Medicinal Massage
Is massage medicinal? I believe it very much is. This article delves into a few key points. "The American Hospital Association recently surveyed 1,007 hospitals about their use of complementary and alternative medicine therapies, and more than 80 percent said they offered massage therapy. Upwards of 70 percent said they used massage for pain management and relief.
Resetting
Massage mind and how it works to help you reset.
12/21/25
Updated: 11/02/2025 Published: 09/02/2025 Medically reviewed by Hakam Asaad
The Connection Between Chronic Pain and Neuroplasticity
Chronic pain is a persistent and often debilitating condition. It affects millions worldwide. Unlike acute pain, chronic pain persists long after the initial injury has healed or in the absence of any tissue damage. This prolonged experience of pain can impact one’s quality of life. It leads to physical limitations, distress, and isolation.
Neuroplasticity is the brain’s remarkable ability to reorganize itself by forming new connections. It plays a crucial role in the development and maintenance of chronic pain. This ability can be beneficial and allows the brain to adapt and learn. However, it can also contribute to the persistence of pain. In individuals with chronic pain conditions, the brain undergoes maladaptive changes. It strengthens pain pathways and makes them more sensitive to these signals.
Understanding the relationship between chronic pain and neuroplasticity is essential. This understanding is essential for developing effective treatment strategies. By targeting the neural changes associated with this condition, doctors can help people regain control over their pain and improve well-being.
The Role of the Nervous System in Chronic Pain
Pain is a complex process involving intricate interactions within the nervous system (NS). Pathways, a network of neurons, are responsible for processing and transmitting signals from the site of injury to the brain. When tissue damage occurs, specialized sensory neurons called nociceptors are usually activated. They’re located throughout the body and can detect noxious stimuli. They include heat, pressure, or chemicals. Once activated, they convert these stimuli into electrical signals. These signals then travel to the spinal cord.
It acts as a relay station. There, these signals are usually processed and transmitted further to the brain. Within the spinal cord, interneurons modulate the pain signals influencing both their intensity and quality. From the spinal cord, the signals ascend to many brain regions involved in pain perception. It includes:
The thalamus
Somatosensory cortex
Limbic system
The thalamus acts as a central hub, relaying signals to other brain areas for further processing. The somatosensory cortex is responsible for the localization and characterization of pain. It helps us find where the pain is and what it feels like. The limbic system is involved in emotions and memory. It contributes to the emotional and psychological aspects. It includes fear, anxiety, and distress.
The nervous system is broadly divided into two parts: the central nervous system (CNS), which comprises the brain and spinal cord, and the peripheral nervous system (PNS). It includes all the nerves outside the CNS. Both play crucial roles in chronic pain. Damage to nerves in the PNS can lead to prolonged and often intense pain. This damage can alter the way signals are transmitted and processed, leading to sensitization of the NS. Sensitization means that the NS becomes overly responsive to pain signals. It’s even in the absence of ongoing tissue damage. This heightened sensitivity can contribute to the development of chronic problems.
The brain, being the control center, adapts to the persistent pain signals through neuroplasticity. While this adaptability can be beneficial, it often leads to maladaptive changes. These changes can reinforce pain pathways. It makes them more efficient at transmitting signals, thus perpetuating the experience of chronic issues.
Brain Changes Associated with Chronic Pain
chronic pain is not just a sensation. It is a complex experience that significantly impacts the brain. It leads to structural and functional changes. Persistent pain can alter the physical structure of certain brain regions. It affects their size and connectivity. For example, studies have shown that people with chronic pain may experience a decrease in gray matter volume in certain brain areas. Those include the prefrontal cortex and the hippocampus. The prefrontal cortex is involved in:
Executive functions
Decision-making
Attention
Meanwhile, the hippocampus plays a crucial role in memory and learning. These structural changes can contribute to mental and emotional difficulties. Those are often associated with chronic pain.
In addition to structural changes, chronic issues also lead to functional changes in the brain. They refer to alterations in the activity between different brain regions. In people with chronic pain, there is often increased activity in brain areas involved in pain processing. For example, the anterior cingulate cortex and the insula. They’re involved in the emotional and mental aspects of pain. It includes attention to it, anxiety, and perceived unpleasantness. Furthermore, there can also be decreased activity in brain areas involved in pain modulation. They’re the prefrontal cortex and the descending pain inhibitory pathways. These pathways normally help to suppress pain signals. However, their reduced activity can contribute to the persistence of pain.
The amygdala is a brain region involved in emotions. It’s also significantly affected by chronic pain. The amygdala’s increased activity can contribute to emotional distress and anxiety. They’re often experienced with chronic pain. These brain changes contribute to the heightened pain perception and the emotional and mental challenges associated with chronic pain.
