever we are to make sure that we're not missing some kind of cancer or fracture or inflammatory disease. We have to do that.

[00:05:44] But I also talked to people about their lives and looked at the links. And so one of the very first patients I saw was this lady who had headaches for 17 years. She'd been to several headache clinics. She had injections.

[00:05:56] She had every medication you could name and nothing helped her. And she told me her simple story, which was that she got the pain when she got a new pair of glasses, a new prescription. Like how can that cause pain for 17 years?

[00:06:09] They tried to fix the prescription, gave her different lenses, whatever, nothing worked. So I said, well, what was your childhood like? She says, well, my mom was fine. My dad was just a little unpredictable. Sometimes he'd come home and be really happy and smiling.

[00:06:22] The other times he'd come home and be so angry to grab me by my shirt and scream and yell at me, what's wrong with you? Can't you do anything right? And she grew up and she was fine.

[00:06:31] She had no symptoms until she was in her mid 40s, late 30s I think. And I said, so what was going on at the time you got the new pair of glasses? You know, she's one of my husband was fine. My kids were fine. My job was fine.

[00:06:45] Anything else? Well, my boss, he was a little unpredictable. Sometimes he'd be really happy and kind and supportive. And other times he would just go off the rails and yell and scream. And it was really hard on me.

[00:06:58] And it was like, oh my God, could this be the cause of her pain? That her brain was primed as a child to be so fearful of a particular type of stress or trauma? And when that stress or trauma recurred in her life

[00:07:18] in a mirror image way, that her brain was trying to send her a message saying, get out of there. Something is wrong. And the brain doesn't speak English. It speaks in pain or anxiety or depression or fatigue or insomnia. And she became fine.

[00:07:34] No doctor, no headache doctor could help her. But using the simple methods that we can talk about, her headaches completely went away after 17 years of chronic daily headaches. And we see the same thing with back pain and irritable bowel and fibromyalgia and all these disorders

[00:07:50] that are in the new ones now. We have elder stand lows and POTS and Nescel activation and there's always something new that we're trying to pin down as a structural problem. We can talk about long COVID even if you want.

[00:08:04] But that just blew my mind in the last 20 years, 21 years now I've been working on it, trying to refine the history, refine the diagnostic methods, and refine our treatments along with lots of other people in the space to do better. Now we have randomized controlled trials

[00:08:21] showing that this stuff works, TSW. This has definitely been encouraging. We're all looking forward to seeing more and more come out obviously replicating some of the great results. It's always a challenge, but it definitely one we're hoping to see methods like this accomplish.

[00:08:37] Discuss how it took you this transition of working into what Dr. Sarno's book really stimulated that where do you see general training of physicians? And this exists obviously in physical therapists where I work. Where is that lacking as far as helping prepare

[00:08:54] clients to enter the world and have the ability to kind of manage these type of cases? Well, obviously we tend to still educate in a more traditional biomedical, very linear pain view of things where structure equals function, equals pain type thought process.

[00:09:09] I'm just wondering where you see the challenges that lie in our training of physicians and healthcare professionals? I'm working with a great psychologist at University of Michigan now to set up a training program for the medical students at University of Michigan. And we're looking at this model

[00:09:25] that I've been thinking about. I haven't really written about it too much yet, but I'm thinking about it a lot. And it's the idea that there's three models, ways of thinking about pain. The original model is the biomedical model,

[00:09:37] the structural model that all pain is due to an injury and the brain just reflects what happens in the body. And sometimes that's a fine model to use for certain types of disorders. If you have a broken arm, you know, well, fix the arm.

[00:09:51] And a lot of patients really want that model because they just want to pill or they want a procedure or whatever it is. And then the second model is the dominant model in the field now, which is the biopsychosocial model.

[00:10:02] So started by George Engel, who was one of my heroes? I don't know if you can see, there's a picture of Dr. Engel up on the wall in my bookcase up there. And so there's nothing wrong with the biopsychosocial model, it's an incredible model.

[00:10:16] But it's been what's happened over the years is the biopsychosocial model has been used in great ways biopsychosocial will have a little bit of each. And when you apply that to pain, what patients hear is biopsychosocial. And part of what they hear is there's something wrong

[00:10:35] in the body and then it's being changed or amplified or processed in the brain and by my social circumstances. And that model works really well for disorders where there is a biological issue. Rheumatoid arthritis or something where there's an inflammatory condition in the body

[00:10:54] and there's processing by the brain and the immune system gets involved and you can do work with that. And the dominant treatments for that are cognitive beef in the psychological space or cognitive behavioral therapy, mindfulness therapies and acceptance and commitment therapies which all are great therapies

[00:11:12] and have a really good track record. But this model is not really a curing model. It's more of a coping model. You've got a problem and we'll help you cope with it. And that's been the dominant model in the field of pain.

