Acute pain is a faithful messenger; the ankle that twists sends a nociceptive signal that protects the joint while it heals. Chronic pain, defined as pain persisting beyond three months or beyond the expected tissue healing time, is something physiologically distinct. Functional MRI studies of patients with chronic low back pain, fibromyalgia, or persistent post-surgical pain show progressively increased activity in brain regions that handle threat, prediction, and emotional salience—the medial prefrontal cortex, anterior cingulate, insula, and amygdala—and decreased activity in the somatosensory regions where the original injury would have registered. The pain experience has migrated from a tissue-driven phenomenon into a brain-driven one, a state increasingly described in the literature as nociplastic pain or central sensitization.
Somatic tracking, formalized by Alan Gordon and tested rigorously in the Boulder Back Pain Study, leverages this neuroplasticity in reverse. The patient is guided to attend to the pain sensation with curiosity rather than alarm, noticing whether the sensation is sharp, dull, warm, tingling, whether it shifts location, whether it fades when attention rests gently on it. The exercise is not distraction or denial; it is the explicit pairing of sensory attention with a felt sense of safety, often supported by a slow exhalation, a relaxed posture, and a mindful reminder that the tissue is structurally fine. Repeating this pairing across many short daily sessions begins to extinguish the conditioned link between sensation and threat. In the Boulder trial, two thirds of participants with chronic back pain became pain-free or nearly pain-free at one-year follow-up, a magnitude of effect rarely seen with any pharmacologic or interventional therapy in this population.
This approach sits comfortably alongside, not in opposition to, conventional structural workup. Red flags such as new neurologic deficit, infection, fracture, malignancy, or progressive autoimmune disease still require imaging and targeted treatment. But for the large majority of chronic pain that persists after a thorough negative workup, the pain is real, the tissue is largely healed, and the lever is the central nervous system. Somatic tracking is also remarkably accessible: it requires no medication, no equipment, and can be practiced for minutes at a time during otherwise mundane activities. Treating the brain as the seat of chronic pain is not dismissing the patient. It is taking the underlying neurobiology seriously and offering a tool that maps directly onto it.
References:
- Ashar, Y. K., Gordon, A., Schubiner, H., Uipi, C., Knight, K., Anderson, Z., et al. (2022). Effect of pain reprocessing therapy vs placebo and usual care for patients with chronic back pain: A randomized clinical trial. JAMA Psychiatry, 79(1), 13-23.
- Kucyi, A., & Davis, K. D. (2015). The dynamic pain connectome. Trends in Neurosciences, 38(2), 86-95.
- Kosek, E., Cohen, M., Baron, R., Gebhart, G. F., Mico, J. A., Rice, A. S. C., et al. (2016). Do we need a third mechanistic descriptor for chronic pain states? Pain, 157(7), 1382-1386.
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