How To Assess Symptoms to Differentiate Structural VS. Brain-Generated Causes
By Kent Bassett
Most doctors are not trained to help patients when they can’t find a structural cause of their symptoms, which is the case in about one out of every four doctor’s visits. Pain is a very common symptom—we all get pain, and about 80% of us will develop chronic pain in our lifetimes. It’s estimated that 90% of chronic pain cases are not caused by structural damage, but rather through neuroplastic processes in the brain. That is a recipe for millions of people getting funneled through a medical system that profits from their chronic illness rather than helping them resolve it.
We’ve come to believe that learning how to suss out whether symptoms are brain-generated or structural is an essential life skill. We all have a powerful brain-body connection, and understanding how it works allows us to live more wisely, be confident that our bodies are resilient, save money on ineffective and medical treatments, and seek out brain-first treatments that are tailored to address the underlying causes of our suffering.
In this podcast linked to above, Dr. Howard Schubiner walks people through a system he developed to teach doctors and therapists how to assess whether symptoms are structural-based (tissue damage), or neuroplastic-based (mind-body). Many doctors give patients incorrect information, especially about back and neck pain—for example, studies show that 85% of neck and back pain is not caused by structural damage.
The system Howard Schubiner, MD devised for assessing pain and other symptoms for being “brain-generated” is called F.I.T. (looking for signs of the symptoms being Functional, Inconsistent, and/or Triggered).
Signs that a symptom is functional are when symptoms arise despite no injury preceding them, or endure long after an injury would have healed. Soft tissue injuries usually heal within a few weeks, and the worst injuries, like ACL tears or broken bones usually heal within months. So if pain has lasted a year or longer after an injury, it is considered functional since it is not caused by damage any longer. (note: MRIs are extremely sensitive to normal changes due to aging that are not causal of pain and are frequently misinterpreted by physicians. Learn more about that on our back and neck pain page.)
Inconsistent refers to when the pain or symptom switches on and off, migrates, or spreads in a way that is not typical of structural-damage pain. In the video below you can see Alan Gordon, LCSW discovering how somone’s back pain moved from their lower back to their upper back, despite no new injury occuring. This is the discovery of the symptom being inconsistent (migrating), and is not characteristic of structural injuries.
Triggered refers to if symptoms can be switched on and off or dramatically shift because of conditioned responses to innocuous stimuli like foods, weather, time of day, stress, moderate activity, or fear. In the example video below, not only is Felicia’s neck pain discovered to have started in the absence of any injury (functional), she also talks about how it is triggered by the activity of driving and turning her neck but not by other similar activities.
Creating a Mental Image of How Structural-Caused Pain Functions
It can be helpful to have a mental template for how structural pain works, by reflecting on your experiences of pain from structural injuries in your life. Picture your own experience, have you ever suffered from a broken bone, a sprained ankle, or a cut on the skin? How did the pain from that structural injury function? For example, did it migrate to other parts of the body? Did it dramatically worsen while anticipating or experiencing stress? Did it get three times worse in the morning or night? Did the symptom switch off for a day or two and then switch back on without any new injury occurring? Was there a delayed onset, as in did you get a sprained ankle that started hurting 3 days after twisting it? The answers to these questions is usually no. That is not how structural, or “secondary” pain works.
Structural-caused, musculoskeletal pain tends to stay at the site of injury and not migrate, and tends to stay relatively steady in intensity. Also, injuries heal over time and structural pain reduces along with it, rather than getting worse over time.
If you keep this mental template for structural pain in your mind and compare your pain syndrome to it, you may gain insights into the two types of pain we can feel. Primary chronic pain is intimately tied into the fear and emotional centers of the brain, and when the brain generates these symptoms it usually is imperfect, it slips up—it cannot perfectly mimic structural pain. The classic case is patients whose symptoms go away or diminish dramatically on weekends or on vacation.
Seeing the pain move around or go up and down by a lot because of stress can be an opening for insights to accumulate about the brain-body connection. These insights can be documented and added to an “evidence list” for questioning assumptions that pain is always a measure of tissue damage. Discovering that the body is in fact not damaged, but healthy, can go a long way toward alleviating pain and sending someone down a path of recovery.
It’s important to note that for many patients, their mind-body chronic pain is very consistent and doesn’t show signs of being triggered either. But if they have a functional diagnosis (like IBS, fibromyalgia, POTS, or back pain without muscle control issues, etc.), they can still recover through brain retraining. In other words, the qualities of inconsistent and triggered are best thought of as being sufficient to assess pain as being brain-driven, but they’re not necessary.