[00:11:25] We'll help you cope with the pain. They're not assessing what the cause of the pain is. It's just saying you have pain and will help you down regulate your brain and your nervous system and that'll help. And the research on the model has shown positive effects

[00:11:39] but relatively small effects and effects that tend to not persist over time. This is very clear in the thousands of studies that have been done. So it's not a bad model at all. The model that we're using is what's called the symptom perception model

[00:11:53] which has to do with the fact that our brain creates what we experienced and this is based on the predictive processing and this is the particular answer your question Mark. This is the art that's missing in our training the idea and most people

[00:12:10] at all levels of training are missing this and not getting this because the symptom perception model tells us that our brain literally creates what we experienced and the simple way we know that is that we don't see with our eyes. We see with our brain.

[00:12:26] If you needed your eyes to see you couldn't see in your sleep when you dream. So obviously the brain can create the images that we see and the brain is the way the brain works is predicting what it's what we see. When you see a bird flying over

[00:12:40] actually you can't our brain can't process the bird flying or the insect flying it has to predict how it's gonna be make it smooth to make it look like it's a smooth path. And whenever you're predicting what's gonna happen you're gonna make mistakes.

[00:12:55] So the brain has to filter out billions of bits of data all the time and only pay attention to what salient and then our science is called that the salience network and the salience network lets us pay attention to what's really important.

[00:13:10] If a car swirves toward you on the freeway your salience network kicks in immediately and you have an immediate reaction as your brain's always looking out for you. And so with vision we don't see with our eyes we see with our brain

[00:13:23] and our brain is gonna make mistakes. Eyewitness reports of crime are completely and are notoriously inaccurate. When a police officer goes to a scene of something do they see a gun or not? Well it depends on what their brain sees. What we hear is the same thing

[00:13:38] and what we feel is the same. So the simple fact that you can have an injury without any pain, that's simple fact which has been shown and replicated thousands of times in the literature means that it's not an injury that causes pain

[00:13:53] it's not a one to one relationship. It's because the brain decides to create pain at some level. Usually it does it within a nanosecond and usually when there's an injury you get pain because the brain's there to try to protect us. And then if you take the opposite

[00:14:07] where there's thousands of examples of people who had pain without any injury which is a simple story the guy with the nail through his boot had severe pain but no injury at all, what does that tell us? And research shows a lot of great research from UCLA

[00:14:24] and from the University of Michigan showing that stress and emotional input to the brain activates the exact same parts of the brain as does a physical injury. And this simple fact tells us that all pain is created in the brain.

[00:14:39] It's created in the brain either through an injury or through some stress or emotion situation that leads to this danger alarm signal which produces pain or other alarm symptoms, anxiety and so on and that that pain is of course 100% real.

[00:14:58] It's all the same it's all created by the brain. So it's just as real to have pain that's coming from a broken arm as it is coming from a broken heart. It's just as, and it can be just as severe

[00:15:10] and our patients are like, how can my brain for the pain that's so frigging severe and debilitating and lasting for years how can that possibly be my brain? And the answer is it happens all the time. We've got new data that we can discuss about back pain

[00:15:30] and the etiology of that as well. So that's what's missing. And I think those in different, and these different models are really highly useful. They're all useful, but I think they should be applied to the correct disorder with the correct patient.

[00:15:47] So the patient may not want our simple perception model your processing model. They may reject it. A lot of people do, I mean, surprise. Oh, it's in your brain. Are you saying it's all in my head doctor? You know, you know, F off. We hear that a lot.

[00:16:02] We're all over a lot of your, you know, when you try to explain this to somebody, they're like, yeah, right doc. You know, I think I need a different doctor or different PT. But for certain disorders, like headache, migraine, we'll talk about back pain in a minute,

[00:16:16] fibromyalgia, irritable balsam, your most chronic pelvic pain where people are diagnosed with pudendolaryngia, irritative stitis, bulavidinia, cossidinia, vast majority of those I would argue from our experience and data is mind-blowing pain or narrow-circuit. Wondering if you think, because you point out, and I definitely see this clinically

[00:16:39] and I'm sure a lot of the people listening see the same thing of just this rejection of that type of thought process. And I'm wondering if you see in your practice where people almost have to go through a journey before they're ready to accept this type of narrative.

[00:16:52] And the journey, unfortunately, a litany ofologists and specialists and massage therapists and physios and chiro's and all, we could probably go on and on and listen. Folks who take that, like I'm gonna find it and fix it type of thing and type of issues

[00:17:06] and we'll get into how you kind of evaluate who is that right patient, where it's more that kind of centralized pain like you speak to in some of your work. I'm just wondering, do you feel like that journey just needs to happen for some people

[00:17:18] or are there people who are ready to take on that narrative even early on in their journey with persistent pain issues? Yeah, great question. It's very cool. I would say most people need a process. And there's nothing wrong with the process of ruling out medical problems.

