Podcast: New Therapy Quiets Brain’s ‘False Alarms,’ Aims to Cure Chronic Pain

Chris Casey: Hello and welcome to a special episode of our CU Anschutz Medical Campus

podcast, which as of today has a brand-new name. My name is Chris Casey and I'm the director of digital storytelling here on campus. It's a pleasure as always to be joined by my co-host, Dr. Thomas Flaig, vice chancellor for research at CU Anschutz. So Tom, are you ready for this big new reveal we have today?

Tom Flaig: It's pretty exciting and there's been a lot of talk about this for a while, and the old name was, I guess serviceable in some ways, but I love the new name. It's great. It captures what we're trying to do here. You got a new graphic with this, which is really sharp.

Chris Casey: Very sharp, done by our graphic artist Jenny Merchant. Excellent work.

Tom Flaig: Do you have a theme song though? Got to be a new theme song with this.

Chris Casey: We are toying around with revising our theme music.

Tom Flaig: Wow.

Chris Casey: That could be a future project.

Tom Flaig: When you say we, is that something you'd personally be involved with?

Chris Casey: I do futz around on guitar, but I do not consider myself skillful enough to be our background music. But anyway, we'll see. We may revise our background music. So anyway, we have an excellent show today. We're excited to talk with Dr. Yoni Ashar about his research into neuroscience-based ways to alleviate chronic pain. But still, let's take just a moment to go a little bit deeper into this new name. We are moving on from CU Anschutz 360 to our new title – Health Science Radio. We think this name better speaks to the essence of our show. And so let's just break it down a little. I'll start with the Health Science part. So that speaks for itself as in each episode here, we tap the expertise and innovation of our brilliant CU Anschutz Medical Campus faculty and some of the groundbreaking research they're conducting. But the other part of our name – radio – some people might say, well, why radio? Why not podcast? So Tom maybe you can speak to that.

Tom Flaig: So we're sitting here right now in the Fitzsimons Building on the CU Anschutz Medical Campus. This building opened up in early December 1941, about a week before Pearl Harbor. So I always think, and my office is here, I always think of the historical nature of this campus. It was a military hospital campus dating back to 1918. If you think of radio, I guess I think of sort of the golden age of radio, right. It was the golden age of radio – World War II or thereabouts. Maybe also the time after that where people would gather and listen to messages in that way. And the icon sort of harkens back to this historical note of it so I like the historical connection to this place and radio. And, I also imagine, I've seen pictures of the base theater. So again, all these troops recovering, thousands of troops recovered here. They would bring in national performers who would come here to recognize the troops, entertainment and so forth. So there was some sense of, I think, people coming here and televising that or using radio, putting this out on radio and so forth. So I like that tie-in as well.

Chris Casey: That's excellent. Yeah, I agree. I think it's kind of a halcyon callback to when this campus really began to flourish and come into its own as a health science center in the Denver area. So anyway, here we are in a new year with our new name. Welcome to Health Science Radio. And as I mentioned, we are excited about our guest today. Dr. Yoni Ashar is an assistant professor at the CU Anschutz Medical Campus. He completed his doctorate in clinical psychology and neuroscience at CU Boulder and an NIH funded postdoctoral fellowship at Weill Cornell Medicine. Dr. Ashar directs a research laboratory using functional MRI brain imaging, natural language processing, and other clinical and computational tools to understand how mind and brain processes influence health, especially chronic pain. His main research focus is investigating a new class of psychological and neuroscience-based treatments aiming for recovery from chronic pain. So Dr. Ashar, we like a little more informal touch here at Health Science Radio, so we'll refer to you by your first name. Hello, Yoni, and welcome to this episode.

Yoni Ashar: Thanks so much, Chris. It's great to be here and how exciting to be on the first-ever episode of Health Science Radio.

Chris Casey: Great. I'm glad you're buying into our new brand.

Yoni Ashar: I've bought in.

Chris Casey: Maybe just to start, Yoni, with the big picture of some of your research, could you just talk a little bit about what your impetus was. What set you down the path of exploring different ways to help patients? I mean, let's face it, chronic pain is something millions of people experience, perhaps one of the most ubiquitous problems health-wise out there. But what set you down the path to help patients relieve their chronic pain?

