Post knee-surgery pain - need advice

My question is for those who had experiences with knee surgeries.

My partner is a former ultra-marathoner. He had a meniscus surgery about 15 years ago, then returned to running and ran multiple 55K races in the mountains in his 60-ies. He is definitely not a hypochondriac and knows well how to push through pain until it no longer hurts. He has had very difficult last 3 years, including multiple serious illnesses and retirement, on top of the pandemic and other factors. He is very stressed out right now for a number of reasons.

In the past few weeks he started complaining about a dull pain in that same knee. He is generally skeptical about TMS, although he agreed with me on a few occasions that the pains he had at the moment were TMS-related. He also told me that his knee pain that led to the surgery could have been TMS because it happened when he had very difficult period in his life. He outright does not agree with me that this current pain could also be TMS. When we go hiking, it does not hurt much when we go uphill, but downhill is killing him. He says that stretching helps for a short period of time.

I am reluctant to push him to accept that it is TMS.

Do you think it could be TMS? What if it really is physical now that his knee was compromised by the surgery?

He says that after the surgery his knee was never the same and he always "feels it" (he can't really explain well what it means), whether it hurts at the moment or does not.

Thanks in advance to all the respondents!

 

This is an AWESOME topic starter. There is a couple of hidden gems in your post here to be mined out.

So are most people, thus the mega-trillion dollar pain industrial complex

Other Md's used to occasionally agree with Sarno that SOME injuries might be TMS, to which he countered, "Than why do you NEVER make that diagnosis?"

Let me preface my comments with, Your partner and My son sound like two peas in a pod, albeit several years apart in age.
I have spoken with a number of sensible people who have acknowledged that PAST injuries might have been TMS, but I feel like that is not real 'agreement' because even I, when I was recovering, could see a lifetime of TMS episodes
TMS Ironclad Principle Number one : Hindsight is always 20/20

My son 'believes' in TMS because when he was younger we 'cured' a lot of pains that the doctor couldn't. My son is also a pitcher and the star player on our local sandlot team . He pitched two complete games over the last month. Most Pro's don't do that in a year any more because of 'injury' and 'preventing injury'. We won the championship and I haven't heard any complaints about his arm, BUt.....

I noticed he started 'being careful' and told me his arm was hurting(before we won). He also knows about TMS, but swore to me this was NOT. I am not in his body, BUT I do know he is super duper conscientious, ultra hyper responsible and Mr. Does everything for everybody. He is the sort of 'godfather', of his social group and he is such a rock, other young men with problems come to him for help and guidance.
He recently took a pay cut to learn a lot more difficult carpentry than he was going to learn working for me. He also is the head of his own household. He also finally has a long term serious GF. He also just took over MY business and is our CEO. He also, in spite of our sandlot games allegedly being 'friendly' and relaxed, wants to win. Always. He'll pitch 9 innings of shut out baseball, go 2 for 4 and drive in 6 runs and tell me 'I need to work on my swing... I am not hitting the ball as well as I could'

So, in spite of his certainty that his arm issues aren't TMS, I have noticed that the pain seems to come when a big game is coming up, or he's on a really difficult project, or someone else is leaning on him. All simultaneously. But HIS pain is real.

..and when I read about your partner, I saw the same thing going on. The running downhill thing? That could be conditioning... the first time he noticed the discomfort was when he was running downhill...so running downhill is the problem.

I am not a pitcher. I have never run 55k (geez!)... but I know what causes TMS in myself from decades of experience and it is hard NOT to assume we are all similar. I tend to rule out TMS first before I treat any problem as 'real'. And, I have had very few 'real' problems when I sat back, got out a pen, discussed it with a bro...

BUT, good luck getting someone else to see it, no matter how close they are to you. It would be like YOU drinking the first glass of bourbon ever made and trying to explain it to a bystander. If they don't have the experience or the 'aha' moment it is very hard to pass it on....even to my son who is probably a lot smarter than me. Even to my partner who is a dancer and intellectually agrees, but assures me her 3 year old broken wrist is 'real' pain and not because of the domestic drama in our lives (LOL)

and regarding meniscus, and Baseball players who get Tommy John surgery? I believe it is like what Sarno said about discs in our back. The pain shows up and we look for a structural anomaly and go 'aha!' see? THERE is the problem...while meanwhile ignoring our inner personal pains and struggles and need for a distraction. My Knee was KILLING me one summer.. I am so glad I never went and had it looked at lest I get told of my meniscus issues, that might have crawled up in my head and rented some room.