[00:17:36] We want that to happen, obviously. I'm a physician. I know there's disease in the world. So we want that to happen. But on the other hand, some people can pick it up really easily because it's not that counterintuitive to recognize that when you have a stressful day

[00:17:52] you might get ahead of it. It's not that counterintuitive to recognize when you're suddenly put on the spot in front of a bunch of people, they have to speak that your stomach turns into a knot. It's not that unusual to think that when someone's

[00:18:04] a pain in your neck, in your life that you might get neck pain. I mean, it's not that unusual. Luis Hayes sold like millions of books about this, about the symbolic nature of pain. It's not always true or applicable, but it certainly happens.

[00:18:19] And so some people tend to latch onto it quite quickly. And then some people go overboard. They've read Dr. Sauer and they say, oh, all back pain is mind body or all my anica is mind body. And clearly that's not true either. Because we need to evaluate people

[00:18:36] that's just part of the process. I wonder if we can get into a little bit of the process. We spoke before we started our recording today and the pain reprocessing there, one piece of a more kind of comprehensive nation assessment that you do.

[00:18:50] One big part of it is making sure the type of pain is being delineated and not just again, everything assumed to be centralized pain and then not everything assumed to be true nociceptive tissue driven pain. I'm wondering if you can speak to a little bit

[00:19:04] of the process you go through to kind of take through this kind of approach. Yeah, that's really important. And I spent so much time working on this. And so we published on this and there's a new study that we just published that I'll tell you about

[00:19:19] at the end of this little section here. But the bottom line is of course, job number one, as I said, real auto structural problem. Get the routine medical test. Make sure that the studies have been done number one. Number two, do not over interpret data.

[00:19:34] And I'm sure you're well aware of this and hopefully most of your audiences are aware of this but we show a slide to all of our patients, every doctor and every physio and every chiral need to see this slide that 80% of 50 year olds have degenerative disease

[00:19:50] without any pain, 90% of 60 year olds, 60% of 40 year olds have degenerative disease with no pain at all. It goes up to 95% as you age without pain and back pain does not rise with age. It levels up if the 50s or 60 level. And bulging this are the same.

[00:20:09] You can see the exact same pattern with the majority of people and even 30% of 30 year olds have bulging this without any pain. And so to attribute and it's the same with facet, facet arthritis and the other spondylolisthesis, et cetera. So if you over interpret that

[00:20:28] and you blithely assume that the pain is due to what's on the MRI ignoring the data that these findings can be normal, I think that's a disservice to the patients. It's the same thing with small fiber neuropathy and personal neuropathy type things.

[00:20:44] EMG is showing EMG is a nerve conduction velocity study showing minor changes that were normal in a lot of people and shouldn't be over interpreted. And we know from Cramer's work on X-rays, just plain X-rays, if you have a severe totally damaged hip,

[00:20:59] yeah, you probably need a new hip, okay? Obviously, but mild to moderate arthritic changes in shoulders and these joints are normal in a lot of people. Laboral tears in shoulders and hips are normal in a lot of people without pain. I mean, there's ample data to show that.

[00:21:17] So get the good evaluation, rule out structural problems. Secondly, don't over interpret tests and have an open mind. Well, if you have an open mind, then you're left with, I don't know, maybe it's your hip, maybe it's not, maybe it's your back, maybe it's not.

[00:21:30] So what we've developed is the third step of the process which we call the rule in process. How do you rule in a neurosurgeon problem? Well, the way you do that is with the characteristics of the pain. And so I've developed this something called the criteria

[00:21:46] is the pain functional? Is it inconsistent? And is it triggered? And what that means is pain, and most people really understand this. It's not rocket science. It's not like I created some magical formula but I just put it together in ways that are simple and easy to use.

[00:22:01] Functional pain, if you have sciatic pain in your leg it's gonna be the back of the leg or the side of the leg or the front of the leg depending on what dermatomet is, right? But if it's the whole leg, well, that's not, that's functional.

[00:22:13] That's not a nerve. No nerve goes to the whole leg. If it's both legs, it's bilateral. You can certainly have pain that's bilateral if you have a central lesion, if you have diabetes or something. But frequently pain that's bilateral started on one thumb

[00:22:27] and Jesus went to the other thumb. But the x-rays aren't showing anything much and it's not rheumatoid arthritis. So what is it? And so you see this bilateral that also tends to be functional. You see pain that started without any provocation. It woke me up at night.

[00:22:41] Well, what's going on at night? Your brain's active at night. I'm just mindless asleep. And it is, so that's the kind of functional. It's in a wide area. It's the whole side of the body and the whole head or whatever. And then of course certain disorders are functional

[00:22:56] like migraine, tension, headache, fibromyalgia, irritable bowel. These things we know we've done evaluation and there's no actual tissue damage in the body. So that's functional. Inconsistent means the pain turns on and off. So I was talking to the other day she had severe headache pain.

[00:23:13] It just went on and on and on. Doctors couldn't help her, no one could figure it out. She said, I'm gonna go to Hawaii. She went to Hawaii, boom, pain turned off like that. She came home, boom, pain turned on again.