Yoni Ashar: My path has been a bit of a winding one. I started in computer science and then took a strong personal interest in meditation and that led me to the world of neuroscience and psychology. And my early work was on placebo effects, which are the power of belief to bring healing, and it was really exciting and fun to work on. And one of the places that we most see placebo effects is in pain. That's what got me into pain. And basically as the journey unfolded, I learned about this work some colleagues and mentors were doing on chronic pain and how the power of belief and emotion and chronic pain is actually even far greater than it would be for acute pain, like stub-your-toe kind of pain. And the journey has been continuing since, and it's been a lot of fun so.

Chris Casey: Great. And could you talk about physiologically what's going on with pain? We hear when there's an amputee, people who've lost a limb, they still feel ghost pain, if that's the correct term.

Yoni Ashar: Phantom pain.

Chris Casey: Phantom pain. Yes, thank you. So the impulses are going there into their brain that the limb is still there. And could you explain just a little bit about how maybe even after there's been an amputation or say an injury has been healed, that the brain somehow continues to still send signals out to the body that there's pain?

Yoni Ashar: Yeah, pain is just such a puzzle. We think of it as such a simple phenomenon and one of the most basic aspects of our existence, of the existence of any animal really, but in reality, it becomes so complex like the example you gave Chris of having pain in the body part that doesn't even exist anymore. How can that be? And one thing we've learned from decades of pain neuroscience is that the brain processing of pain is incredibly complex. It involves dozens of regions with all kinds of redundant and overlapping processing, and ultimately pain is an output of the brain, not an input. So we often think that like, oh, my back hurts, and that's because I'm getting pain signals from the back. But really pain is created by the brain based on what it believes – based on signals it's getting from the body. And in the example of phantom pain, that seems to be true as well. It's like the brain is holding onto this memory of the limb that used to be there and of the injury it's sustained.

Tom Flaig: I'm really glad we're starting this podcast by thinking about pain and not diving right into your work. So I'm an oncologist; I treat cancer patients. I think a lot about pain and pain is such a thing and it affects people in such substantial ways. I'm just really interested to see your approach to this, the connection. I too have thought about things like the placebo effect. People use acupuncture, other things very effectively to deal with pain and how we sort of think about this in allopathic medicine and so forth. So again, I'm glad we're starting this conversation by talking about pain in such a general concept.

Yoni Ashar: Exactly. It’s very relevant for cancer pain as well. Like in cancer patients, people will have, say, bone tumors and some patients might have massive tumors and no pain. Some patients look at the scans and you say, ‘why are you in so much pain? This doesn't make sense.’ There's a mismatch between what we see in the body and the person's experience. And I just want to even pause right here before we go any further and say, no one's ever making up their pain. Patients aren't exaggerating. The pain is real.

Tom Flaig: Very real.

Yoni Ashar: But there's a lot that's driving it that you can't see in standard medical testing because it's happening in the brain.

Tom Flaig: It's very important to say that and I completely agree. I've had patients that have one bone lesion and intractable pain that changes their life. Then there are patients who have 20 bone spots and they're not developing a pain phenomenon from that feeling.

Yoni Ashar: Exactly. The pain is so much more than just the bone lesion.

Chris Casey: Well, maybe if we could just transition then, Yoni, into a study that you were involved with, which sampled a pretty large sampling of patients. Could you explain just what the study involved, how many folks were involved, what levels of pain they were dealing with, and then what your study set out to find?

Yoni Ashar: Yeah, so we recruited 151 patients from the Denver-Boulder area with chronic back pain. And we were testing a treatment called pain reprocessing therapy, which is a psychological or behavioral treatment that aims to help retrain people's brains out of pain. So one of the ideas here is that pain is a danger signal. Pain is our brain's way of saying danger, injury, threat. There's something in our body that's a problem and sometimes the brain can be wrong about that. So most times in our lives when we feel pain it's because we were injured, we bumped our elbow on something or put our hands on the hot stove, but sometimes our brain's creating pain even when there is no injury. And the reasons for that are something we're still learning about. But one way to think about it would be a kind of a better-safe-than-sorry policy – that the brain's trying to protect us. Pain's our way of protecting us. And if the brain's not sure if there's an injury or not say, well, let me just create pain just to play it safe and try to protect this body. But sometimes it's mistaken and the pain at that point, we can think of it as a false alarm, meaning the alarm is really going off, but actually the body's healthy and sound, and maybe there are a few wisps of smoke, but there's no fire in the body.

Tom Flaig: So false alarm, the bell is going off, you're feeling the pain, but there's not a true source of danger or fire or whatever.