The Impact of Neuroplasticity on Pain Perception
Neuroplasticity is the brain’s ability to reorganize itself by forming new neural connections. It plays a dual role in chronic pain. It allows the brain to adapt and learn, but it can lead to maladaptive changes that worsen the pain experience. Continuous stimuli can trigger the brain to rewire itself. It strengthens pain pathways and makes them more sensitive. This process can lead to an increased perception of pain, even in response to non-painful stimuli. For example, a light touch that would be perceived as painful by someone with chronic pain.
Maladaptive neuroplasticity plays a significant role in the development of chronic pain conditions. The brain’s rewiring in response to continuous pain can lead to a vicious cycle where pain leads to more pain. The strengthened pathways become more efficient at transmitting signals. It leads to a heightened perception of pain, which in turn further reinforces these pathways. This cycle can be difficult to break.
However, neuroplasticity is not always detrimental. The brain also has the potential for positive changes that can be harnessed for relief.
Therapeutic Interventions Leveraging Neuroplasticity
Our brains are constantly changing and adapting, a quality called neuroplasticity. This ability can be leveraged to help manage chronic pain. Several therapies focus on retraining the brain to change how it processes these signals.
Cognitive-behavioral therapy helps people understand the connection between their thoughts, feelings, and pain. It teaches coping strategies to control pain better and reduce its impact on life. Essentially, CBT helps rewire the brain’s response to pain.
Physical therapy uses movement and exercise to improve physical function and reduce pain. Specific exercises can help reshape the nerve pathways involved in pain, making them less sensitive. This approach helps the brain learn new, healthier movement patterns.
Neuromodulation uses electrical stimulation or magnetic fields to change nerve activity. These methods can target specific areas of the brain or spinal cord involved in pain processing. By altering nerve signals, it can help reduce pain and improve quality of life.
These approaches offer hope for chronic pain management. These therapies offer potential for reducing pain and improving quality of life. However, further research promises even more targeted and effective approaches.
Lifestyle and Non-Medical Approaches to Pain Management
Beyond specific therapies, lifestyle choices also play a big role in brain health. These approaches support neuroplasticity naturally.
Meditation and mindfulness practices can help change how we perceive pain. By focusing on the present moment and observing sensations without judgment, we can learn to manage pain sensations without getting overwhelmed by it. Mindfulness helps rewire the brain’s response to signals.
Diet, sleep, and stress changes are crucial for brain health. A healthy diet provides the brain with the nutrients it needs to function properly. Good sleep allows the brain to repair and reorganize itself. Managing stress reduces the impact of stress hormones on the brain. All these factors support neuroplasticity and can reduce pain.
Holistic approaches like yoga, acupuncture, and massage can also be helpful. These methods often combine physical movement, relaxation, and mindfulness. It can support neuroplasticity and reduce pain. While research on their specific effects is ongoing, many people find them beneficial.
The Future of Chronic Pain Treatment Through Neuroplasticity
The future of chronic pain treatment looks promising thanks to advances in our understanding of neuroplasticity.
Neuroscience research is constantly revealing new insights into how pain works and how the brain changes. This knowledge is leading to the development of new treatments. It includes targeted medications and innovative techniques.
AI and brain-computer interfaces hold great potential for pain control. AI could personalize treatments based on brain activity and pain patterns. Brain-computer interfaces might allow people to control their brain activity to reduce pain.Harnessing neuroplasticity is revolutionizing how we approach chronic pain. By understanding how the brain changes, we can develop more effective and personalized treatments. This offers hope for a future where chronic pain is managed more effectively, leading to a better quality of life for millions of people.
11/25/25
The Journal of Pain
Volume 24, Issue 9, September 2023, Pages 1582-1593
“I don't have chronic back pain anymore”: Patient Experiences in Pain Reprocessing Therapy for Chronic Back Pain
Author links open overlay panelHallie Tankha *, Mark A. Lumley *, Alan Gordon †, Howard Schubiner ‡, Christie Uipi †, James Harris §, Tor D. Wager ¶, Yoni K. Ashar §
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https://doi.org/10.1016/j.jpain.2023.04.006Get rights and content
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Referred to by
The Journal of Pain, Volume 25, Issue 5, May 2024, Pages 104441
Matthew K. Bagg, Dana A. Hince, Mervyn J. Travers, Piers Truter, Gemma M. Orange, Benedict M. Wand
Highlights
•
Analyses of interviews aimed to understand how pain reprocessing therapy reduces pain intensity.
•
Reappraisal to reduce the fear of pain was a powerful treatment mechanism reported by the participants.
