The idea that the brain is plastic in the sense of changeable, adaptable, malleable is, I’ve come to believe, the single most important change to our understanding of the human brain in 400 years. Norman Doidge
The Bay Area Medical Associates in Sausalito, California is not a place you want to end up at. This pain clinic treats people with intractable pain – people who have tried everything they can think of without success. It’s the end of the line for most of the pain patients it treats. It is, as Michael Moskowitz, director of the clinic, told Norman Doidge, the place “where people come to die with their pain”.
Moskowitz’s story was the first one featured in Doidge’s captivating 2016 book “The Brain’s Way of Healing: Remarkable Discoveries and Recoveries from the Frontiers of Neuroplasticity.” Moskowitz knows of what he speaks when he’s talking about pain. In 1994, while waterskiing he flipped over and hit the water awkwardly with his head. Despite everything Moskowitz tried – morphine and other opioid drugs, physical therapy, traction, self-hypnosis, anti-inflammatory drugs etc. – the pain strengthened, and even worse, spread. Thirteen years later, not only was it present on both sides of his neck but it had spread to the middle of his back. In constant pain and out of options, Moskowitz turned to an unlikely idea – neuroplasticity.
Neuroplasticity refers to the ability of the brain to alter the way it’s functioning. If a portion of your brain is damaged, for instance, other portions of your brain can take over the functions that have been lost. People who’ve had strokes can regain functioning by physically and mentally prodding the brain to create new connections. Over time, bit by bit, undamaged areas of the brain can learn, at least to some extent, to take over those functions.
Neuroplasticity’s core thesis is that neurons that wire together fire together. The more they fire together, the stronger the connection they produce and the more powerful they become. Think of a river carving out a channel. The more water that flows through that channel the slicker and deeper it becomes – and the harder it is for the river to breach its banks. On earth, rivers that become deeply entrenched can carve their way through rising mountains.
Neuroplasticity proposes that the sensations we experience, activities we engage in, the thoughts that we think, the feelings that we return to again and again – they’ve all carved out channels in our brain.
At the time Moskowitz began his experiments, however, the relationship of neuroplasticity to pain, however, was hardly known. Now we know that if we experience an injury or an illness that continuously saturates our brain with pain or other unpleasant sensations, those pathways will strengthen.
Pain that persists is terrifying because it sets off the amygdala, before the parts of the brain that modify our emotional responses can be turned on. The result is that we re-experience the trauma that caused the pain and this trauma is continuously reinforced by it. The terror demoralizes us. Moskowitz
By the same token, the “use it or lose it” rule also applies to the brain. If you stop appreciating things, finding ways to be joyful, etc. those pathways and your ability to experience those feelings will diminish.
The Chronicity of Pain
Chronic pain is a much more complex process than acute pain. In contrast to acute short-term pain, chronic pain includes an important “learned” component. Many studies have shown that the brain takes what it believes will happen in the future into account when it decides how much pain it should deliver.
If the brain believes that actions can be taken to relieve pain, our experience of pain will diminish, but if the brain believes that the pain will get worse, it will actually ramp up our pain levels substantially. (The same process presumably applies to activity and fatigue; if the brain anticipates that fatigue or pain will result, it will clamp down on our ability to be active.)
Believing that future injury is likely, the brain keeps whacking us with pain stimuli in order to compel us to find ways to heal the injury. Immobilization certainly works in acute pain – an injury, after all, needs time and rest to heal – but in chronic pain, it produces a physiological state that results in more – not less – pain. Similarly, the brain produces fatigue, pain and other flu-like symptoms during an infection to give us time to heal.
But what if the brain for one reason or another gets stuck in a pain-producing mode? Thirteen years later, after taking all the medications and therapies medicine could provide, Moskowitz, a pain specialist, not only remained in pain but his pain had spread from one side of his neck to the other side and down his back. He was getting worse, not better.
Competitive Plasticity to the Rescue
“I don’t believe in pain management anymore. I believe in trying to cure chronic pain.” Moskowitz, in “The Brain’s Way of Healing”
The key factor, Moskowitz found, however, had to do with the “use it or lose it” phenomenon and a process called “competitive plasticity”. Competitive plasticity recognizes that the same areas of the brain can engage in many different functions.