Yoni Ashar: Exactly. Now the false alarm is just as obnoxious and irritating and difficult as the true alarm, but the causes are very different. And that's because the causes are in the brain at that point. Basically, the wiring got too sensitive. Think about in a car alarm where the wiring got so sensitive. Now every time a leaf touches the car, the car alarm starts going off, but really the leaf's not dangerous to the car. So we don't need that level of sensitivity. And what we're trying to do in this treatment, pain reprocessing therapy, is return the alarm system sensitivity to a healthy place where it really goes off if a burglar was breaking in and really doesn't go off if a leaf is touching the car.

Tom Flaig: Now, is this approach novel or is this a thing that's been tested over time? Is this new work in this field or just a different application of it perhaps?

Yoni Ashar: That's a great question. The roots really go back and you can even look back to the ancient Greeks and work about how it's really all about how we, I wish I could remember the Greek philosopher right now, but it's all about how we, I think the Stoics talked a lot about it's how we interpret events that happen to us, not the events itself. And fast forwarding more recently, there's been a lot of work on psychological treatments and understanding the role of the brain and pain. So this work we're doing builds on a lot of prior work, and we think we have an approach here that is different and is new relative to prior approaches.

Chris Casey: And as I understand, there's a fair amount of talking that happens with the patients. Could you explain how pain reprocessing therapy works in a clinical setting?

Yoni Ashar: Yeah, for sure. We're trying to teach patients a specific set of techniques for retraining their brains to feel safe or to interpret those sensations from the body through a lens of safety and then the brain will start to bring down that danger level and the pain can start to come down. So the first thing we need to do is figure out for a particular patient what's causing their pain? Do they actually have a large disc bulge that's causing the pain or does it seem like it's brain-derived pain? Then we give them a lot of education, kind of like we're doing right now, right here, telling people, look, it's really the brain. The brain can learn. It doesn't mean the pain's not real, the pain is real, but it's driven by the brain. And then techniques for, I would say, learning safety. And that means starting to move again, starting to exercise. If you hurt your back playing tennis, get back and start serving the ball again and backhand and forehand and techniques for going inward and learning to pay attention differently to those sensations because a lot of times people have a lot of fear and anxiety around those feelings. I'm thinking of one of my friends who was given a diagnosis of degenerative disc disease, which is very terrifying if you don't know what that is. Oh, degenerative disc disease. Every time he would feel a sensation in his back, he would think, well, my discs are degenerating, so this is the best my back will ever feel, and every day is going to get worse and worse. And so people get terrified about these sensations in their body. And I'll skip ahead when he found out, when he came across all this work, he now lives pain-free because it turns out this degenerative disc disease is highly prevalent and tons of people with no back pain have it, and it sounds much worse than it is. It's actually a pretty normal condition, nothing to be afraid of and so forth.

Tom Flaig: Commonly denoted on radiologic reports, right?

Yoni Ashar: Yeah.

Tom Flaig: Particularly certain ages.

Yoni Ashar: Yes, exactly.

Tom Flaig: So how long does this process of pain reprocessing therapy take, and how intense is the actual training with the patients?

Yoni Ashar: In our work we've tested, it's nine sessions. Each session is about 50 minutes, and we had some really encouraging results in this trial. So what we found was that two-thirds of people who were treated with pain reprocessing therapy were pain-free, or nearly so, after treatment, which means they said they had zero or one out of 10 pain compared to, it was 25% in the control group.

Tom Flaig: And this would be individual sessions? Are these group sessions?

Yoni Ashar: Yeah, individual sessions. Although we're now starting to test a group format to try to scale this out.

Chris Casey: And yeah, emotionally, it was pretty startling to see how the pain reprocessing therapy worked on one particular individual who was featured in a recent “Today Show” segment. I guess it was a man locally who suffered lower back pain and he had just a transforming experience. Could you talk a little bit about that, The “Today Show” subject and his experience? It was pretty amazing.

Yoni Ashar: So this gentleman had years of pain and was hospitalized more than once for the pain and was considering surgery, but really didn't want to go down that road. Somehow he heard about our trial, got in and, nine sessions later, was pain free. And that's the really remarkable thing. One of the most exciting things for me about this work is that most traditional psychological approaches for pain, you can consider pain management, trying to help people live better with their pain, how to cope with your pain. We're going for something very different. We're trying to help people recover from their pain. So it's not learning how to live with your pain, it's learning how to unlearn your pain and get rid of the pain. And that's a very exciting possibility that you could actually do something with your mind, with your beliefs, with your emotional state that then causes the pain to dwindle and ultimately vanish – or more or less vanish.

