A clinical commentary on an article featuring Dr Howard Schubiner
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Gerry Gajadharsingh writes:
“A retired osteopathic colleague and historian, John O’Brien, recently sent me the article reproduced below. I thought it was excellent in many respects and found Dr Howard Schubiner’s approach both interesting and clinically valuable. He explains clearly how pain may persist after tissue healing, and how fear, expectation, emotional distress, learned associations and predictive processing can contribute to the continuation of symptoms. The results reported for Pain Reprocessing Therapy are certainly encouraging.
I do, however, have difficulty with the repeated use of the term “neuroplastic condition” and with the breadth of disorders placed under that heading. Neuroplasticity describes the nervous system’s normal and essential capacity to change and adapt in response to experience, learning, injury and treatment. Neuroplastic changes may contribute to persistent pain through sensitisation, learned threat responses and altered predictive processing; equally, neuroplasticity is one of the mechanisms through which recovery, rehabilitation and new patterns of regulation become possible.
It would therefore be more accurate to say that some persistent pain states involve maladaptive neuroplastic changes rather than describing the person as having a “neuroplastic condition”. The internationally accepted mechanistic term is generally nociplastic pain: pain arising from altered nociceptive processing when symptoms cannot be adequately explained by ongoing tissue damage or by a lesion or disease of the somatosensory nervous system. Even this term requires care, because nociceptive, neuropathic and nociplastic mechanisms may coexist in the same patient.
That distinction matters clinically. A patient may have degenerative, inflammatory, mechanical or neuropathic pathology while also developing central sensitisation, fear conditioning and predictive amplification. Altered processing does not make the underlying biological contribution irrelevant, just as structural abnormalities on MRI do not prove that those abnormalities are responsible for the patient’s pain.
Persistent pain often sits along a continuum and may reflect a mixture of peripheral nociceptive input, neural sensitisation, autonomic dysregulation, immune and inflammatory activity, endocrine and metabolic influences, musculoskeletal dysfunction, past experience, emotional context and learned prediction. The same caution applies when diverse problems such as migraine, irritable bowel syndrome, pelvic pain, temporomandibular disorders, dizziness and tinnitus are grouped together. Neuroplasticity may be relevant to all of them, but that does not make them fundamentally the same condition.
Likewise, producing symptoms by asking someone to imagine a triggering activity offers useful evidence that expectation and predictive processing are involved; it cannot, by itself, exclude continuing peripheral or wider regulatory-system contributions. It demonstrates the participation of the brain, not necessarily the absence of pathology elsewhere.
Emotional trauma, chronic stress and adverse childhood experiences can unquestionably initiate, amplify or perpetuate physical symptoms in some people. They are not necessarily the primary cause in every patient. Replacing an exclusively structural explanation with an exclusively emotional or brain-based explanation risks exchanging one form of reductionism for another. Patient selection, careful medical evaluation and accurate differential diagnosis therefore remain essential.
My preferred formulation is that some persistent pain conditions involve altered nociceptive processing, sensitisation, learned threat responses and predictive mechanisms. These changes may reflect maladaptive neuroplasticity and can become partly independent of the original tissue injury. They should nevertheless be understood within a biopsychosocial and multisystem assessment, recognising that nociceptive, neuropathic and nociplastic mechanisms frequently coexist.
This preserves what is valuable in Schubiner’s work without turning neuroplasticity into a diagnosis or implying that the nervous system operates independently of the rest of the person. With that qualification, the article offers an accessible and important account of why some patients do not improve through structural treatment alone.”
Clinical Disclaimer
This article is intended for educational and informational purposes only. It does not constitute medical advice and should not replace individual consultation with a qualified healthcare professional.
The chronic pain you’re feeling —
could it be an emotional injury?
Aches aren’t always from physical trauma, Dr Howard Schubiner tells Elisabeth Perlman
Elisabeth Perlman | The Times | 27 July 2026
How important is the connection between mind and body? Profoundly, according to Dr Howard Schubiner. In his two decades as a professor of medicine, he has treated countless patients whose severe back pain, migraines and fibromyalgia was not improved by either medication or surgery. For them, the traditional biomedical approach, as he calls it, which looks for structural damage to fix, simply didn’t work.