•
Participants described insight into the pain-emotion connection as a crucial treatment component.
•
The therapeutic relationship, the therapist's belief in treatment, and peer models were also key elements.
Abstract
In a recently published randomized controlled trial, two-thirds of the patients receiving a novel psychological treatment, pain reprocessing therapy (PRT), reported elimination or near-elimination of chronic back pain. The mechanisms of PRT and related treatments remain poorly understood but are hypothesized to center on pain reappraisal, fear reduction, and exposure-potentiated extinction. Here, we investigated treatment mechanisms from the participants' perspective. A sample of 32 adults with chronic back pain who received PRT completed semi-structured posttreatment interviews about their treatment experiences. The interviews were analyzed with multiphase thematic analysis. The analyses identified 3 major themes reflecting participants’ understanding of how PRT led to pain relief: 1) reappraisal to reduce fear of pain, which included guiding participants to relate to pain as a helpful indicator, overcoming pain-related fear and avoidance, and reconceptualizing pain as a “sensation;” 2) the link between pain, emotions, and, stress, which included gaining insight into these connections and resolving difficult emotions; and 3) social connections, which included patient-provider alliance, therapist belief in the treatment model, and peer models of recovery from chronic pain. Our findings support the hypothesized mechanisms of PRT centered on pain reappraisal and fear reduction, but also highlight additional processes from the participants' perspective, including a focus on emotions and relationships. This study underscores the value of qualitative research methods in illuminating the mechanisms of novel pain therapies.
Perspective
This article presents participants' perspectives on their experience engaging in a novel psychotherapy for chronic pain, PRT. Through pain reappraisal, linking pain, emotions, and stress, and connecting with their therapist and peers, many participants reported an elimination or near-elimination of their chronic back pain with therapy.
Keywords
Pain psychology
pain reprocessing therapy
psychological interventions for pain
pain reappraisal
back pain
A substantial body of research documents the key role played by psychosocial factors in the development, maintenance, and severity of chronic pain.1, 2, 3, 4, 5, 6, 7 This recognition has spurred the development of several psychological/behavioral chronic pain treatments, including widely studied treatments like cognitive behavioral therapy (CBT), acceptance and commitment therapy, and mindfulness-based therapies.8, 9, 10 Randomized controlled trials support the efficacy of these treatments in reducing pain and disability, but meta-analyses indicate that effect sizes are small compared to no treatment or usual care, and even smaller when compared to active controls.9, 11, 12 Specifically, full recovery from chronic pain is rarely reported with these leading treatments.
Yet, emerging pain neuroscience suggests that substantially reducing or eliminating chronic pain may be possible, at least for some people. Recent models highlight a subtype of chronic pain, often termed primary or nociplastic pain, in which pain is driven primarily by central nervous system processes in the absence of peripheral tissue injury.13, 14 For this subtype, pain may be a learned signal that reflects anticipated or perceived threat, reinforced by fear and avoidance behaviors.6, 15, 16, 17 This dovetails with recent models emphasizing that emotion and other affective experiences are actively “constructed” by distributed brain processes, guided by appraisals of the meaning and threat value of stimuli, and suggests that the pain experience (especially primary chronic pain) can be constructed mainly by supraspinal processes.15 This suggests the possibility that some cases of primary chronic pain can be reversed by changing appraisals of the meaning and threat value of pain, targeting pain-related affective processes, and disrupting fear-avoidance learning processes—though more evidence is needed.18, 19
Pain reprocessing therapy (PRT) is a recently developed psychological therapy for primary (nociplastic) chronic pain, which aims to reduce or eliminate pain. Theoretically, PRT does so by accomplishing 2 core change processes: first, PRT helps patients reattribute the causes of their pain from their bodies to their brains; and second, PRT helps patients reduce fearful avoidance of their pain, learning that it is not dangerous.20, 21 This therapy builds on existing evidence-based interventions, including pain neuroscience education22, 23 and pain exposure therapy.24 It uses a core technique of “somatic tracking” of pain and fear/anxiety while patients engage in behaviors that elicit pain (eg, walking, bending, lifting). This technique, when coupled with a clear message that their bodies are not damaged but that their brains have learned to activate the “pain alarm,” is designed to help patients shift their attributions of the cause and meaning of pain and reduce fear of pain and bodily damage.