...just some thoughts

 

@Baseball65 , thank you for your insights! I do agree that what my partner has looks very much like TMS. He does not want to go to the doctor with his knee, so my hope is that this pain will eventually fade away. And kudos to your son, he seems to be an awesome young man! I hope he will accept that excessive stress and pressure in life requires respective mental and emotional discipline and attention in order to stay healthy. Young people tend to think that they are tough and therefore indestructible - and often pay the price. Best of luck to both of you!

 

I've had three right knee arthroscopic surgeries. The first, in 1992, was to debride my torn medial meniscus. The other two, in 2002 and 2010, were microfracture surgeries in an effort to repair two worn spots in the medial articular cartilage above the meniscal damage. The cartilage in those spots is three-quarters thinned out, presumably due to the loss of cushioning caused by the earlier meniscal resection.

Prior to these surgeries, I was neither ignorant of TMS nor a TMS skeptic. I developed low back pain in 1967 and had persistent recurring episodes despite having the gamut of standard nonsurgical medical treatments. Sarno published Healing Back Pain in 1991. I heard him promoting the book on a morning TV talk show and immediately bought it. What I learned from the book and put into practice enabled me after about six weeks to stop the back pain completely, and it has never returned. I was familiar with Sarno's symptom imperative concept, but it never occurred to me that my knee pain, which began a year later, could be TMS because, after all, I had imaging that showed my meniscus was torn and subsequently had imaging that indicated worn articular cartilage, not to mention the microfracture surgeon's post-surgery direct observation reports confirming the wear.

None of the three surgeries did much for my knee pain. I had been an avid golfer but gave that up due to knee pain after playing. In addition, even moderate normal activity like ascending or descending stairs or walking on uneven ground was followed by knee pain. For years, my mindset was that "I have significant structural damage in my right knee. No wonder it hurts to do these things, and I am worried about more structural damage occurring unless I am really careful not to stress the knee ." When we moved, I insisted on buying a one-story house to avoid stairs.

I now know the knee pain was what Sarno called TMS and Schubiner calls PPD because I have been free of knee pain since 2018. That happened when I changed my mindset regarding the pain. How I accomplished that is too complicated to go into on this forum. (It involved learning a lot about neural pathways beyond what Schubiner teaches and learning about the often bastardized biopsychosocial model of pain.) The simple version, however, is that I was able to do what Sarno prescribed: understand and accept that the cause of my knee pain was psychological, not structural.

As you likely know, Sarno did a telephone interview with patients seeking an appointment in an effort to screen out those who would be unable to accept that their pain was psychological rather than structural. Here is how he described that in The Mindbody Prescription: “Most of the large population of people with these pain syndromes reject the idea of an emotionally induced process and would, therefore, derive no benefit from our therapeutic program, since acceptance of the diagnosis is essential to a successful outcome. Currently I accept about 50 percent of those who call.” As great a clinician as Sarno was, he learned from experience that he had no transformative power to persuade the unwilling 50 percent.

Pushing your partner to accept that his new knee pain is TMS could be an uphill battle, but putting that aside I am puzzled why he is open to the idea that his old knee pain might have been TMS but not his current knee pain. Perhaps the reason is that he thinks (a) the original surgery, having left his knee “never the same,” made it vulnerable to further wear and tear, (b) additional wear that tear has occurred over the years, and (c) the additional physical damage is the cause of his new pain. If so, I will reiterate that my meniscal debridement left me vulnerable to wear and tear of the articular knee cartilage, and additional wear and tear did in fact happen. Yet, eight years after my second microfracture surgery, the aching vanished when I changed my mindset.

 

Thank you! This is exactly the answer I was looking for. I was looking for an affirmation of my belief that meniscus problems are no different from bulging disc problems in the spine. I myself have occasional pains in my knees, but they jump from one side to another, feel more like muscular pain and eventually disappear, which convinced me that they are TMS.

I am curious to know more about your route. Not to denigrate Dr. Sarno's prophetic genius in understanding the cause of chronic pain, I personally never bought into his explanation of pain being a distraction by the brain or oxygen deprivation. I understand why he did what he did. He came up with this concept decades before modern neuroscience was born. Now that we know so much about neuroplasticity, we must do better than that.