Nowhere in the brain is this better demonstrated than with pain. Pain is such a fundamental and important sensation that the areas of the brain that process pain signals overlap with other areas of the brain which govern movement, emotions, vision, thoughts, etc. Because six of the nine parts of the brain involved with pain are also involved with mood, it’s easy to see why pain is so often associated with depression and vice-versa.
It’s not surprising, then, that strong pain – and/or presumably, fatigue – signals can interfere with very basic processes as the brain devotes more and more attention and energy to assessing, thinking about, worrying about, etc. pain/fatigue.
As pain-processing areas expand in the brain, we lose our full ability to problem-solve, regulate emotions, resolve conflicts, relate to others, distinguish other sensations from pain, effectively plan… Every time the pain worsens it feels like it is here to stay…The amygdala is not a place of moderation. It is a place of extreme emotions, fight-and-flight and post-traumatic stress disorder. Moskowitz
Moskowitz’s key insight was to try and devise ways to wrench back the brain to normal functioning – to change its “learned behavior” and stop its focus on pain.
The process he devised was both counterintuitive and multidimensional. Recognizing the brain’s push to immobilize him and prevent further injury had only strengthened his pain pathways, he reasoned that overriding his brain’s signals to rest, to lie down, etc. could help, but that was only the start of the process.
Realizing that he needed a counter-stimulating force, Moskowitz developed a way to force his brain to process something other than pain. Because our brains devote so much brainpower to processing visual stimuli, Moskowitz focused on using visual stimuli to steal back regions of his brain that had been captured by pain.
His first patient was himself. Moskowitz drew a map of what a brain in chronic pain looked like: a map indicating that large parts of his brain had been hijacked by pain. Each time he experienced pain, he pictured his brain as it was – and then he imagined his pain map shrinking.
Moskowitz’s recognition that he had no easy task before him provided another key insight. He’d, after all, been in pain for a long time. His brain had had 13 years to learn how to process and deliver pain signals as efficiently and as devastatingly as possible.
He was engaged in a relentless battle to reconstruct how his brain was functioning – so he practiced assiduously – and recognized it would take time to “unlearn” that process. Every time he experienced pain, he fought back with the visual signal of the pain map in his brain shrinking.
Moskowitz’s dedication made the difference. It took him three weeks of practice to notice a “very small” decrease in his pain levels. After a month, his pain reduction visualization process had become so automatic that he never let a pain spike go by without attacking it.
By six weeks, the referred pain that had crept from his original injury in his neck to the middle of his back had disappeared. Four months later, pain in his neck began to shut down. Within a year, the neck pain that had bothered him for 13 years was totally gone. Moskowitz had effectively rewired his brain so that he no longer felt pain that area.
After an accident, Dr. Michael Moskowitz, a pain doctor, tried and failed to treat his pain – which widened and grew worse and worse over time.
As is common in a state of chronic pain, Moskowitz’s brain, over time, devoted more and more of its resources to assessing and paying attention to his pain. This process not only increases pain levels but, by taking resources away from other areas of the brain, it can impact one’s mood, ability, cognition, movement, etc.
Applying neuroplasticity findings to pain, Moskowitz created a visual based approach designed to tone down his brain’s response to pain.
He used the process of “competitive plasticity” to consciously tell the pain-producing parts of the brain to disengage.
His approach required a relentless and disciplined approach but eventually he was able to rewire his brain and completely turn off what had been a raging and out-of-control pain response. After 13 years, he became completely pain-free.
Moskowitz used the same approach with a nurse – with a back injury so severe surgeons were unwilling to operate on her. Despite being in severe pain for over a decade, and despite still having a serious back injury, the nurse was able to turn off her pain response as well and now leads a normal life.
Moskowitz’s is just one of many approaches which are using the innate neuroplasticity of the brain to treat disease.
She was declared disabled. In constant pain no matter how many painkillers she took, she became depressed and suicidal. Ten years after her accident, she was taking huge doses of morphine and spent entire days in her Jacuzzi. The slightest movement could trigger unbearable amounts of pain.
It was all she could do to make it to Moskowitz’s office. He’d been treating her for five years without much success when he developed his pain visualization process.