So what was the explanation? Unresolved emotional pain is at the heart of some people’s conditions, Schubiner tells me over Zoom from Michigan, where he is director of the Mind Body Medicine Center at Ascension Providence Hospital. In such cases, their real, physical symptoms have been manifested by the brain’s neural circuits. That’s possible, he says, because “the parts of the brain that are activated when you have a physical injury are the same parts of the brain that are activated when you have an emotional injury. That’s a fact.”
Many physical ailments are not “neuroplastic” in nature, he writes in a new book Unlearn Your Pain — this “is not about curing cancer, heart disease, diabetes, dementia or Parkinson’s disease”, he insists — but those that can be include chronic neck and back pain, fibromyalgia, irritable bowel syndrome (IBS), tension and migraine headaches, pelvic pain syndromes, temporomandibular joint (TMJ) disorders, dizziness and tinnitus.
Schubiner has personal experience of this, having suffered neck pain at a point in his working life when he was overwhelmed by stress. “I saw a physical medicine and rehabilitation doctor and started physical therapy. The MRI of my neck showed three bulging discs and evidence of arthritis,” he writes. However, after attending a mindfulness retreat his discomfort improved.
Schubiner reflected on his own anomalies after reading The Mindbody Prescription by Dr John Sarno, a rehabilitation specialist who has been credited by the comedian and writer Larry David among many others with curing his back pain. Sarno observed that some patients suffered intense back pain despite having only mild, or no abnormalities on X-ray and MRI scans, while others with severe imaging abnormalities felt no pain at all.
“The pain and stiffness came on suddenly, lasted several days, and then resolved, only to return a month or two later,” Schubiner writes of his own neck problem in Unlearn Your Pain. “If the pain was due to bulging discs and arthritis, why wasn’t it there all the time? Was it stress building up in my life that triggered the attacks? Was there a correlation between my meditation practice and a reduction in neck pain? Maybe.”
Patients must first undergo a medical evaluation to rule out structural conditions requiring traditional treatment before concluding that a condition is neuroplastic, he says. Only when physical damage, tumours, acute infections, nerve damage or an autoimmune disease are discounted can you look at whether a person has a history of other neuroplastic conditions, childhood trauma or significant life stress that correlates with the symptom onset. “I never want to mistake a physical disease for a neuroplastic condition,” he says. “That error is one that no physician ever wants to make.”
Why an MRI showing abnormalities may be less conclusive than you think
In 2015 Waleed Brinjikji and colleagues from the Mayo Clinic published their analysis of MRI data from 33 studies in the American Journal of Neuroradiology. Of 3,110 people who reported no back pain, disc degeneration was found in 37 per cent of asymptomatic 20-year-olds and 96 per cent of asymptomatic 80-year-olds. The researchers wrote that “imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal ageing and unassociated with pain.”
Why your pain signals may go awry
We all have a danger or alarm signal in the brain that is there to protect us, but it sometimes misfires. “When faced with a critical amount of either physical or emotional danger, the brain is likely to warn us, much like a smoke alarm warns us of fire,” Schubiner writes in his book. He cites studies showing that emotional distress — such as looking at a photograph of an ex-partner after a recent break-up — activates the same pain-processing regions in the brain as physical injuries.
Do you respond to pain with the seven Fs?
Most people with neuroplastic pain react to symptoms with the seven Fs, Schubiner says.
- Fear: worrying about the symptoms
- Focus: frequently monitoring them
- Fight: resisting them
- Frustrate: getting angry at them
- Figure them out: internet searching, seeing more doctors or other healthcare practitioners
- Fix them: which, when unsuccessful over time, makes the symptoms more persistent
- Forlorn: getting upset about the symptoms
“Neurons that fire together, wire together — and they get stuck in this danger loop,” he says, “which means that triggers like turning your head, eating certain foods or driving on the motorway, could lead to the fear of the sensation, which leads to the prediction that it’s going to occur, which leads to the symptom occurring. This is known as predictive processing. But when you give your brain a different experience, you expose a prediction error. Now you’re moving, driving or eating a certain food without fear, but with safety, so the brain now learns, ‘hey, this is okay’.”