It was the concept of neuroplasticity that made me see the light. Not until I watched a video of the pain management doctor showing a beautiful animated diagram of how physical pain can trigger emotional pain, it dawned on me that the reverse was also possible. Needless to say, I was watching in shock, how the doc immediately jumped to the conclusion that antidepressants were needed to reduce physical pain - and thinking about how narrowminded those MDs can be. For me, that video was a turning point in understanding the mechanism of chronic pain as neuroplasticity in action.

I know what you mean. I will continue working on him. Luckily, he has no intention to have another surgery. Many thanks again for your reply!

 

Hi, TG957. I am having trouble with formatting for some reason, so I have manually put a couple of your comments above in italics and my response in regular font. .

I am curious to know more about your route.

Sure, I have a history of multiple forms of TMS and its equivalents, so when I retired in 2010 I decided to use my newly abundant free time to pursue a new hobby, namely, to learn everything I could about chronic pain. I started out by studying ISTDP because I knew Sarno’s chief psychologist had been trained in that, reportedly by its founder Dr. Habib Davanloo. Davanloo’s books are out of print, but I read a number of books written by ISTDP practitioners that Davanloo trained.

After studying ISTDP, I read the second edition of Schubiner’s Unlearn Your Pain, with its emphasis on neural pathways while also including some ideas from ISTDP. ISTDP claims to be based in part on neuroscience, so between that claim and Unlearn Your Pain, I decided I needed to learn about neuroscience. I soon discovered the work of neuroscientist Joseph LeDoux, who has spent decades researching how the brain responds to threats to one’s survival and well-being. LeDoux has essentially no interest in the neuroscience of pain, but he is a wonderfully clear writer, and I learned a great deal about basic brain neuroscience from him.

Then I came upon Butler & Moseley’s Explain Pain approach to treating chronic pain. Moseley was a regular physical therapist for a decade but with further schooling transitioned to researching the neuroscience of pain. With his neuroscience training, Moseley goes into details about neural pathways that Schubiner does not discuss in his books, perhaps because Schubiner thinks that would turn off too many people. I happen to find the details interesting. If you have the time and interest, I highly recommend the second edition of Butler & Moseley, Explain Pain (2015). Moseley’s tour de force is Moseley & Butler, Explain Pain Supercharged (2017), where he explains in molecular detail how psychological stress causes chronic pain. Unfortunately, Explain Pain Supercharged cannot be understood without first reading Explain Pain, and even then it is a tough go. Moseley introduces the key chapter in the book as follows: “This chapter contains some pretty hardcore biology and some brand new ways of making sense of it. . . . We know this chapter will be tough going and hard reading for everyone." He continued: "(Dave [his coauthor] has read it five times and almost gets it!).” I did not fully understand the chapter despite reading it multiple times until I found a paper by central sensitization guru Clifford Woolf and a colleague of his in the Neural Research Plasticity Group at Harvard, as well as some similar research papers.

I am now firmly with Moseley and what he calls contemporary pain science, some of which I will describe below.

Not to denigrate Dr. Sarno's prophetic genius in understanding the cause of chronic pain, I personally never bought into his explanation of pain being a distraction by the brain or oxygen deprivation.

I did buy into those two things from the time I read Healing Back Pain until I got into my post-retirement new hobby, but no longer. First, the phenomenon of phantom limb pain shows the brain can create pain without having to produce it through causing mild oxygen deprivation in body tissue. A person with phantom limb pain has the sensation of pain in a body part that does not even exist, let alone exist in an oxygen deprived state.

Second, Sarno’s distraction theory views the brain’s creation of pain as protective, that is, it protects us from experiencing emotions (mainly anger) that we have learned are too dangerous or painful to experience. Sarno said he came up with this theory when psychoanalyst Stanley Coen suggested to him that TMS is what psychoanalysts call a defense mechanism. The cornerstone of ISTDP is that psychodynamic conflict among emotions related to a person’s attachment relationships—love of the other person, anger at the person, guilt about the anger, and sadness related to the relationship—induce the person to learn defense mechanisms that keep some or all of these core emotions repressed, and the repression leads to various problems including but not limited to chronic somatic pain. The objective of ISTDP treatment is to help patients become aware of and overcome their learned and habitually used defense mechanisms so they are fully aware of their conflicting attachment emotions and can deal adaptively with them. Consequently, a big focus of ISTDP treatment is on patient’s defense mechanisms. There are many, many Freudian defense mechanisms. See, e.g., Blackman, 101 Defenses: How the Mind Shields Itself (2004). ISTDP does not regard pain as one of them, and I think rightly so.