[00:23:23] She said, oh, I know what this is. It's not rocket science. It turns off when you're going to, when it's there when you're sitting in a certain chair but not there when you're sitting in another chair. And the PTs and the chiro's are saying,

[00:23:34] oh well, it's the way you're sitting. It's the posture. It's the, it's the, you know, oh that chair is just a little softer. It's like, okay, is that really gonna make that much difference? Maybe I get it. If you're trying to fit it into a bio,

[00:23:49] into a structural model, you can always find a way to do that. But if you look step back and say, God, it's really turning on and off. It's sometimes it's on the right side of the back and other times it's on the left side of the back.

[00:24:01] Oh, why is that? And we're saying, well, the neural circuits are turning one pain on and turning the other pain off. So that's inconsistent. And then triggered means triggered by innocuous stimuli. Is it worse with light or sound? Is it worse with stress?

[00:24:16] Is it worse when you go to visit your in-laws? Is it worse with the weather? Is it worse when you're, and then the big one is, is it worse when you're bending over or twisting? Okay, so if you have back pain, it's worse when you're bending over.

[00:24:31] Well, that sounds structural obviously. It has to be structural. But if we have an open mind, it could be a conditioned response. It could be that the brain is sensing danger in the movement of bending over and this happened all the time. How do you sort that out?

[00:24:45] Well, you ask, you have to probe and you have to listen. And you have to say, well, is it always hurt when you bend over? Sometimes it doesn't, sometimes it doesn't. That's interesting. Why is that? Does the structural problem sometimes there and sometimes not there?

[00:25:00] If your arm was broken, sometimes it hurts and sometimes it doesn't. I don't think so. And then I've got this other thing, which is really like my pride and joy testing, which is basically asking if you have pain with bending over, asking people to stand up

[00:25:14] and they're having light pain or no pain. And that's them to imagine bending over. And you would be amazed. How often people say, yeah, I just imagined bending over and oh, my back started to tighten up or I got this tension or anxiety in my chest.

[00:25:29] Your brain is showing you that's afraid of bending over. And then you can reverse that in one minute, 90% of the time. And it sounds silly, but I just tell people, well, that's interesting. We have all this data that we just, the whole evaluation,

[00:25:44] it looks like this is a non-structural pain. This is a no-see plastic condition that you're dealing with, which is real. You're not crazy, it's not in your head, you're not nuts. It's not because you want the pain, it's not your fault, it's real. This is common.

[00:25:59] You see this all the time. So what if you tell yourself that you're okay? You're safe, you're not in danger. That there's nothing wrong with your back. Why don't you just tell yourself that in a blind and then you imagine bending over.

[00:26:11] Then they go, okay, well, that's right, yeah, sure. I'm safe, I'm not in danger, there's nothing wrong with my back. Now I'm imagining bending over with a smile on my face. And I say, well, what happened this time? Oh, my back didn't tighten up. Holy crap.

[00:26:24] You just changed the neural circuiting of your brain. And now all of a sudden it all becomes clear. It's whole evaluation that we did. And then obviously the final thing that I didn't even touch on yet is you can look at,

[00:26:36] well, what was going on in your life when the pain started? What was your childhood like and all those sorts of things. And how do you treat yourself? You know, are you really hard on yourself? Are you really, you know, somebody,

[00:26:46] you know, it started with a, you know, somebody had worked and didn't, you know, pass you over and gave somebody else emotion. And then you start beating yourself. What did I do wrong? What's wrong with me? Why can't I succeed? And that kind of triggers more

[00:27:01] of the danger of signaling the brain. So that's a model we use. And we studied it just recently. We just published a paper in the journal of pain that just came out, I don't know, this year, a couple weeks ago, I guess,

[00:27:12] where we evaluated 200 people using this model, desired tree practice, unselected, people with chronic neck and back pain, totally unselected, not selected for, oh, you're coming to a research study on stress, you know, or something like that. You're coming to a physiatrist because you have pain

[00:27:29] and this physiatrist who's a fantastic, I mean, Bill Lowry in Lake Charles, Louisiana, blue collar population, not some upper middle class, you know, deal going on down there. And these folks, and he evaluated using the same criteria I just gave to you. And if you have 222 people coming

[00:27:49] to a regular usual PM and R practice, like all of his partners in his own practice, 95% of them would be diagnosed having a structural problem, roughly, 90 to 100%, depending on the doctor. His data that he came up with using these criteria was 88% were non-structural.

[00:28:09] We just published this, it means 12% were either structural or combined. And he says, he says, this is a cautious number. This is not a wild, I'm not, if I think it might be structural, I'm gonna put it in the structural data. And there were some that were,

[00:28:24] he thought were structural, that we put in the structural category that future data showed him, it was actually non-structural. But we didn't change the category for the purpose of the study. We wanted to keep it conservative. And this, I don't know, to me, Mark,

[00:28:38] this is just revolutionary data to have a real data showing us. People have written about this for years. In the Lancet articles on chronic back pain, published a couple of years ago, they say 88, 85, 95% of low back pain is non-specific. Well, what does non-specific mean?