PRT includes several points of difference from leading evidence-based psychological treatments, such as CBT, acceptance and commitment therapy, and mindfulness-based therapies. These evidence-based treatments typically view all chronic pain as stemming from a complex, unknown interaction of peripheral tissue problems and psychosocial/brain processes, and do not aim to subtype patients. These treatments further view pain as something that can be modulated by psychosocial factors, but typically not generated by the brain in the absence of injury. The goal of these treatments is typically to help patients live more adaptively with their pain, but not to eliminate pain. For example, a widely used CBT manual states that “since chronic pain can typically not be cured but only managed, it must be viewed as an illness… [and] the focus of [treatment] is to improve the individual’s quality of life and functioning.”25 It is possible that how these leading treatments approach chronic pain may limit their efficacy relative to treatments like PRT, which are based on a distinct perspective.
PRT was recently tested in a 3-arm clinical trial with adults with chronic back pain.20 Participants randomized to PRT experienced large reductions in pain intensity: 66% were pain-free or nearly so at posttreatment. Gains were largely maintained over the 1-year follow-up. Effects of PRT on pain intensity were mediated by large reductions in fearful pain beliefs. Accompanying changes in brain function were observed using longitudinal functional magnetic resonance imaging (fMRI), with reduced prefrontal responses to evoked pain and increased prefrontal-somatosensory functional connectivity for PRT versus control conditions. Such impressive clinical outcomes motivate the need to better understand how PRT accomplished such pain reduction or elimination, and quantitative data alone (ie, self-report rating scales of the therapy process and outcomes) do not tell the full story of patients’ experiences during an intervention.26 To complement the previously published quantitative results, we report here results from a qualitative analysis conducted on posttreatment interviews with participants who received PRT.
Qualitative methods provide an important window into treatment mechanisms. They allow researchers to learn from participants what they think led to change. Only a handful of qualitative studies have been conducted on pain interventions27, 28, 29, 30, 31 and no qualitative studies of PRT have been conducted. Thus, the primary objective of the current study was to understand the core change processes of PRT from the perspective of the patients. A secondary objective was to explore pretreatment beliefs and expectations regarding the treatment process, as it has been suggested that many people with pain will not be open or willing to engage with treatment models presenting pain as brain-generated. To address these objectives, we conducted a multiphase thematic analysis of interviews conducted with participants randomized to PRT in the previously described trial.32
Methods
The PRT Trial
Full details of the original trial design, sample, procedures, interventions, and outcomes are presented in Ashar et al20; key points are noted here. Adults with chronic back pain were recruited from the community. They were eligible if they were between 21 and 70 years old, had back pain worse than leg pain, and had an average pain intensity of at least 4 (on a 0–10 scale) during the past week, with pain on at least half the days over the previous 6 months. A total of 50 patients were randomized to PRT, 5 of whom did not initiate PRT, leaving 45 who started treatment; 44 of these patients completed the treatment. PRT was provided by 2 experienced PRT therapists with degrees in social work, 1 male (A.G.) and 1 female (C.U.), with all patients completing an initial assessment and education session with a physician experienced in this treatment approach (H.S.). This study was approved by the institutional review board (IRB) of the University of Colorado Boulder, and informed consent was obtained from each participant.
Posttreatment Interviews
Following the completion of PRT, patients were invited to participate in a semi-structured interview about their experiences during treatment. Interviews were added to the trial after it commenced, and participants who had already completed the trial were invited back to participate in the interview. Interviews were provided by 32 patients (73% of the 44 patients who completed PRT), who constitute the current sample. Eight of the 32 interviewed patients had completed treatment several weeks or months prior to the interview, whereas the other 24 patients completed the interview within 1 week of the end of PRT. Twelve participants did not respond to requests to return for an interview. Participants were not compensated separately for being interviewed, outside of the compensation received for the study participation as a whole.
In-person, semi-structured interviews were completed in a behavioral testing room on the University of Colorado campus and lasted an average of 14.2 minutes (SD = 8.19). Interviews were conducted by research assistants and included questions about back pain history and treatment, pretreatment expectations, and the impact of PRT (see Table 1 for the interview guide). Interviews were video recorded and transcribed by artificial intelligence, followed by an accuracy review by a professional transcriptionist. In the Results section, we have detailed the participants’ identification number (ID), age, gender, and pre- and posttreatment pain rating when providing quotes to provide readers with a better sense of each participant (eg, ID 132, 28F, painpre = 5, painpost = 1).
Table 1. Interview Guide
1.
How long have you had chronic back pain?
2.
What have you previously tried to alleviate the back pain?
3.
What was your initial expectation at the start of the study?
4.
Did you expect the treatment to help you?
5.
Has this study changed your relationship to your chronic back pain?
a.
Prompt: (If the treatment helped them): What about the treatment do you think was most helpful?)
6.
How much pain are you in right now?