Contemporary pain science also views the brain’s creation of pain as serving a protective function, but in a totally different way than Sarno. It says the brain creates pain to protect us from actual or potential tissue damage. For example, if you sprain your ankle while jogging, the pain induces you to quit jogging and limp home, whereas if you kept jogging you would risk more tissue damage. Similarly, the pain induces you to take it easy on your ankle during the healing process so that it can proceed without interruption by further injury. Contemporary pain science regards pain not as a learned defense mechanism but rather as an innate response to actual or potential tissue damage provided by evolution because it helped our long-ago ancestors survive.

The obvious question that arises is this: Then why does the brain create TMS/PPD pain in the absence of any actual or potential tissue damage. Alan Gordon gives the short answer in his Pain Recovery Program in the Day 2 lesson titled “The Nature of Pain.” He says the brain is not perfect; it blunders when it creates TMS/PPD pain because evolution has not given us a nervous system that can distinguish between physical stress and emotional stress. The longer answer, which Gordon did not go into, is that emotional stress triggers a cascade of internal chemical events that ends up producing a flood of pro-inflammatory cytokines, which in turn in turn cause nerve fibers in the peripheral nervous system and/or the spinal cord to misfire and send the brain messages of actual or potential tissue damage that are false, i.e., there is in fact no actual or potential tissue damage but the messages say there is. In short, the neural pathways involved in creating pain misfire. The main reason they misfire is that immune cells and immune-like cells modulate synaptic transmission and upregulate it to send false tissue-danger messages to the brain. The biggest development in pain science since the turn of the century is exploration of this phenomenon, which is known as the neuroimmune interface.

I have left out detail about the neuroimmune interface because it involves mind-boggling esoteric terminology such as long-term potentiation, microglia, astrocytes, TLR4s (stands for toll-like receptor 4), HMGB-1 (stands for high mobility group box-1 proteins), and so on. Suffice it to say that ultra high-powered microscopy has enabled neuroscientists and immunologists to discover precisely what is going in molecular detail. Moseley has not been involved in this research, but with his neuroscience training he is fully conversant with it, and he translates it into somewhat less mind-boggling language in Explain Pain Supercharged. Most of the scientists actually doing the cutting-edge neuroimmune interface research are trying to discover a new drug that will stop chronic pain because (of course) that’s were the money is. Mosely is skeptical, and I think for good reason, that they will ever find a pharmaceutical solution.

What Moseley adds to the mix—and it is really important in the absence of a pharmaceutical solution—is that pain science education can prevent one’s brain from being fooled by false tissue-danger messages. When your brain receives tissue-danger messages, it assesses whether the situation is dangerous enough that it needs to create pain to protect tissue somewhere in your body. To do this, your brain analyzes the incoming tissue-danger messages in light of all the information stored in its long-term memory bank, and this generally occurs entirely outside of your conscious awareness. Your brain takes into account everything you have learned whether by experience or instruction and regardless of whether or not the learning is accurate (e.g., your doctor told you “this bulging disk on your x-ray makes your back too fragile to lift more than 20 pounds without risking more damage”) plus everything you believe regardless of whether or not the belief matches reality (e.g., you believe “sleeping on a soft mattress is bad for my fragile back”) plus everything you value, and so on—in short, everything that makes you who you are. If your brain concludes that the incoming tissue-danger messages mean you really have new tissue damage or potential tissue damage somewhere in your body, it creates pain there.

If you have learned contemporary pain science and stored the information in long-term memory, that will affect how your brain evaluates the incoming tissue-danger messages. To borrow language from a leading researcher in this area, you will know “the biological mechanisms that create and sustain the two conditions [acute pain versus chronic pain] are very different.” Acute pain is the product of correct tissue-danger messages, and the pain goes away when the tissue damage heals or, in the case of potential tissue damage, if the pain induces you to take protective measures that avoid any tissue damage. In contrast, if pain persists beyond normal healing time, then your brain will know that the continuing pain is almost always the product of false tissue-danger messages and there is no reason to continue creating it. (I say “almost always” because there are rare exceptions, but these generally are detectable by a competent medical exam.) If you understand and accept all this, then your brain will conclude that the currently incoming tissue-danger messages are false and will stop creating the chronic pain. Strikingly, the matter comes down to Sarno’s prescription to think psychological, not physical—with the psychological part expanded to include what Sarno could not have known, namely, what contemporary pain science has revealed about the neuroimmune interface and the molecular effects of psychological stress. Sarno was indeed prescient.