[00:28:56] What we're doing is we're taking non-specific, which means I don't know. And we're taking it out of the biopsychosocial model where it's some bio, some psychos, some social. We'll do a little bit of everything, which shows effect, but not long lasting and curative effect.

[00:29:13] And we're putting those people, not everybody, but those people, the 88%, into the symptom perception model, the predictive processing model, the nociplastic category. And when you know, you actually have a nociplastic problem. When you actually know that there's nothing wrong

[00:29:31] with your back and I have a good story to tell you about that in my own personal story with my foot pain. I can tell you in a minute. Once you know, it can make all the difference in the world. And our techniques, the pain we're processing,

[00:29:44] the emotional awareness, the how we treat ourselves, the changes in your life, those treatments are designed to not manage the pain, reduce the pain. They're designed to eliminate the pain. And that's what people want. People don't want their pain to be managed really, right?

[00:30:03] You go to the main pain centers in the country, and I'm not gonna name names, but the biggest pain centers in the country and you get a pain management program, which is based on the biopsychosocial model. We'll do a little, we'll do some of physical,

[00:30:17] we'll do some of the mental, we'll do some of the acupuncture and the massage and we'll put it all together and we'll manage your pain. We can't care it, but we'll manage it. We think there's a better model for the people

[00:30:30] who are willing to engage in that model, not everybody, and the people who have the disorder that fits that model, not everybody. But I would argue it's the majority of people with chronic pain. So you mentioned it's obviously, like you said, pretty eye-opening data that you see there,

[00:30:46] 88% not having structural pain yet. I would probably venture a guess that 100% of them went into that setting thinking they had a structural thing. So there lies the problem of like, how do you transition these folks to understanding that there is more to pain than structure?

[00:31:03] We've already touched upon that a bit. I would like to get into a little bit about the emotional piece that you kind of work with with your approach. I think that's one thing that I know for me personally and then talking to clinicians,

[00:31:16] you know it's not a comfortable area to delve into when anger and tears are shed in rooms. Sometimes I used to just go the other way. I didn't know how to process it personally because it was just, you get to get comfortable

[00:31:28] in some of these contexts with patients and kind of getting in the mud with them. But speak to a little bit about, I know there's parts of it where you do expressive writing and emotional disclosure. You also do your emotional awareness and expression therapy as part of it.

[00:31:42] You don't maybe have to get into the exact details of it, but can you speak to kind of how that gets into your approach? Yeah, absolutely. Well, the PRT part, the thing we processed in the program has been shown to be highly effective for eliminating pain

[00:31:57] in the majority of people in our Boulder Backbone Study. And we are doing two more PRT studies this year in addition to that. So, and there's another study out of Harvard that showed again 66% roughly had eliminated pain using the PRT approach,

[00:32:16] which is basically making the pain less dangerous. When you start bending over, you're saying, I'm okay, I'm okay. When you start walking, when you start moving. So your neurons are fired together, wired together. And so, when every time you move and bend with back pain,

[00:32:32] every time you eat something because you're just going to bother your stomach or every time you with your headaches, every time something, some trigger, the weather changes, you're afraid and you're teaching your brain and reinforcing over and over and over again this pain spiral of pain, fear, pain.

[00:32:49] And so we reverse that in PRT by helping people be more empowered, less afraid. And sometimes it's hard to do obviously, how do you make yourself not afraid of pain? Not easy, but gradually over time we teach them how to change the neural circuits

[00:33:06] in their brain by linking, pairing empowerment and safety and even joy with movement as opposed to fear with movement. And that changes the neural circuits and those can change on a dime. Well, basis of neural circuit, pain turns on and off. Well, hey it's turning on and off.

[00:33:23] It went away when you were in Hawaii. It went away when you were on the boat with your buddies. That means it can go away. There's hope, there's optimism. So the PRT part is basically that. Now the emotional awareness and expression part is a little bit more sticky.

[00:33:39] And one of the physical therapists, the main physical therapist that I work closely with is Charlie Merrill in Boulder, Colorado. He and I teach on this specifically for PT's and Cairo's and massage therapists any kind of manual body work folks, us, etc. And Charlie has become comfortable

[00:34:00] dealing with emotions to some degree over time. You gradually train yourself. Like somebody says, you know, what do you notice? Here's another thing, you know, what do you notice when you think about that colleague at work who's tormenting you? Pleasure eyes and just put yourself in that position

[00:34:19] of what's happening, being in the at work situation. What do you notice? Again, same thing. I get tension in my chest. I get tightness in my back. Okay, well yeah. So what would you like to say to that person? Not what you could say or should say.