Tom Flaig: Is there any evidence – that there's certain types of pain that are more applicable to this kind of work? Back pain, neuropathic pain, chronic pain, acute pain?

Yoni Ashar: Yeah. So this is a really good fit for a category of pain that's called nociplastic pain. It's quite a mouthful. Most people haven't heard about it. And another term is primary pain. That's coming out in the ICD-11, which is a diagnostic code book used internationally. And so primary pain, or nociplastic pain, both refer to basically brain-generated pain, and that's what is a good fit for (this treatment). That is we believe most cases of chronic back pain, most cases of tension headache, that we don't have data on that yet. We have a lot of encouraging clinical experiences, fibromyalgia, a lot of these conditions that doctors can't find anything wrong, no one can figure it out, especially when people have had pain in multiple different body sites. I had stomach pain when I was a kid and back pain in my 20s and I started getting migraines in my 30s. This is a classic presentation of nociplastic pain or primary pain.

Chris Casey: So they go through the nine weeks of therapy, what happens when the nine weeks are over and they're set off onto their lives, go back to their normal lives, maybe trying to do more physical activity that they'd shelved for a long time because of the pain. How do they continue to keep the pain at bay at that point? Have you taught them ways they can self-administer (the therapy)?

Yoni Ashar: Yeah, I think there's really two main ways that for me boil down the essence of the treatment. One is stay active, do the things that you were afraid to do because those things are not dangerous to do. You're not going to break your back, you're not going to dislocate your shoulder because your shoulder is healthy, your back is healthy. So, one is staying active and the other is this kind of messaging that we can give ourselves. And the message is, my back is safe, my shoulder is safe, my head is safe. These body parts are not damaged, they're not injured, they're strong, they're healthy. And it's reminding ourselves that, telling ourselves that on a daily basis, helps the brain update its belief. Because what's driving the pain, we believe, and there's emerging evidence for this, is the brain's belief that the body is injured. And if you just keep telling yourself, no, my body's not injured, your brain will get the message and it'll start to bring down the pain because it no longer needs to generate it.

Tom Flaig: I wonder if we want to shift and talk more specifically about the study itself?

Chris Casey: Sure.

Tom Flaig: With that, I mean the study was intriguing. It was a decent-size study, 150 patients. Can you talk about what sort of patients were selected or eligible for the study?

Yoni Ashar: Yeah, we tried to be pretty broad here. It was back pain. And so by broad, I mean if people had stenosis, no problem, welcome in. Scoliosis, no problem, welcome in.

Tom Flaig: So, stenosis is a tightening, scoliosis is a curvature of the spine.

Yoni Ashar: Exactly.

Tom Flaig: Some anatomical things.

Yoni Ashar: So, these anatomical findings like stenosis, scoliosis, these are highly prevalent in pain-free populations – tons of people have them and don't have pain. They're often what we would call an incidental finding. So yeah, sure you might have it, but it has really nothing to do with your pain. So we don't get nervous when we see scoliosis, stenosis. Yeah, maybe that's the cause of your pain, but it's a good chance it's really incidental and unrelated because if you take a hundred people with no back pain whatsoever and you scan their backs, you'll see all sorts of findings and they've got no pain. So we aim to be pretty broad and include all these folks. We excluded people with indications that might make you think there is something in the body. So, when people had leg pain worse than the back pain, we excluded them because that's a sign of potential radiculopathy, shooting pain down the back of your leg. That's kind of suggests that the nerve root might be pinched in the back. You're an oncologist, Tom, so we excluded people with a history of metastasizing cancers because you just don't know. There could be a cancer cause of the pain and PRT is not really meant for that kind of pain.

Tom Flaig: What about patients that were on stronger pain medication, for example? Were they in the study? Or if they were on narcotic medication? Opioids?

Yoni Ashar: Great question. We did not select on that as, luck of the draw had it, very few of the patients in the study were using narcotics. We just happened to get less of a population using those narcotics.

Tom Flaig: Yeah, that can complicate the picture. And then was it mild pain, moderate pain, severe pain cut off in that regard?

Yoni Ashar: This was a moderate-pain population. On average, say four out of 10 pain intensity.

Tom Flaig: And then you described the interventional a little bit. So it was, I think nine sessions, one hour each. And that was over what length of time, those nine sessions?