I can fit the foregoing into something Schubiner said near the end of his Commonwealth Club of California lecture that you arranged. In response to the moderator’s question about the Feldenkrais method, Schubiner said that what he seeks to do is calm the brain, and this in a sense is a placebo effect. He defined the placebo effect as requiring four elements: first, having an explanation of what is wrong, second, having a technique to use to fix the problem, third, having a practitioner you trust, and fourth, having hope and optimism. Contemporary pain science gives me an explanation of what is wrong if I have persistent pain (which is infrequent the last several years), a technique to use to fix it, and hope and optimism that the technique will stop the pain. I do not have a healthcare practitioner I trust, but I trust what contemporary pain science tells me is wrong and how to fix it, and that gives me hope and optimism.

• (Please ignore the file attached below. It is an earlier draft of my above response, and apparently the tmswiki software won't allow me to delete it.)

 

@Duggit , wow, you definitely dug into it, quite deeply! Took me a while to study your response and get my thoughts together - and I still have a lot to digest. I am hoping to retire this summer and have more spare time on hand, but not sure I would have enough determination to follow your lead through the Moseley's Explain Pain Supercharged! But I listened to his lectures where he offers a highly simplified explanation for lay people, which satisfied me at the time.

A person with phantom limb pain has the sensation of pain in a body part that does not even exist, let alone exist in an oxygen deprived state. Yes, that was a strike against both oxygen deprivation and protection theories for me, too. Another strike against those was my own healing from dystonia (involuntary muscle contractions), which could not be explained by oxygen deprivation or by protection of any kind. However, the concept of fight-flight response of the body by releasing hormones and triggering automatic functions helped me explain why my muscles contracted but would not relax.

The longer answer, which Gordon did not go into, is that emotional stress triggers a cascade of internal chemical events that ends up producing a flood of pro-inflammatory cytokines, which in turn in turn cause nerve fibers in the peripheral nervous system and/or the spinal cord to misfire and send the brain messages of actual or potential tissue damage that are false, i.e., there is in fact no actual or potential tissue damage but the messages say there is. In short, the neural pathways involved in creating pain misfire. The main reason they misfire is that immune cells and immune-like cells modulate synaptic transmission and upregulate it to send false tissue-danger messages to the brain. The biggest development in pain science since the turn of the century is exploration of this phenomenon, which is known as the neuroimmune interface.

This is it! Not dissimilar from what I arrived on, albeit on a much deeper molecular level. Misfiring of the neural signals is the cause of chronic pain. Moseley's model also explains very well the mechanism of the stress-induced autoimmune diseases and chronic inflammation processes that do not necessarily fit the "Sarno"-type chronic pain patterns.

Contemporary pain science gives me an explanation of what is wrong if I have persistent pain (which is infrequent the last several years), a technique to use to fix it, and hope and optimism that the technique will stop the pain. I do not have a healthcare practitioner I trust, but I trust what contemporary pain science tells me is wrong and how to fix it, and that gives me hope and optimism.

The above makes sense. Most of my family members (some of them are burdened by medical degrees) consider my recovery a placebo effect. Even if it was, I would take placebo over ketamine shots or surgeries. However, I do think that there is a difference between placebo and Sarno's method in how it applies to the most difficult cases. Placebo implies a passive approach. Patient takes a pill, wakes up next day without pain. It does work that way for some of the TMS-ers who read the book and watch their pain disappear within a day or a month. But it is not how it worked for many people here on this forum. We had to actively re-wire our brains in order to heal our nervous systems to the point that it eliminated faulty neural paths. Placebo concept does not explain well why for many people TMS returns and becomes a game of a whack-a-mole. It takes a focused effort to recondition our brains to the point that they no longer produce misfiring of the pain signals.

I think you edited out a comment on Moseley's skepticism in regards to the development of a universal painkiller after I saw it in the original post. I do agree with Moseley. For as long as our bodies continue to generate conditions that lead to the misfiring of pain signals, painkillers will only have a temporary effect. I find mindfulness and meditation to be the most effective non-pharmaceutical prophylactic against imbalances caused by the outsized stress. Only if we learn how to process external stress factors through our system without letting them harm us we would be free of chronic pain and other chronic illnesses caused by stress.