[00:34:38] What would you like to say to that person? What's the urge, you know, you've got anger toward them, right? What's the impulse? So simple, right? And you can write it out, we can do it in your mind. And what would you want to do to them?

[00:34:49] You know, just your, what would the anger want to do? You would never do this. We don't condone violence. But what would the anger want to do? Oh, that's easy. I want to say to him, F off.

[00:35:00] I want to say to him, you're a fucking piece of this. And you know, you're worth us. I'm not putting up with you anymore. And I just want to shake them. I just want to slap them or push them and walk away. How does that feel?

[00:35:14] Man, that feels good. Now let it go. Just let it go. If you're hanging onto anger, what's that doing to your brain? Danger, what's that doing to your back? Tight, tight, tight. We have a good research showing that anger that this actually causes,

[00:35:30] there's a great study by John Burns in Chicago where he showed when people wrote about their anger, their back, literally the back muscles, literally tightened up. So here's this, how simple is that, right? You can do it in writing, you can do it in your imagination.

[00:35:44] Now let it go. And now, is there any hurt? Is there any sadness? Okay, it's sad. It's sad for you that your boss can't see your value. That's sad. What do you do with sadness? Anger is to protect, to defend yourself. Sadness is to connect.

[00:35:58] So what do you do with the sadness? You turn it into compassion for yourself. I'm okay, I'll be all right. I can handle it. Now move on. Maybe I'll look for another job. Maybe I'll just do my job and not worry about the able other person

[00:36:15] and things will work out. I'll be okay. And what do you need to do? Maybe you do need to look for a job. Maybe you need to say something publicly to your boss about that person or you need to say something to that person

[00:36:29] but you're not gonna punch him and you're not gonna swear at him. You're not gonna do that. You've already done that. Now you're gonna approach him with civility, but standing up for yourself in assertive. And this works in marriages and works in families

[00:36:44] where people need to be able to be civil but assertive and loving to the people they're helping to realize it hurts when you say that stuff. I care about you. I love you. It hurts when you say that stuff. I mean, I'd really appreciate it

[00:36:57] if we could find other ways to deal with this. In that process, that's the essence of E-A-E-T right there. And it's not that complicated. And we've written about it. We have manuals on it. And I don't know, do you think you're a physio kind of guy, right?

[00:37:13] Does that sound that scary to you to just what I described? Does that sound normal? No, it doesn't sound scary. I think sometimes, and I'd be curious to your thoughts too is just clinicians sometimes feel like they got to paint themselves into this box

[00:37:26] as I'm a physical therapist. Where, you know, and into the emotions and the muddy gray areas of pain is just an uncomfortable thing. And I spoke to this to other guests too. It's like, I just think sometimes it's a security blanket for us to hold onto

[00:37:40] of just like, I want to resolve it all to this linear pathway because that's what can give somebody comfort in the clinic. But yet when we see people come in with these complex pain states and a lot of emotions and things like that,

[00:37:52] I mean, we do them a significant disservice by not engaging with some of these emotions and different things like that. And as you mentioned, it's something you can have some conversations with people. Do you ever feel like that's a challenge for some, and maybe physicians as well,

[00:38:09] but I know I've seen it in physical therapists where like, I'm not a psychologist. Why am I going to be doing this stuff? I don't, I'm crossing scope of practice barriers here and this is something I shouldn't be doing. Thoughts fall on that.

[00:38:21] Absolutely, there's no doubt about that. People are afraid, they're afraid of getting sued, they're afraid of scope of practice, they're afraid it takes too much time. Absolutely. But what are you going to do? You know, what are you going to do? You're going to just ignore that

[00:38:35] when you know that's the thing that could turn off the pain like that and your patient or client would be eternally grateful to you. What are you going to do? Maybe you dabble a little or maybe you find a therapist that can work with you. That's awesome, right?

[00:38:51] Obviously not all. You know, the role of the medical people can be to diagnose and the role of mental health people can be to treat using these models. That's a great model, great model. Just not everybody has that or can develop that or whatever

[00:39:05] but certainly if someone, you know somebody like you falls on the way of saying, look I just can't get into that. I'm like fine, I have no problem with that. Do your good assessment. Use your fit criteria. Assess them clearly and confidently

[00:39:20] and tell them and explain to them in loving terms that their pain is real, they're not crazy and it's their brain that's producing it and they can have complete recovery. Do that. If you can do that, huge service. Huge service to your patients

[00:39:35] and if they don't buy into it, fine you can keep doing the man you say, fine you can do, let's do more physical therapy. You already had three courses, well they'll do four or maybe there's some injections you want.

