Back pain: how to cope with it by working with your thoughts

Often, unpleasant sensations originate in the psyche. “Pain Reprocessing Therapy” was found to be effective in a recent study.

What would you say if you were told to consider changing how you feel rather than getting a massage and taking painkillers for back pain? No, this is not a silly joke, but a real therapeutic tool that has sometimes been found to be as effective as painkillers. Back pain represents not only one of the most common problems, but also one of the most striking manifestations of the close connection between the psyche and somatics. About 85% of the time, it is not possible to determine the cause: the nerves are not pinched, the vertebrae are intact, the intervertebral hernia does not press on the spinal cord, there is no focal point of acute inflammation. There are no reliable ways to remove it: even analgesics are often ineffective.

Increasing evidence suggests that back pain may be caused by psychological factors. Among the arguments in favor of this theory are the results of a clinical experiment recently conducted by scientists from the University of Colorado. In their study, they used a new method called Pain Reprocessing Therapy (PRT). In comparison to conventional treatment and placebo, it was more effective. Within one month, 73% of subjects who received two remote PRT sessions per week were pain-free or nearly pain-free. Additionally, this effect lasted for at least a year. Objective measurements and computed tomography of the brain confirm the findings. According to the authors, a major advantage of the new method is that it can be applied independently without requiring special training or health risks. If you want to try it out, we have prepared the PRT description from the study appendix.

PRT: what is it and how does it work?

There are five main components of pain reprocessing therapy. A few steps are required to control pain: 1) realizing that pain is a reversible reaction that originates in the brain; 2) being convinced of pain’s origin and reversibility based on their own experience; 3) learning to evaluate pain in terms of its real danger to health; 4) solving accompanying emotional problems; 5) switching to a positive perspective.

1. The origin of pain, reversibility of pain, and pain-fear cycle

The concept of rethinking pain begins with the understanding that pain can be experienced in the absence of wounds, injuries, or physical impairments. Pain is a warning sign. Its primary purpose is to prevent damage. As an example, if you place your hand on a hot stove, the pain will prompt you to remove your hand before it gets burned. There is a problem with the alert system activating without physical damage. The brain can interpret even harmless body signals as threat signals. When this happens, the pain is like a false alarm. There is a fire alarm (the pain is real), but no fire (no harm to the body).

Fear is the main aid to pain. An individual who is completely focused on the pain sensations and is very frightened by them will receive a confirming signal: the pain is dangerous. Consequently, the pain becomes persistent. The cycle of pain-fear begins: 

• Fear is caused by pain; 
• By placing the brain into high anxiety mode, fear causes the pain to increase; 
• Fear grows as pain increases; 
• Fear causes more pain. 

To break this vicious cycle, you must change your attitude towards pain – stop being afraid of it. As you learn to perceive pain without fear, its power gradually wanes.  

2. Gaining corrective and reinforcing experience

If you believe pain is a sign of illness or injury, it is difficult to overcome the fear of it. Thus, in the first phase of therapy, the main goal is to realize that pain occurs in the brain and not in the body. Three reasons make this difficult.

• Biological Inertia: Evolutionarily, our brains are programmed to recognize pain as a feeling of physical injury. 
• Patients have previously been diagnosed with back pain due to actual physical disorders (herniated discs, disc degeneration). 
• Many people with chronic back pain have a mental association between pain and specific bodily positions (standing or sitting) or activities (walking, running, bending over). Having these associations reinforces the belief that pain is caused by a physical disorder. 

You can counter the mental link between pain and perceived physical impairment by showing as many examples as possible that pain is not confined to a specific part of the body, but originates from the central nervous system as a whole. The following is the convincing evidence.

• Pain occurs when you’re stressed.
• Pain appears without any physical damage.
• Pain occurs intermittently.
• In addition to pain, there are many other psychosomatic symptoms.
• There are psychological factors that trigger pain, such as social conflict.
• Physical activity that is problematic may not cause pain all the time.

Creating a list of the facts that support the mental origins of pain is useful. For instance:

• The MRI showed that my spine is fine.
• Other forms of the same pain – migraines, irritable bowel syndrome – plague me as well.
• I started having back pain two weeks after moving in with my parents.
• The pain is worse in the weekdays, but is more manageable on weekends.

3. Pain perception and assessment from a safe position

A key component of PRT is “somatic tracking”. The goal is to allow the patient to fully explore their pain while maintaining a sense of security. Somatic tracking is used both for spontaneous internal pain and when pain and fear are triggered by certain physical activities. As an example, if a patient experiences pain while sitting, the therapist teaches them how to perform somatic tracking in that position. It consists of three components: 1) mindfulness; 2) assessment of the real danger of pain; and 3) a positive attitude.

• Being aware. Consider your pain from an outsider’s perspective. As accurately as possible, describe how you feel. Determine, for instance, how clearly and precisely they are located. Do not try to distract yourself from the pain – keep an eye on it as an object of study. As mindfulness alone is often insufficient to neutralize fear, it is usually combined with a second component of somatic tracking. 
• Assessing the risk of pain. Prepare yourself on your own or with a therapist to accept pain in safe state. A sting or burning sensation is uncomfortable, but not life threatening. Remind yourself that you are physically fit. Body signals are misinterpreted by your brain as danger signals. We all feel different sensations when we tense our back muscles. In most cases, they are interpreted by the brain as pleasant or neutral. You would most likely enjoy a similar burning sensation if you experienced it in a hot tub. However, now you perceive this sensation through the lens of fear, so it seems painful to you. In fact, your muscles, tendons, and ligaments are in perfect condition. Changing your perception of pain as a safe sensation is only possible if you have enough evidence that pain is not always an indication of physical damage or dysfunction. 
• Ensure a positive attitude. A good way to turn the emotional charge from minus to plus is through humor. The therapists Alan Gordon and Elon Ziv suggest this intervention as an example: “Imagine your back is the sea and your senses a school of fish you’re admiring, and your therapist is a friendly sea turtle swimming nearby.” 

It is possible to practice somatic tracking independently as well as under the guidance of a therapist. In the course of tracking their pain, patients often gain more corrective experience. As you become convinced that you can sit, stand, walk, or bend over with little or no pain, you become aware that your pain is not caused by your body, but rather by your brain. As a result of this, you no longer fear physical activity. It also allows us to continue to perceive pain without anxiety, frustration, and despair.

4.  Handling the associated emotional problems

In a state of increased anxiety, one tends to perceive everything as a threat. His body twitches at loud noises, flinches at touch, and perceives any sudden sensation as painful. Moreover, a sense of threat can arise from a tendency to destructive psychological reactions, such as painful self-criticism and excessive expectations.

PRTs are responsible for reducing the overall voltage level. Achieving this goal involves managing emotions, processing traumatic experiences, and understanding complex interpersonal relationships. In response to decreasing levels of anxiety and stress, the brain begins to perceive bodily sensations as safe, leading to a lessening of pain. The detection and processing of problematic emotions are accomplished through appropriate therapeutic methods (e.g., Emotional Awareness and Expression Therapy – EAET).

5. A reorientation toward positive perception

The purpose of PRT is not only to reduce the sense of danger, but to also increase a general sense of security. As chronic pain patients become accustomed to focusing on negative and unpleasant bodily sensations, they often perceive everything through the lens of fear, including emotions and even their own personalities. In broad terms, PRT is used to switch from extreme to calm mode. Focusing on pleasant sensations is one of the most accessible methods of switching. As an example, on the breath. Focus on warming, cooling, filling, and emptying the lungs as you breathe in and out slowly. Practicing calm awareness of pleasant bodily sensations enhances your ability to perceive unpleasant ones without fear.