 

TG957, I want you to know that I am not ignoring your post commenting on what I said about the placebo effect. I just spent several hours tonight writing a too-long reply. When I was nearly finished and tried to put it aside to take another look at it in the morning when I am fresh, everything I wrote suddenly vanished. I must have inadvertently erased it. This is not the first time that has happened to me, and I have no idea what I am doing wrong. I am fairly accomplished with Microsoft Word, but apparently I have no clue how the tmswiki software works. (If I were repressing my current anger, Sarno's theory might predict I would have a TMS attack.) I don't have it in me to try again. I give up.

 

@Duggit , I am so sorry that you are experiencing technical difficulties. I would be more than happy to help you troubleshoot your problem. This reply to my post may not be the last one you would like to make, so it is important that we get your wisdom and knowledge back to this forum. I don't think the issue is TMSWiki software, it is likely your browser and settings on it that are giving you a problem. I experienced the opposite problem with this software, it tends to save every draft every few minutes, and I often find my drafts that I no longer wish to preserve still sitting there. Feel free to message me directly if you want help, I will give it my best.

 

Thanks for your offer of help to troubleshoot my problem. Once in a while it happens; usually it does not. I have no clue what I did, or did not do, on my keyboard that accounts for the difference. Therefore, I don’t know what I could tell you that would enable you to help me. I have discovered the software has a Safe Draft button. Perhaps that will solve my problem though I am unclear whether a single click of the button results in automatic continuous saving or whether it is necessary to click the button every so often to save one's most recent work.

These family members, including those burdened with medical degrees, seem to be mired in an obsolete view of the placebo effect. Here is how Jo Marchant described that view in her New York Times bestseller Cure: A Journey into the Science of Mind Over Body (2016): “Back in 1954, an article in the medical journal The Lancet stated that placebos comfort the ego of ‘unintelligent and inadequate patients.’ Although doctors might not put it so bluntly today, attitudes haven’t changed much since then.” Marchant reports that around the time of the Lancet article, governmental agencies began to require placebo-controlled trials for approval of new drugs. A new drug would not be approved unless it produced better results than an inert pill. She says the framework of placebo-controlled drug trials is the basis of modern medical practice because it allows scientific determination of which medicines work and which don't. Given this framework, she suggests that "the placebo effect is of no interest [to physicians] beyond being something to guard against in clinical trials."

Marchant devotes the first three chapters of Cure to modern research on the placebo effect. Although she is a journalist and author, her PhD in genetics and medical microbiology equips her to evaluate the methodology used and conclusions reached in medical research studies. She dispels the view that placebos work by tricking gullible patients into believing they have less pain than they actually do. While it is true that a placebo does not work unless the patient expects it to work, she says the research shows this patient expectation leads to “measurable physical changes in the brain and body.” She provides a number of examples. For instance, a placebo can trigger the brain to produce endorphins. (The term “endorphin” is an amalgam of two words: endogenous morphine). This natural morphine relieves or stops pain but without any of the adverse side effects of exogenous morphine that is put into the body by ingestion or injection. Endorphins are just one of many chemicals that a placebo can induce the brain to produce. Marchant says a prominent placebo researcher "emphasizes that the placebo effect isn’t a single phenomenon but a ‘melting pot’ of responses, each using different ingredients from the brain’s natural pharmacy.” (Switching for a moment from Marchant to Moseley and Butler, they say “the medicine cabinet in your brain” can produce a cocktail of hormones that works throughout your body to dampen down tissue-danger messages from reaching your brain.)

Marchant is under no illusion that the placebo effect is a cure all. First, it is “limited to the natural tools that the body has available.” It can't enable a person with cystic fibrosis to "create the missing protein that their lungs need any more than an amputee can grow a new leg." Second, a placebo affects only symptoms, i.e., “things we are consciously aware of, such as pain . . . .” There is little evidence that placebos can affect things we are not consciously aware of such as cholesterol and blood sugar levels. Pain, of course, is an unpleasant conscious sensation; we feel it. So pain is a good candidate to be influenced by the placebo effect.

Schubiner is not unaware that people with an outdated view of the placebo effect have criticized his approach to treating PPD on the ground that it is “merely” a placebo. I don’t know if you have read the book that he coauthored with psychiatrist Allan Abbass titled Hidden from View: A Clinician’s Guide to Psychophysiologic Disorders. They collaborated on the first and last chapters; Schubiner wrote chapters 2 through 4, and Abbass wrote several chapters on ISTDP. In chapter 3, Schubiner responded to the placebo criticism as follows: “[W]hen neural coding of expectations of chronic pain or other PPD symptoms is the underlying reason for the persistence of symptoms, changing the expectation (which is the definition of the placebo effect) can literally cure the disorder.”