Yoni Ashar: That was over a month. So we packed it in; we did two a week. The first session was with a physician. The physician, they assessed (each patient), and people told them, ‘you have nociplastic pain. Your body's healthy, the brain's the cause.’ It can really help to hear that from a doctor because a lot of people have heard opposite messages from doctors. People have heard messages like, ‘you'll be in pain the rest of your life.’ I can't tell you how many patients have told me their doctor said that to them. So, one session with a doctor and then followed by eight sessions with a therapist aiming to teach patients these techniques to retrain their brain out of pain.

Tom Flaig: And what were the main findings of this study, the outcomes related to the endpoints you measured?

Yoni Ashar: Yeah. So, the main outcomes here were that after PRT, pain reprocessing therapy, about two thirds of people were pain-free, or nearly so – meaning zero or one out of 10 pain (intensity).

Tom Flaig: With no pain medication or other adjuncts?

Yoni Ashar: No pain medication, no adjunct treatment. They were, and it's really remarkable, these patients were telling us, I don't have back pain anymore. That's not something that you typically hear after these psychological treatment trials. What we're used to hearing is saying, my pain's a little better and it doesn't bother me as much. What people in this trial were telling us is, ‘I just don't have it anymore,’ which is really exciting and neat. Yeah, so that was the main outcome. And also we've done some work trying to dig into, well, how did this happen? This can't just be a magic trick. There has to be an explanation. And so we've been digging into this idea that we're calling pain attributions. It's kind of a bit of a mouthful but what we mean by that is to what do you attribute your pain, meaning tell me in your own words, what do you think is the cause of your pain? So this is why we asked our participants, tell me in your own words, ‘what do you think is the cause of your back pain?’ And remarkably, no one had really asked anyone this question before. And what people told us before treatment was, well, we we're here in Colorado, so people said snowboarding accidents, ski accidents, being too sedentary, being too active, bad posture, weak muscles, strong muscles, so all these attributions, all reasons we got were heavily body focused and we asked people the same question after treatment, what do you think in your own words is the cause of your back pain? And after PRT people told us things like my brain, my emotions, my relationship with my spouse. That's what's causing my back pain. And so, it's a very different story in terms of what people are telling themselves about the cause of the pain. And what we found is that the more people shifted to a mind- or brain-focused story, the more their pain went down.

Tom Flaig: Was this a multi-center study? I know you work here at CU Anschutz, but is this a multi-center study?=

Yoni Ashar: It was single-site study. So, we're hopefully moving toward multi-center studies as well.

Tom Flaig: How long does it take to train a physician, for example, to be able to administer pain reprocessing therapy or to work with patients in that regard?

Yoni Ashar: It really depends how bold they are, in my experience. I've talked with some physicians who just don't feel comfortable or confident telling a patient, ‘your brain is the cause of the pain’ because, well, what if we're missing something or how is the patient going to react? And there's some doctors we talk with who are like, ‘oh my gosh, this all makes sense.’ And they just jump on and they love this and they find that their patients are getting much better when they're clear with them about the cause of the pain.

Tom Flaig: You worked with physician investigators for this. What was their background? Were they the surgeons? Were they primary care physicians? Variety?

Yoni Ashar: Internal medicine has been (involved), and family medicine have been some of the biggest disciplines where we've gotten the best uptake.

Tom Flaig: Well, maybe it's more the primary care realm.

Yoni Ashar: The primary care realm.

Tom Flaig: Which is seen frequently.

Yoni Ashar: Exactly. And yeah, I think that's right.

Chris Casey: And was there also an MRI imaging component to this, Yoni, where you actually

could show things that were firing up in certain areas of the brain with this sample of patients?

Yoni Ashar: Yeah, that's right. So we used functional MRI, which is a brain imaging technique, and we scan people's brains before and after treatment. And what we found was that there was less activity in these pain processing regions like the mid-cingulate and the anterior insula. And there were changes in connectivity from these regions to the primary somatosensory cortex. So we saw on the brain scan some of these changes that potentially correspond to what the participants were telling us that they're not on pain anymore. We're seeing these changes in the brain and there's still a lot left to understand in terms of how the brain learns pain and how the brain can unlearn it, but we're working on that and trying to unpack it.

Chris Casey: What could be next? Could this expand into migraine therapy? So many people suffer from migraines and tension headaches, I suppose, things of that nature. Is there an avenue there that you're going to explore as well?

Yoni Ashar: Yeah, absolutely. So we need to test this in other pain conditions. Migraine and tension headache are top choices. Would love to run a study in that population. I know clinically I've heard anecdotes, people who have used these approaches and had great success, but we need data.