[00:39:46] You say oh no I don't want to do it. There's other medications. There's always options, right? But at some point they may, they might have heard you. They might have heard that. And at some point they may want to come back to that

[00:39:57] because as you said earlier, there's a process. There's a journey that they go through then they're not ready to really hear this and that's fine, right? They're the ones in charge of their lives. We never force this on anybody. But if you do that service to them

[00:40:10] and you can find somebody and there's lots of people virtually and that doesn't have to be in your community virtually that we have a professional organization nonprofit, the Psychophysiologic Disorders Association, pptassociation.org and there's a website. And we've got our website. There's, you know, list of practitioners

[00:40:29] all around the world who can do this work. And so there's therapists and coaches even who can help people through this process once the person has come to the diagnosis of a nociplastic or a symptom perception or a neural circuit or a mind-body situation.

[00:40:48] Certainly the resources thankfully are growing out there and I think hopefully we see more and more resources out there. I'm wondering if we could speak to a little bit of what you see as the kind of healthcare system challenges

[00:41:00] that we face to kind of incorporate such a model of care, you know, reading some of your work, be able to take a two hour assessment and really dive in deep with somebody and do things yet. You'll have clinicians saying, well, 15 minutes. I have like 30 minutes.

[00:41:15] I mean, what do you see as like, is that something where there's just, you know, the person's just got to find somebody who's got time to listen and can sit down and have a face-to-face, you know, human conversation, curious, you know, caring conversation.

[00:41:28] Or where do you see that challenge as far as incorporating this type of work? Huge, huge issue. And so if you're the kind of practitioner who wants to get into this with a certain patient then look at half an hour at the end of the day

[00:41:45] or 45 minutes at the end of the day, we can sit down and talk with them. But if you're the kind of person who really doesn't want to do that and it doesn't make sense, you might try it with a few people, you might love it.

[00:41:54] It's so much fun. It's so enjoyable to have that interaction with people face-to-face, eye-to-eye, you come up with stuff and they go, oh my God, that's amazing. Thank you so much. It's just so gratifying because burnout occurs when you're seeing people for 10 or 15 minutes

[00:42:10] and you don't have time and it's frustrating. This is actually a cure for burnout in my humble opinion. But anyway, so that's one option to do that with selected patients. But how do you find those selected patients? What you do in your 15 minutes is you do your assessment

[00:42:24] and you explain it in one minute about, we've seen a lot of people who've recovered completely by doing this brain-based model and you might be interested in maybe or not. Here are some resources. Take a look. For example, on my website there's a link

[00:42:39] to six cartoon videos, animated videos that explain predictive press. They're five to six minutes each. You can take a look at some videos. You look at YouTube all the time. Take a look at these videos, see if they make sense to you.

[00:42:51] If you wanna read something, there's a book or here's an article or here's some other videos. And all these are available to help your patients to get a sense and then they fall into, yeah, wow, that resonates. That sounds like me.

[00:43:10] I mean, I have so many people who've read my book and say I see myself on every page. I can't believe it. I never heard about this or I had a woman who was a doctor, physician. I had several physicians who had chronic pain

[00:43:22] and had to retire from working. They had to stop working because their pain in their arms or their back or their head was so severe. And they came to one of these websites. There's a bunch of them. Mine is not the only one.

[00:43:33] And after five minutes of reading it, they said, oh my God, now I know what's wrong with me. They've been to so many doctors and other caregivers that once the model is there, sometimes people go, that's gonna work, I can't believe it.

[00:43:47] And then they're ready to do that work. So just a referral for resources can be a huge thing. If they don't want it, they said no, that's ridiculous. That doesn't make any sense. Fine, we got lots of other treatments you can try and if they don't work,

[00:44:01] you can always come back to this next year. Some of the physicians with chronic pain, I think sometimes that can be the hardest population to switch, I mean, obviously it sounds like they had been through enough to where they were ready to take on board.

[00:44:13] But I think sometimes physicians, and similar with some physical therapists who are still kind of ingrained in that like biomedical view of things, it can sometimes be a hard, hard switch to make. I've worked with a few surgeons, especially Tennessee's things very mechanically and structurally based.

[00:44:28] But when they open the eyes to like, wow, okay, that makes a lot of sense. It can be obviously transformational for a lot of those folks. This is a life and death issue. Literally, a life and death issue. You're gonna live your, it's not living

[00:44:42] when you're living in severe chronic pain. That's not a life. I heard a story the other day with some guy who his best friend was a doctor, best friend since childhood and my guy I know was trying to explain to him

[00:44:56] that his pain, he should at least look into the mind-body approach. And the guy refused, refused, refused. The guy ended up committing suicide because of the chronic pain. So sad. Those tragic stories and yeah, you're right. It is life and death and you see a lot of people

[00:45:12] where automatically shrunk, where it is only pain and nothing more. And having some of these approaches can be pointed out very transformational for a lot of people. So I wanna respect your time today, how I greatly appreciate it. As we wrap things up today,

[00:45:27] I'm wondering maybe if you can give us an idea of like you've already alluded to a little bit some of the coming studies that you're working with. I'm wondering can you see the future of this type of approach moving towards and then maybe if clinicians are looking to

[00:45:42] kind of gain some skills in this approach, what word they can look for it? Yeah. Well research-wise there's a two PRT, Pain Reprocessing Therapy Studies that are ongoing now. One in Boulder, one in Denver. The one in Denver is at the VA hospital. There's two emotional awareness

[00:45:57] and expression therapies going on now. One at UCLA, Brandon Yarger instead of it. And one in Chicago and Detroit that I'm working with with Mark Lumley who's the incredible psychologist that I work closely with and he and I helped develop EAT together.