Analysis of Interview Data
The analysis of interview data was based on qualitative descriptive methodology, as our goal was to inquire naturally about participant experiences during an intervention study.33 A multiphase thematic analysis using the methodology of Braun and Clarke34 was used to identify the core themes and change processes during PRT. Coding was completed by 2 researchers (authors H.T. and J.H.) using NVivo 12 qualitative analysis software (QSR International, Burlington, Massachusetts). These coders were selected as they had little prior contact with or knowledge of the PRT model, were not associated with the original clinical trial, and therefore served as relatively objective parties with limited prior conceptions of PRT mechanisms.
Analysis began with a thorough reading of all 32 interview transcriptions followed by the 2-phase analysis. Phase 1 used a theoretical analysis or deductive approach, which identified interview content directly related to the treatment processes proposed a priori by PRT therapists and researchers. That is, we examined how participant experiences mirrored, or diverged from, the processes that the PRT creators believe elicit change. Phase 2 went back to the original transcripts and analyzed all of the interview data utilizing an inductive, data-driven approach to identify any underlying content that was not necessarily related to the researchers’ a priori hypotheses. The 2 coders subsequently conferred to discuss the identified codes, condense overlapping areas, and consider areas of disagreement. Overall, there was substantial agreement between the 2 coders, establishing the intercoder agreement. The multiple-coder process facilitated discussion among members of the research team, who critically interpreted the preliminary results. The research team helped to organize, define, and refine the themes by grouping and collapsing the codes, including discussing differing opinions on the theme categorizations,35 and agreed on a final set. These analytic procedures aim to ensure a complete, thorough, and rigorous analysis while minimizing researcher biases.36
In the Results section, we first present participants’ experiences with pain before treatment and their preconceptions about what to expect from PRT. We then present participant reflections on their experiences with PRT, which is the primary focus of our analyses. We include the frequency of participants who are represented in each theme. Although reporting such quantitative data is not traditionally included in qualitative research, we believe that these data will better illuminate and represent participant experiences of PRT in this trial.
Results
Participant Characteristics
The 32 interviewees ranged in age from 23 to 68 years (M = 48.13; SD = 15.08), the sample was 50% female and primarily White (93.6% White; 5.3% Asian or Pacific Islander; 1.1% other), and the average pain duration was 11.68 years (SD = 11.26). The average baseline pain intensity of the interviewees was 4.13 (0–10 numerical rating scale, SD = 1.66) and the average posttreatment rating was 1.19 (SD = 1.26). Interviewees reported an average pain intensity decrease of 2.94 points from baseline to posttreatment (ie, mean pain reduction of 71%). At posttreatment, 24 of the 32 participants (75%) were “pain-free or nearly pain-free,” operationalized as reporting an average pain intensity for the past week of 0 or 1.
To investigate potential bias in our sample, we compared the 32 interviewed participants to the 12 PRT completers who were not interviewed on several demographic and pain-related variables. Participants who were interviewed tended to be older (48.1 vs 37.0 years) and more likely to be male (75% vs 50%) than those who were not interviewed. Interviewees and non-interviewees were similar in baseline pain duration (M = 11.68 vs 10.83 years), posttreatment pain intensity (M = 1.19 vs M = 1.17), pain interference (M = 1.00 vs .95), depression (M = 11.88 vs 13.17), and anxiety (M = 14.75 vs 15.75). Additionally, the percentage who were “pain-free or nearly pain-free” posttreatment was the same, 75%, in both groups. Thus, the interviewees did not differ with respect to treatment outcomes compared to the full sample of participants who received PRT, though some demographic differences were present.
Life Before Treatment
The majority of participants described pain that interfered with daily life, with constant efforts to alleviate the pain that provided only “momentary relief.” Participants discussed numerous back surgeries, physical therapy, pilates, and steroid injections, and disclosed taking “huge doses of narcotics,” which “numbed” the pain temporarily but “it never really went away.” Participants described how pain negatively impacted not just the ability to physically engage in daily activities, but also the enjoyment of activities that were favored before the onset of pain: “I lost the ability to hike and bike and dance and engage in things that gave my life meaning and that brought me joy” (ID 113, 59F, painpre = 7, painpost = 4). Many participants described seeking multiple opinions and treatment from medical professionals without relief, leading some individuals to reach a place of pain acceptance—"So that was the point where I was just like, well, I guess I'm just gonna deal with pain for the rest of my life and that's the way it is” (ID 312, 25M, painpre = 3, painpost = 1). A sense of hopelessness was communicated, as participants felt as though their pain would never subside and, therefore, the only path forward was to learn how to “coexist” with it.