And the other direction I'm really keen to then, we're working on is to understand the mechanisms. What really changes in how people think and feel that helps them get out of pain? What are those key mechanisms we need to get engaged psychologically and also at the neurobiological level, what's

changing in the brain, too, that both causes this pain to continue and then can help people recover from pain.

Tom Flaig: This study was published in JAMA Network Open and you've been receiving lots

of questions about it, I imagine. Were you surprised by the findings? Were they what you expected?

Yoni Ashar: I was floored. My jaw dropped. We just didn't imagine. I didn't really believe that people could get out of pain. So we were collaborating with some clinicians who had developed this treatment and they were optimistic that people can get out of pain. But I didn't really believe it because I was running the study, and just if you look in the published literature, you don't see really examples of large numbers of people having dramatic pain reductions following talk therapy.

Tom Flaig: In terms of your research plans. So, you've had this study getting published. There's been certainly some discussions around it. Where would you go next from a research point of view?

Yoni Ashar: The first thing is it's a little boring, but we need to replicate these findings. They're very exciting, but good science is just replication. Can this be repeated with a slightly different population of patients, maybe a little more severe? Can other clinicians get these results besides the clinicians in the first trial? So there's that. And then more exciting future directions include different populations, digging into the brain, imaging more and understanding what's happening there. And another future direction I'm working on and very excited about is also psychedelic-assisted therapies for chronic pain, and here on campus, we have two studies ongoing for psychedelic therapies. And our working hypothesis is that psychedelics open this window of neuroplasticity where people can then relearn new behavioral patterns or new beliefs about themselves, and that's how it helps them recover from depression and PTSD and substance use disorders. And so, this would be perfect for pain as well, for nociplastic pain. If we can open that window of plasticity and help people shift their beliefs and behaviors, I think there's a lot of exciting potential there.

Tom Flaig: As you think about your research, what are the barriers to moving this type of research forward? You've commented about your surprise, and how you got these results and others haven't. So what do you see as the barriers to getting to the next steps?

Yoni Ashar: At a societal level, I think one of the big barriers is finding out, so at the societal

level, I think one of the big barriers is developing a payment model with insurance companies that works. That's been a major challenge. I have multiple clinical colleagues I'm thinking of who haven't found a way to make it work. And at the end of the day, this is a behavioral therapy and reimbursement rates are relatively low and it's hard to do that, to make it work from the insurance perspective. The other, I think, challenge is that traditionally medicine and psychology have been siloed. And so you go to a doctor's clinic, you talk to a doctor, or you can go see your therapist, but what does your therapist know about anything medical whether your stenosis is the cause of the pain or not? So we need to bring these disciplines together and have physicians and psychologists and neuroscientists collaborating to help understand for each person what's causing their pain and how can we help them get better.

Tom Flaig: Yeah, there's the structure of medicine, how we've organized ourselves in

medicine. If you ask patients, they'll oftentimes say, in so many words, the mind-body connection. It's intuitive to patients that there's connections here that we're not fully recognizing in the medical sphere. And part of that, I think is how we've organized ourselves and all the complications around medical delivery today.

Yoni Ashar: Exactly. So I would love to see, hey, I put this out there. I'd love to see a CU

Anschutz mind-body medicine clinic where we come together from different disciplines like GI and physiatry and neurology and all these patients like headache and stomach pains and back pain. They actually could be potentially better housed under an integrative approach to mind-body that really centers on the mind-body connection.

Tom Flaig: You actually see in my career though, that the value placed on multidisciplinary

medicine, getting surgeons along with medicine doctors and diagnostic radiologists together in a room discussing cases – that's certainly appreciated and valued now. So this is along that trail, I think.

Yoni Ashar: Absolutely. I think there's been great strides and I'm really optimistic it's going to keep moving that direction.

Chris Casey: Well, this is right on brand for what we think the essence of our program's about, kind of pushing health science forward and what you're doing here, Yoni, with this pain reprocessing therapy, certainly falls right into that direction. What would you say, Tom?

Tom Flaig: What a great initial broadcast for Health Science Radio. This is fantastic.

Chris Casey: Definitely.

Tom Flaig: And I've been looking forward to this topic since I saw it, and really appreciate the work you're doing here.

Yoni Ashar: Thanks so much, Tom. Thank you, Chris. Great to be on this episode of Health Science Radio.

Chris Casey: Thank you. I like the way you enunciated that. Thank you very much.

Yoni Ashar: Thanks.