Moskowitz introduced Jan to his new approach by having her first read Norman Doidge’s first book, “The Brain That Changes Itself”. Then he had her visualize her pain brain maps shrinking. She also visualized the pain signals coming up from her lower back into her brain, and then having the brain not react.
Moskowitz told her to look at the brain maps seven times a day, but Jan, locked into her massage chair at home, looked at them constantly. By the third week, she was beginning to have a couple of minutes a day without pain. By the fourth week, she was pain free for as long as half an hour – the first time that it happened in over 10 years.
By the time Doidge talked to her a year and a half later, this woman, with intractable spinal injuries so severe that surgery was not an option, was completely out of pain. She told him that she felt that she had been asleep for a decade, and now all she wanted to do was to stay up for 24 hours a day and catch up.
Doidge found the process Moskowitz was applying no different than those he had seen working in the victims of stroke, physical trauma or other conditions. The gains are tentative at first, but if the practice is aggressively applied they build over time. Doidge even compares learning to reprogram the brain to learning a musical instrument – or more aptly, perhaps, learning a new language. The practice is most difficult at first but gets easier over time.
Moskowitz’s patients’ pattern of change is also consistent with what we see when the brain learns a new skill, like playing a musical instrument or learning a language. The time frame is typical of what I have seen in significant neuroplastic change: the change occurred over weeks (often six to eight weeks) and required daily mental practice. It’s hard work. Doidge
Eventually, though, Moskowitz’s technique changed the programming of Jan’s brain’s so completely that it learned to disregard the pain signals emanating from her injured back without her thinking about it.
(Moskowitz) thinks that once they have learned and practiced the technique over hundreds of hours their unconscious mind takes over the task of blocking pain by using competitive plasticity” Doidge
This is where the lines we like to draw between the brain, the mind and the body become blurred. Moskowitz’s and Jan’s brains, though no fault of their own, had become broken. For whatever reason, the normal response to injury – which should result in the pain signaling lessening – failed to kick in. Instead, no matter what treatments either tried – and both had access to all of them – their pain levels increased and increased.
Note that Jan was an RN and Moskowitz was a highly trained professional working in the pain field. After trying everything under the sun, what finally worked for them was a visualization practice aimed at the brain – a process that most of us would probably scoff at. Yet that process was powerful to enable a woman whose back was too damaged for a surgeon to operate on her to live without pain.
It was all done through “behavioral therapy” – a conscious manipulation of the brain to change an unconscious brain programming. We program the brain all the time. Learning how to drive a car requires a conscious effort which ends up being an automatic, learned behavior. Why not use the same process to program the brain to respond to internal stimuli – pain signals – differently?
“It is a fact that brain and body reliably turn conscious effort into unconscious effort to unconscious action that allows us to move from learning to mastery, returning the disease of persistent pain to the fleeting symptom of acute pain.” Doidge
It should be noted that not everyone has had such a dramatic response. Moskowitz believes that the willingness to engage in the practice – to again, again and again visually beat back down those pain sensations – has something to do with that. He’s working with Dr. Maria Golden to beat them down in another way, though, by using pleasurable sensations to grab the brain’s attention and wrench it out of its pain pathways.
You can find Dr. Moskowitz and his colleague, Dr. Marla Golden, at www.neuroplastix.com which, among other things, includes therapeutic brain animations which can be used to turn down pain levels, the doctors talking about their treatment approaches, and “The Neuroplastic Transformation Workbook” for those who want to try their techniques.
Moskowitz’s program is just one instance of many that have been developed to use neuroplasticity to reduce pain and other symptoms.
Annie Hopper’s Dynamic Neural Retraining System
Annie Hopper, for instance, is using neuroplasticity in a different way in her Dynamic Neural Retraining System (DNRS) program to attempt to heal what she believes is a broken brain in MCS, FM and ME/CFS. She pins the blame on damaged sensory processing which results in inflammation, fatigue, pain, etc. and attempts to rewire the limbic system and reduce an over-active stress response using different methods from Moskowitz’s.
I started the six-month program this week. Five months with an unrelenting “cold” which has not responded to antivirals, supplements, etc. gave me an extra incentive to try something new. Hopper, like Moskowitz, emphasizes the need for repetition and practice, practice, practice.
- Coming up – a DNRS ME/CFS success story from a medical professional. This person is not over ME/CFS, but over time, she has seen substantial improvement
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