Treatment Expectations
When the participants learned of a study offering a novel psychological treatment aiming to eliminate pain, they responded with a range of emotions and expectations. The majority (n = 20; 62.5%) of participants expressed mixed attitudes about the treatment, such as a “healthy skepticism” and being “cautiously optimistic.” For many participants, it was the first time they were told that the cause of the pain was not in the periphery (ie, not in their back), which led to feelings of doubt about the study and research team because most participants had previously received explanations related to back pathology and magnetic resonance imaging (MRI) findings. Additionally, this study was the first time many individuals heard of the idea of psychological treatment for pain reduction. Although there was initial hesitancy about the relationship between psychology and bodily pain, this novel treatment idea elicited optimism, as participants spoke about how they were “willing to learn and try anything” (ID 1036, 58F, painpre = 2, painpost = 1) to alleviate their pain because prior attempts had been unsuccessful.
The other 12 participants (37.5%) were split evenly: 6 expressed only positive expectations about the treatment, including approaching it with an open mind, healthy curiosity, and a willingness to participate. In contrast, 6 participants (18.8%) disclosed only hesitancy and skepticism about the treatment, stating they were “not very hopeful” (ID 113, 59F, painpre = 7, painpost = 4) that a psychological treatment would ease the physical pain that had been interfering with their daily lives for so long. These latter participants were suspicious of a psychological approach; 1 described it as “pseudoscience” (ID 774, 27M, painpre = 5, painpost = 1), and another said that the thought of psychology alleviating physical pain seemed “very fishy” (ID 39, 23F, painpre = 3, painpost = 0). These 6 were also hesitant to believe that any new treatment (psychological or medical) would provide pain relief, as “nothing else has worked so I don't know why this one would” (ID 1160, 50M, painpre = 5, painpost = 3). Despite these initial hesitancies, these participants proceeded with treatment.
Major Themes and Subthemes of PRT as Experienced by Participants
A total of 30 codes were identified during the multiphase thematic analysis. These were collapsed into 3 themes, representing the core change processes that participants perceived as responsible for PRT’s benefits. The themes were 1) reappraisal to reduce fear of pain; 2) the link between pain, emotions, and stress; and 3) social connections. Under each theme lies subthemes (see Fig 1), which represent participants’ views on the specific therapeutic components in each core process, with representative quotes displayed in Table 2, Table 3, Table 4.
Figure 1. Qualitative themes and subthemes.
Table 2. Representative Quotes From Theme 1: Reappraisal to Reduce Fear of Pain
Sub-theme 1: Relating to Pain as a Helpful Indicator
1.
That's the work I want to continue doing, is, if I have a severe pain burst, finding a way to really see it as an opportunity and a gift as opposed to something that's going to take me down a downward spiral. (ID 1036, 58F, painpre = 2, painpost = 1)
2.
I became aware that the pain, for me, was a signal that I'm stressed out, or not taking care of myself. That instead of resisting it and me being fearful about it, that I really changed my attitude about it, and can really now see it as this signal. (ID 575, 59F, painpre = 3, painpost = 0)
3.
Now, I kind of go, "Oh! Thank you!" Instead of, "Oh, I wanna resist this, this is awful, it's this debilitating thing, I can't get out of bed, it's so painful if I put my foot on the floor in the morning." It's gone from that to, "Oh, okay, thank you for sharing. I want to understand what you're trying to tell me," and kind of just check in on what situation is occurring in my life that is making my body have a fear response. (ID 575, 59F, painpre = 3, painpost = 0)
Sub-theme 2: Overcoming Pain-Related Fear and Avoidance
1.
It really has made me less frightened of the pain. I mean, it used to be every time I started out on a hike…I would be worried, I would be concerned. I'd take painkillers, I'd do what it took to be able to do that without it. just because I was frightened that I was gonna have pain, it was not gonna be a fun experience. Now…if I get a little bit of pain, I deal with it. It's not like it's killing the hike. In fact, it goes away frequently. It's like ‘eh, don't worry about this, this is really not a problem.’ And by the end of the hike I'm feeling great. (ID 1084, 66M, painpre = 1, painpost = 1)
2.
I think the fear in relation to stress, anxiety, your expectations that pain is gonna be there. That's the fear. The fear that it's not gonna go away or it's just gonna get worse…Not ever be able to exercise again or just constantly be that grouchy, anxious person. (ID 814, 44M, painpre = 5, painpost = 0)
Sub-theme 3: Reconceptualizing “Pain” as “Sensation”
1.
Sensations can come on, they're temporary, they're not dangerous. (ID 1036, 58F, painpre = 2, painpost = 1)
2.