[00:46:13] All these studies are NIH or federally funded, low, well controlled. They're all randomized controlled trials, all comparing musculoskeletal pain to like our EAT study versus CBT versus ACT. So we'll see, are they all the same or treatment as usual? One head investigator says, look they're all the same.

[00:46:36] One's not gonna be better than another. We've got several, we've already got two, well two semi-large, pretty large studies actually of EAT versus CBT showing EAT actually was better. That data is there. So we'll see in this new study, we'll see. Science data shows

[00:46:52] well there's a long COVID study starting at Harvard and another back pain study started at Harvard with Mike Dunino. So and the Boulder and the Colorado studies that were the only ashara. So really high-level good solid researchers. In terms of training,

[00:47:06] we've got an app, mobile app called Ovid DX. We've got a full course called Freedom from Chronic Weak course and it's called PRT, EAT and the whole, the whole subnet. We've got the PRT study and the PRT training courses in Los Angeles

[00:47:21] run by Alan Gordon's group of pain repress this therapy institute, I think it's called. Great people. We've got the EAT training course that Mark Lomley and I run and then the PT course, Beyond Pain Management Group and so many PTs have now been trained

[00:47:40] by Laura Mermos, who's one of my heroes who has really done a tremendous amount to advance the field of pain and the studies he's done are amazing. But what he's finding is that education alone isn't enough. Alone isn't enough and that's why the work

[00:47:56] in your salivary that you've had on your podcast, his work takes it to the person which helps them see in their body. CPTs can be such an amazing resource because they're working with people in their bodies and they can instead of saying,

[00:48:11] geez, you know, you worked on your ebbs for so long they need to be even stronger as opposed to saying like, wow, when you move you're okay, you're safe. Let's have you move with joy. Let's just have you move your arm. Let's have you move your back

[00:48:25] with calm and peace and safety. Isn't it? Your back's okay, I've evaluated it. You've done all the work. Now we can click your brain in to teach your brain that your back is safe and now when you bend over it's gonna be fine

[00:48:40] and you're telling yourself you're okay. Practice that, practice that, practice that. Walk a little bit with joy, five steps and then walk 10 steps with joy. You guys can do that and it's amazing. So our course that Charlie Merrill and I run, you know, is just perfectly designed

[00:48:55] to take what we consider and I'm not missing Laura Merrill, I love Laura Merrill, he's the hero of mine to take it to the next level beyond the pain education, beyond the CBT and ACT type stuff to the level of peer.

[00:49:09] And I'm only saying this because of the data that's what the data is showing us and we'll follow the data and we'll see. But I'm so excited about this revolution and pain management, this revolution and pain rehearsal. I think you speak to some of the issues

[00:49:23] with the Traeger study where it showed that pain education on its own. Lorimer was involved in that study, he was one of his, he had published about it and wrote about how it was kind of a disappointment in his but then we're just like CFT, PRT

[00:49:35] and the approaches you spoke to today where it's taken it that next step of like, hey, it's a piece of the puzzle but we need to go further and it's great to see methods like yours starting to take hold and take it that next step

[00:49:48] and seeing some encouraging results that we hope to see more of in the future. We'll link more of the trainings that Howard mentioned in the show notes. So if anybody's interested, you can definitely go in there and check it out. We'll also link some of the articles

[00:50:01] that were referenced today in the show notes. I'm gonna leave it at that today, Howard. Again, thank you so much for your time and thank you so much for the great work you're doing to help us better manage folks in pain. It's a privilege and an honor

[00:50:12] and really appreciate what you're doing to get all these diverse and important messages out to a community of people who are on the front lines and you need help because it's hard. It's hard work. It is hard work, but as you mentioned, so rewarding work

[00:50:26] and again, those of you listening really appreciate you listening if you can subscribe on wherever you're listening to your podcast and then if you're watching on YouTube, if you can subscribe on YouTube, we greatly appreciate it. So we can spread this message to more people

[00:50:38] would be at a clinician or maybe it's a person struggling with pain who comes across this and changes their journey. So thank you for listening. That's all for this week. We'll talk to you all next week. This has been another episode

[00:50:51] of the Modern Pain Podcast with Dr. Mark Karjula. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modernpaincare.com. This podcast is for educational and informational purposes only.

[00:51:05] It is not a substitute for medical advice or treatment. Please consult a licensed professional for your specific medical needs. Changing the story around pain. This is the Modern Pain Podcast.