Why you may be prone to a neuroplastic condition
According to a study conducted in the 1990s by Dr Vincent Felitti, a physician with Kaiser Permanente in San Diego and Dr Robert Anda, an epidemiologist at the Centers for Disease Control and Prevention, adults who suffer traumatic events in childhood have a much higher chance of developing chronic pain as well as anxiety and depression. But Schubiner cautions: “You don’t have to be exposed to major trauma in childhood to develop significant neuroplastic conditions in later life. Children who are feeling fearful of going to school because they miss a parent, feel alone or are being bullied can develop neuroplastic symptoms of abdominal pain, headaches…”
He also says that certain personality traits such as perfectionism and intense self-criticism may make people more prone to developing neuroplastic conditions.
Schubiner assesses whether or not a patient meets the “Fit” criteria. The pain is “functional” if symptoms affect the function, not the structure of the area — for example, if after a physical injury pain persists long after the wound should have healed. The pain is “inconsistent” if it shifts locations or varies based on the time of day or stress levels and improves when the person is distracted, for example. The pain is “triggered” if it’s activated by anticipating a stressful event or by innocuous stimuli like a specific smell.
Schubiner sometimes uses “provocative testing”, which is when he gets patients to imagine doing a triggering activity and that alone causes discomfort. This demonstrates that a learnt neural circuit, not a physical injury, is to blame for generating the symptom.
Dr Michael Donnino, professor of medicine and emergency medicine at Harvard Medical School used this testing method on people suffering from long Covid who experienced fatigue triggered by physical activity; 70 per cent of participants experienced a physical reaction — such as fatigue or dizziness — simply by imagining doing the activity.
The power of pain reprocessing therapy
Pain reprocessing therapy (PRT) is an evidence-based treatment by which patients can “unlearn” chronic pain that has no medical explanation through a series of techniques.
“Most people have some doubts when starting this process,” Schubiner writes in the book. “They wonder if there might be some diagnosis that might have been missed or that they might need more testing. People who are stuck in doubt will often have a more difficult time with PRT.”
He cites a study showing how self-affirmations can change the brain by reducing its perception of threat and suggests asking yourself “what’s wrong with me?” and answering “nothing!” alongside repeating affirmations such as “I am healthy. I am strong”.
Another part of PRT is somatic tracking, a form of mindfulness, developed by the psychotherapist Alan Gordon. “It’s about trying to separate from the pain, trying to be indifferent, trying to be curious, trying to be playful, trying to be anything that changes the brain from the fear cycle to the safety cycle,” Schubiner says.
You can ask yourself questions like: Where exactly is the pain located? Is it dull, sharp? Does the sensation move?
Another element of PRT is gradual exposure to pain triggers and physical activity. While it’s not a good idea to push yourself too much, try to do the activity whether symptoms occur or not, which Schubiner refers to as “outcome independence”.
Along with Gordon and others, Schubiner studied the impact of PRT on those with chronic back pain in a trial published in JAMA Psychiatry, and, after a five-year follow-up, found that 55 per cent of those who’d had it remained pain-free, or nearly so, over a five-year period.
How to learn to let it go
Self-compassion can be an important part of the healing process, Schubiner believes, and emotional awareness and expression therapy (EAET) — developed by Schubiner and Mark A Lumley, a clinical psychologist — can be used to address the underlying causes that sensitised the danger signal in the first place.
“Patients are encouraged to recall a conflict, a person or a situation to experience, express and resolve emotions including anger, guilt and sadness,” he writes in his book. “The emotional expression is done in their imagination, which allows for changing the brain’s memory and neural circuits. This process avoids and actively discourages real life anger or violence, which typically leads to escalating conflicts.
“The patient is encouraged to express their underlying emotions in their mind to the imagined/remembered other person, using words and actions.” He describes the approach as: “You imagine it, you feel it, you express it, you let it go.”
Source: Elisabeth Perlman, The Times, 27 July 2026. Article text reproduced from the copy supplied for editorial preparation.