I’m paying attention to where I'm feeling something and it's not bad sensations. It's just sensations. (ID 1087, 64F, painpre = 4, painpost = 3)
Table 3. Representative Quotes From Theme 2: The Link Between Pain, Emotions, and Stress
Sub-theme 1: Gaining Insight into the Connection Between Pain, Emotions, and Stress
1.
I think I just was so overwhelmed emotionally. The coping strategies I was using, I just couldn't do it anymore. And it had to go somewhere and it went to my hip. (ID 113, 59F, painpre = 7, painpost = 4)
2.
I think it's just knowledge that everyone should have. That you have this amplifier, or potentially linked to your pain, and your perceptions, or the fears, or the dangers around what might be going on in your body can contribute to that pain, or headaches, or anxieties, or probably all kinds of other things. (ID 1141, 35M, painpre = 5, painpost = 1)
3.
I still do have moments of genuine pain. I actually, sort of, re-injured myself a couple of weeks ago doing a stupid thing power lifting. But, looking from the perspective of realizing that my pain does get worse with anxiety, I almost feel like I've been able to distinguish different kinds of pain. (ID 29, 23F, painpre = 3, painpost = 0)
4.
I learned how connected my emotional state was with this pain. And recognizing that some of the emotions that I've tended to repress within my life were a huge component to that pain… (ID 312, 25M, painpre = 3, painpost = 1)
Sub-theme 2: Experiencing, Allowing, and Resolving Difficult Emotions
1.
We kind of went back to my childhood and sort of looked at my…my vulnerability, my incredible shyness and social anxiety…and the messages I got growing up about caregiving from my mother and productivity from my father, and how those all sort of came together as a child to sort of cause me to develop a way of coping in the world. And coping with my anxiety that really put the needs of others ahead of my own. (ID 113, 59F, painpre = 7, painpost = 4)
2.
…be willing to engage with the emotions or things that you haven't wanted to deal with in your life. It's really…hard, but it's worth it. (ID 312, 25M, painpre = 3, painpost = 1)
3.
Allowing myself and giving myself permission to feel and experience those emotions has been big. (ID 312, 25M, painpre = 3, painpost = 1)
4.
The principles just build on each other and I never would have guessed that childhood issues could be affecting the way I feel in my physical body today. (ID 605, 44F, painpre = 5, painpost = 0)
Table 4. Representative Quotes From Theme 3: Social Connections
Sub-theme 1: The Patient-Provider Relationship
1.
I got really comfortable with her and just sort of let myself get into it and not feel intimidated or embarrassed or anything like that. It was really helpful. (ID 38, 57F, painpre = 6, painpost = 1)
2.
He's very open. He's vulnerable, himself, so he's easy to trust. He's very passionate about this work. It's all very authentic. It's a very caring and trusting environment. (ID 575, 59F, painpre = 3, painpost = 0)
3.
And I think he then went a little bit deeper and he did that in such a way that was really so skilled…He was firm and consistent and always believed that this pain is something that I could soothe and quiet. But he didn't discount why I was struggling. (ID 113, 59F, painpre = 7, painpost = 4)
Sub-theme 2: Therapist Belief in the Treatment Model
1.
[The physician] and [therapist] were so positive that my pain would disappear. They were 100% sure. I was like, "Well this is definitely going to work, it's going to work and I've got to do everything I can to make sure that it works." So I was totally committed to making it happen. (ID 1027, 68F, painpre = 4, painpost = 1)
2.
Once I had a conversation with [my therapist]…That's when it started to hit me…once I understood like from just a purely intellectual standpoint, then I knew, “okay I'm gonna do this. This totally makes sense to me.” And then I was in, all in after that. (ID 893, 45M, painpre = 5, painpost = 0)
Sub-theme 3: Peer Models of Recovery
3.
So I actually, looking back, think I needed one of those experiences of doubt, like severe doubt, about this whole thing, because after that is when he put me in touch with two [former patients], and I got to hear what they had experienced. (ID 1036, 58F, painpre = 2, painpost = 1)
3.
And the other thing was I talked to a guy that had been through it and [he was] a former football player, so I came into it thinking I think this might actually work. (ID 893, 45M, painpre = 5, painpost = 0)
Theme 1: Reappraisal to Reduce Fear of Pain
The first core change process identified was the participants’ recognition that the experience of physical pain is not a signal of danger (ie, tissue damage). Aligning with the concept of pain reattribution—one of the key components of PRT—all participants but one (n = 31) described a shift in their perceptions of pain. This shift, from believing that pain is caused by a dangerous physical ailment to believing that pain is a nonthreatening brain process that can be altered, led the participants to respond in new and adaptive ways to physical discomfort. The following 3 subthemes describe how this change process was achieved by participants: 1) relating to pain as a helpful indicator, 2) learning how to overcome pain-related fear and avoidance, and 3) using novel language to describe pain (see Table 2 for representative quotes).
