I don’t know what questions the journalists asked the experts in this NPR story about programs that treat unexplained chronic pain conditions in kids by forcing them “to push their bodies until they are in tons of pain” in order to retrain their brains to ignore pain.

But these are the questions I would have asked them:

1) What evaluations do patients undergo before the program to
determine that there isn’t an undiagnosed condition or injury that
explains their pain? Literally, what lab tests and imaging is ordered?
How many specialists have independently reviewed their case? How sure are you (as a percentage) that you have ruled out every
possible underlying cause of the pain before accepting a patient into
your program?

2) Your program is based on the
theory that the pain persists because patients focus on it. But what is
your theory for how the pain begins? How do you explain experiences like
Devyn’s in which the pain began suddenly out of the blue?

3) There
are many pain experts who believe that what you call “amplified pain”
is indeed caused by an amplification of the pain processing system but is
due to sensitization at the level of neuron, not mediated
by psychological factors like attentional focus. What evidence specifically convinces you that your theory is the more likely one? And
what evidence would convince you that your theory is incorrect? Is your theory falsifiable?

4) You
theorize that the pain is an expression of emotional distress in kids
who are “not in touch with their feelings” and “don’t have the
sophisticated emotional skills they need to manage in an increasingly
stressful world.” Given that girls are generally more emotionally
intelligent and in touch with their feelings than boys, what is your
explanation for why girls are disproportionately affected by these pain syndromes? And if your
theory about the root cause of the pain is correct, wouldn’t the factor
that explains the gender difference then need to be something nearly
universal—like, say, sex-based genetic or hormonal
differences—to produce such a marked gender imbalance in the opposite direction? And if that’s the case, wouldn’t that suggest that biological factors play a more important role than your theory allows for?

5) Many
other experts in what you call amplified pain recommend exercise because of its physiological effect on the pain processing system. What
makes you believe that any benefit from your program is due to the
experience of pain and not the direct effect of the exercise itself?
Have you done a study in which one control group got the exercise only (or the exercise,
therapy, and breathing exercises) but without the focus on ignoring the pain?

6) Similarly,
learning to distract yourself or even disassociate from the pain is a
common way of coping with pain, both acute pain and chronic pain
explained by an underlying disease or injury. Have you done a study in
which you put patients with “explained” chronic pain conditions (say,
rheumatoid arthritis patients) through the same treatment program? If
patients with “explained” chronic pain report comparable reductions in
pain wouldn’t that suggest that what you are offering is not a treatment
of the root cause of the pain but simply a (very unpleasant) way of
teaching patients some pain coping skills?

7) Your
program is rooted in a belief that you should not give more attention
to patients’ pain complaints. An asthma attack and a nosebleed are not
pain complaints. What possible justification was there to ignore these
problems in Devyn?

8) Upon
completion of your program, what training do you provide to patients and
their parents about how to differentiate between their existing pain,
which they are instructed to ignore, and new pain complaints that may be a
warning sign of an unrelated potentially life-threatening medical
problem?

9) How did you get permission to
implement this treatment program if the approach has never been proven
safe and effective in large controlled studies? Do you inform patients
and their parents of the untested, experimental nature of the program?

10) You believe that the alarmingly high and rising rates of chronic pain in the US are caused by the fact that American society has “focused way too much attention on aggressively relieving pain” and our
medical system “asks patients to rate their pain on a scale of 1 to 10,
and treats it like an emergency.” How does this theory square with the
overwhelming amount of evidence that pain is frequently undertreated in the US medical system, physicians get little training on pain
management, and most continue to see pain as a diagnostic clue and not
a problem in and of itself?

11) As our understanding of the neurobiology of pain has gotten
progressively more sophisticated over the decades, many other previously
inexplicable aspects of pain that we resorted to explaining in
psychological terms have become explained in physiological ones (for example, phantom limb pain). Doesn’t this history give you pause
about the wisdom of resorting to psychological theories for pain that is currently
“unexplained”?

12) You clearly believe wholeheartedly that your theory is correct. What if you are wrong?