My initial reaction to this was that you are wrong, but on reflection I think any differences between us likely are only semantic and turn on what the term “placebo effect” means. We learn from Lewis Carroll’s Through the Looking Glass that words can mean whatever a person wants them to mean. Obviously it is important for people to be clear about what they mean to avoid misunderstanding. But a meaning contrary to the conventional meaning is not necessarily “wrong,” especially if the conventional meaning is out of step with modern research. I am going to try to clarify what I mean, and understand Schubiner to mean, by “placebo effect.”

Here is my transcription of what Schubiner said about the placebo effect in his Commonwealth Club lecture, with my addition of bracketed numbers for clarity regarding its four elements:

“The placebo effect consists of people [1] having an explanation for what’s wrong with them, [2] having a technique they can use, [3] having a practitioner that they trust, and [4] having hope and optimism. So when you put all those things together, you get a strong placebo effect. Placebo effect is all you need for brain-induced pain. So what I do is in a sense a placebo effect. I am helping people help themselves by harnessing the power of their own brain.”​

Regarding element 3, Scubiner and Abbass emphasize in chapter 1 of Hidden from View: “As a foundation for this clinical work [of treating PPD], creating trust with your patient is always key. . . . Such a therapeutic relationship with your patient is a necessary ingredient at each step.” I think the reasoning behind this statement is that unless a patient trusts that the practitioner knows what he or she is talking about and is trying his or her best to help the patient, the patient will not truly accept the practitioner’s element 1 explanation of what is wrong and element 2 technique to use to fix it, nor will the patient have element 4 hope and optimism the technique will work. In sum, when all four elements are in place, the patient expects the treatment to work. That is what Schubiner meant, I think, in the chapter 3 quotation above about changing the patient's expectation being a cure for PPD.

Randomized-controlled drug trials certainly involve a passive element 2 technique (ignoring the act of swallowing a pill because that is insignificant). But I don’t see passivity as essential to the placebo effect.

Schubiner’s element 1 explanation of what is wrong is that PPD symptoms are caused by neural pathways, not something physical. In chapter 4, titled Cognitive and Behavioral Interventions, Schubiner lays out a smorgasbord of treatment techniques for patients to use. He introduces them with this statement: “If patients accept the diagnosis that there is nothing physically wrong, their pain, and the accompanying tension, fear, withdrawal, and helplessness can be reduced. Then they can work on reducing the automatic, natural, fearful reactions to pain and other PPD symptoms that are reinforcing the neural pathways that are the current cause of the symptoms.” (Emphasis added.) The phrase “work on” foretells that the techniques are not going to be passive.

The techniques he lays out in the rest of the chapter come under the following headings: Symptom Tracking—Noticing Antecedents, Reappraisal of PPD Symptoms and Reduction of Fear, Conceiving of PPD as a Bully, Use Top-Down Cognitive Interventions (e.g., “there is nothing wrong with me.”), Meditation and Mindfulness Practice, Compassion for Self, Expressive Writing, Emotional Awareness, Examining Life Situations, and Resume Life. As you no doubt are aware, these are hardly passive techniques.

(I’ll end here with an aside. Element 3 of having a practitioner that one trusts does not necessarily require direct contact. I trusted what Sarno said in Healing Back Pain about why my back hurt and what technique I needed to use to fix that. I now trust Moseley’s Explain Pain books and the neuroimmune interface research papers that I have read and relied on to stop more than a decade right knee pain along with several other pains.)

I like your whack-a-mole metaphor for TMS that returns. I think, however, that element 1 of the placebo effect can fully explain the whack-a-mole problem. In Hidden from View, Schubiner provides sample scripts that clinicians can use with their PPD patients. Here is part of one of them:

“All pain occurs in the brain, whether it is due to a structural disorder or not. Pain occurs when our brain activates an alarm or danger signal. Both physical injuries and emotional injuries activate the same danger signal, which triggers pain. . . . When pain occurs (whether due to an injury or a neural pathway process), the brain learns the neural pathways associated with that pain. These neural pathways can become persistent, can be turned off, or can come and go depending on whether the danger signal in the brain is activated. People exposed to stressful life events are more likely to have a danger/alarm mechanism that is sensitive and activates pain and other symptoms.” (Emphasis added.)​

This script is over-simplified for my taste. If I were writing a script for myself, it would be less brain-centric and go into more detail and complexity, including the neuroimmune interface which involves peripheral and spinal neurons as well as brain neurons. But that is just me. Schubiner surely knows from experience what will and will not “sell” with patients.

