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The science behind Pain Reprocessing Therapy

What is Pain Reprocessing Therapy?

Pain Reprocessing Therapy (PRT) is a collection of psychological techniques drawn from pain neuroscience education, cognitive-behavioral therapy, and mindfulness-based stress reduction. These techniques are combined in a unique way that teaches people with pain the following five principles:

1.    The brain gives rise to pain. 

The brain creates the conscious experience of pain, and in fact the brain physically and functionally reorganizes around the experience of pain in a way that is reversible.

2.    Pain is always emotional.

Evidence of the brain’s role in pain can be found in daily experience of pain, such as how pain increases with stress and fear and decreases with feelings of relaxation and safety.

3.    Hurt doesn’t mean harm.

Physical sensations that are uncomfortable and painful are not signs that the body is being harmed. Reinforcing feelings of safety and relaxing the nervous system can lessen the experience of pain.

4.    Dialing down fear can reduce pain.

All types of fear—whether they are related to pain or not—can reinforce feelings of danger and enhance pain. Therefore reducing fear-related thoughts and emotions will increase pain relief.

5.    Positive emotions promote relief.

Seeking out and paying attention to positive emotional experiences and how these experiences feel in your body will enhance pain relief. 

PRT is a protocol developed by licensed clinical social worker Alan Gordan to help people change their relationship with the fear of pain. The PRT approach is supported by a single promising research study, but it currently lacks the robust evidence base that would put it on equal footing with gold-standard approaches like acceptance and commitment therapy, cognitive behavioral therapy, or mindfulness-based stress reduction for chronic pain. In other words, focusing on PRT alone may limit the overall quality of pain management as a whole. 

The reality is that modern pain care has advanced far beyond the confines of PRT and has shifted to a multimodal focus, where the best elements of different treatments are matched to a person’s unique pain experience. This means that each individual is best served by a unique combination of interventions that adapts to their psychology (e.g., pain mindset), goals for pain relief, and how their pain changes from day to day. Aivo has innovated this multimodal approach. Not only do Aivo members get access to tools offered by PRT, but they also receive the best evidence-based treatments available that combine value-based goal setting, relief learning, guided meditations for pain relief, behavioral changes to enhance sleep, exercise and mindful movement, and a deeper dive into pain neuroscience education.

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Neuroscience Behind Pain Reprocessing Therapy

To understand whether you can benefit from the PRT approach, it’s important to understand the scientific rationale behind PRT. As we have described in our previous blog article on the topic, chronic pain doesn’t follow the rules of normal acute pain. Once pain becomes chronic, the pain is no longer dependent on the existence of a normally painful stimulus, such as tissue injury. Acute pain and chronic pain respond to different kinds of treatment and involve completely different parts of the brain. The most innovative research uncovering the real root cause of chronic pain was conducted by Aivo co-founder and Chief Scientific Officer, Dr. Vania Apkarian. Dr. Apkarian is a tenured professor of physiology, anesthesiology and physical medicine and rehabilitation at Northwestern University in Chicago. He co-created Aivo with pain patients and neuroscientists to bring insights from his peer-reviewed research directly into the hands of people living with chronic pain.

Dr. Vania Apkarian

 By peering into the brains of people with chronic pain, Dr. Apkarian’s functional magnetic resonance imaging studies show that acute pain involves brain regions that give rise to normal physical sensations. In contrast, chronic pain is actually created by brain regions responsible for emotional memories (read Dr. Apkarian’s peer-reviewed study here). This explains why pain medications, injections, and surgeries brings only temporary relief, some of the time: they don’t target the emotional brain.

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In his book The Way Out, Gordon hypothesizes that PRT works because it changes the emotional memories that underlie chronic pain. Gordon cites Dr. Apkarian’s research and explains, 

“One of the most important pain studies of the last few years actually captured this process in action. Researchers followed people who had recently injured their backs. At first, their pain was active in the normal pain regions of the brain. But when the pain became chronic, it shifted to parts of the brain associated with learning and memory.” 

Acute pain
Chronic pain

Specifically, Dr. Apkarian found that in acute pain, the brain lights up in areas known for processing sensory information: the insula, thalamus, and anterior cingulate cortex. In chronic pain, a completely different set of regions of the brain known for emotion, emotional learning and reward, light up: namely, the amygdala, hippocampus, and the medial prefrontal cortex. You can read Dr. Apkarian’s peer-reviewed study for yourself here.

 Dr. Apkarian also discovered that the brain, rather than structural changes in the body or spinal cord, can predict who will go on to develop chronic pain. Gordon explains, 

“Combining cutting-edge neuroscience with a little bit of Nostradamus, a group of scientists at Northwestern University embarked on a new frontier: predicting pain. These researchers tracked patients after an initial episode of back pain and tried to predict who would go on to develop chronic pain. Amazingly, their predictions were accurate 85 percent of the time. The scientists didn’t conduct any back exams. They didn’t look at X-rays or MRIs of the spines. In fact, they didn’t look at the patients’ backs at all; they looked only at their brains. By taking brain scans and looking at the level of connectivity between two key areas, the researchers were able to determine with a high level of accuracy whose pain would persist and whose would resolve.” 

Specifically, the two key brain areas include a part of the brain responsible for emotional memory called the medial prefrontal cortex, and the part of the brain that recognizes rewards (e.g., pain relief) and aversive events (e.g., pain), called the nucleus accumbens. In other words, Dr. Apkarian discovered that the risk for future chronic pain is predicted by how the brain communicates information related to emotional learning and reward. You can read Dr. Apkarian’s peer-reviewed study in Nature Neuroscience.

These revelations have important implications for treating chronic pain. When pain management combines the reward of pain relief with positive emotional learning, the brain adapts more quickly to create a new baseline state of lasting relief. “The brain adapts based on our experiences,” explains Dr. Apkarian. “If we are stuck in a never-ending cycle of pain, the brain adapts to that cycle. But if we break that cycle by learning new habits, new routines, and new ways of seeing pain, the brain will adapt to our new reality. We created Aivo to help people harness their brain’s intrinsic ability to break the cycle of chronic pain.”

Dr. Apkarian’s research has expanded to people with low back pain, knee osteoarthritis, chronic pelvic pain, irritable bowel syndrome, interstitial cystitis, fibromyalgia, and complex regional pain syndrome to show that brain changes underlie all types of chronic pain, regardless of the diagnosis. This body of research highlights that the emotional consequences of living with chronic pain can create widespread changes that affect how you move, feel, think, make decisions, and plan for the future. 

The most important message behind Dr. Apkarian’s research is one of hope. Dr. Apkarian emphasizes, “The brain can bounce back from these changes through new emotional learning. The most powerful treatment for pain is between your ears and you can access it right now. We created Aivo to give you new experiences of pain relief, adjusted each day based on the information you share with us. It is a daily dialogue, where we listen to your experiences and recommend the next steps based on what you tell us is important to you. Our goal is to help you move past the pain and see the life waiting for you on the other side.”

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