I want to focus on the sentence in the above sample script that I italicized: TMS pain can persist, can be turned off, or can come and go depending on whether the danger signal in the brain is activated—or as I would say it, depending on whether your brain determines, after evaluating the incoming tissue-danger messages in light of everything stored in your long-term memory, that you really have actual or potential tissue damage. There is nothing about the four elements of the placebo effect that says TMS pain can’t recur. To the contrary, the fact that the pain can recur is part of the element 1 explanation of what is wrong. After a person ends an episode of TMS triggered by emotional stress through applying some combination of Schubiner’s chapter 4 techniques to use, there is no guarantee that he or she will never again be emotionally stressed enough to again trigger TMS. In addition, emotional stress that triggers TMS might prime a person’s danger receptors and/or neural danger-transmission system to become more sensitive so that even lesser emotional stress in the future can result in another TMS episode. That is not inconsistent with the concept of the placebo effect.

I hope the foregoing clarifies what I mean and think Schubiner means by the term “placebo effect.”

 

@Duggit , I am still processing your post. It will take me some time to respond - a lot to think about!

 

Duggit has the same wonderful effect on me.

 

Agreed. Unfortunately, people in science, technology, politics and social settings tend to throw around terms without specifying definitions, which, in turn, can be too abbreviated or purposely trivialized. It does look like our differences are semantic. The original, literal meaning of placebo is "I shall be pleasing". Latin original being rather vague, "placebo effect" can be spun into many definitions, from what my MD relative loosely defines as my uneducated belief in a fake medicine that made me feel better to a much more complex and evolved construct that Dr. Schubiner presents. In my relative's defense, he retired from practicing medicine over 20 years ago, just as neuroscience started producing its most amazing research and clinical applications.

But I am very grateful to you that you got me into thinking more about the nature of placebo and the placebo effect. To the tune of purchasing Jo Marchant book (still waiting for it to arrive) and reading whatever else I could find on both studies and anecdotal evidence of the mindbody-based healing and un-healing (aka nocebo). I am yet to produce any coherent thoughts or even questions on the subject, but I wanted to share some information with you.

There is this medical researcher Ted Kaptchuk whose excellent book on Chinese medicine I read long time ago. He is no longer practicing Chinese medicine; instead, he does some mind-bending placebo research at Harvard Medical School. They test every component of the 4-prong definition of the placebo effect that you quote (explanation-method-trusted practitioner-hope) and try to understand impact of each.

For example, he has given IBS patients sugar pills that were clearly labeled "Placebo pills" and told them that placebo pills are known to provide relief. A statistically significant number of study participants reported disappearance of symptoms. On the subject of whack-a-mole game, a woman who was "cured" from IBS had a re-occurrence of symptoms few years later, and asked for the same pills again - and was "cured" again. Here is the link to his TED talk:

https://www.oshercollaborative.org/video/tedmed-kaptchuk-placebo (TEDMED – Kaptchuk on Placebo - Osher Collaborative)

I am so much looking forward to my retirement so I would be able to spend more time on this fascinating subject!

 

Good for you in purchasing Marchant's book. She talks about Kaptchuk's work in chapter 2. I found chapter 3 about cutting-edge research on the use of placebos to retrain the immune system to be a amazing. Placebos are not the focus of the remaining chapters of the book, but of interest regarding TMS are chapter 6 on rethinking pain and chapter 8 on the fight or flight response. Chapter 8 refers, among other things, to research on the difference between fear and exhilaration in response to stress. I think "exhilaration," used in this sense, includes hope and optimism--the fourth element of what Schubiner said produces the placebo effect. Marchant wrote: "Few of us can remove all the stress from our lives . . . . External problems--debt, rocky relationships, having a child with autism--do not generally damage our bodies directly. What harms us is our psychological response to those circumstances, not the state of our environment but of our mind. And that is something we can control." Some of the other book chapters concern methods or treatments that would not be my cup of tea, but Marchant is a gifted writer whose storytelling style makes her easy to read and engaging. If you can find the time to read the entire book, you might find it enjoyable and informative. I did.