Subtheme 1: Relating to Pain as a Helpful Indicator
All but 3 participants (90.6%) described different thought processes when they noticed an increase in pain. This “change in mindset” meant that they began to view pain as a “signal” to “reflect on what’s going on right now” (ID 113, 59F, painpre = 7, painpost = 4) psychologically or within the environment, rather than responding to pain as if it were a sign of injury or bodily problems. This shift, for example, led 1 participant to acknowledge how she thanks her pain for communicating important messages (eg, about her emotional state) during painful moments. One man stated that he learned how to view his pain as sending him a message, leading him to question—rather than resent—his pain: "What's going on? Did something just happen? Or is there something that's bothering me in life?” (ID 324, 61M, painpre = 6, painpost = 1). One woman discussed the importance of realizing that when she experiences an increase in pain, her pain is signaling to her body that it needs proper attention and care: “When I feel my pain, I take it as a signal to get up, move around, do something else, do something nice for myself. So, instead of cringing every time it comes on, I think of something nice to do” (ID 38, 57F, painpre = 6, painpost = 1).
Subtheme 2: Overcoming Pain-Related Fear and Avoidance
Participants described how they learned to overcome their pain-related fear and avoidance, which is also a main focus of PRT. To achieve this, participants discussed how they were guided through physical movements that were previously avoided due to fear that they would cause pain or injury, only to find that these movements were not as painful as they anticipated and did not cause further injury—rather, participants described a sense of safety when performing them. Fourteen participants (43.8%) acknowledged this process of reduced fear and enhanced feelings of safety as an important step in therapy. During these movements, participants were asked to describe painful sensations objectively and reappraise sensations as safe, which subsequently helped to reduce pain catastrophizing and pain-related vigilance. The positive benefits of in vivo exposure translated to the ability to engage in, rather than avoid, valued activities, which led to feelings of empowerment. As 1 participant commented, “When I do have some pain…I’m more like, ‘Bring it on.’ This is nothing I’m not in any danger. I’m not afraid. If it stays, it stays. If it doesn’t, great, but it doesn’t intimidate me” (ID 1027, 68F, painpre = 4, painpost = 1).
Participants (n = 12, 37.5%) also described learning how to mindfully attend to and reappraise pain sensations as safe, a PRT practice labeled “somatic tracking.” Participants recalled being asked to observe the variance of sensations traveling throughout the body, and then verbalizing the sensations aloud (eg, “Is it burning? Is it spreading? Where do you feel it?” [ID 113, 59F, painpre = 7, painpost = 4]). while reminding themselves that the sensations are non-dangerous, brain-generated “false alarms.” As one man described:
I think I was always trying to make it go away…I think what [my PRT therapist] did more is have me try to feel and analyze the pain, and then see if it changed or not by…just focusing on it… I noticed that I would feel pain in one place, and then it would change a little bit. It would get even more intense or less intense just by thinking about it. So that was a revelation (ID 102, 61M, painpre = 6, painpost = 3).
Participants found that shifting their focus toward their pain and observing what was happening in their bodies helped to reduce pain. One participant learned to “look at the pain…and with your mind, you can sort of make it shrink, make it move, or make it go away” (ID 38, 57F, painpre = 6, painpost = 1). This process of attending to bodily sensations, in turn, helped participants realize that the onset of pain did not signal the presence of peripheral tissue damage.
Another example of how participants learned to overcome pain-related fear and avoidance is by having the nature or causes of their pain challenged by the therapists, or “breaking down what didn’t make sense” by drawing attention to contradictions when the participants discussed their pain. For example, 1 participant shared that her therapist brought attention to “the things that don't quite line up: I have trouble sitting in class for long periods of time, yet I'm a competitive power lifter. How can those two things co-exist?” (ID 29, 23F, painpre = 3, painpost = 0). Being challenged led to an understanding that painful sensations are not dangerous and are brain-generated experiences. As 1 participant said, “I absolutely think that my brain was the majority of my pain…at the very least it was controlling at least 90% of the pain” (ID 1234, 37F, painpre = 6, painpost = 3). This was a pivotal point in the therapeutic process, when participants described a shift in their pretreatment perceptions that a medically based treatment would be the only approach to improve their pain.
Subtheme 3: Reconceptualizing “Pain” as “Sensation”
Nearly half of the interviewees (n = 15; 47%) reported using novel language when describing their pain, which promoted changes in mindset. The most common shift was no longer referring to physical discomfort as “pain,” but rather describing it as a “painful sensation” or simply a “sensation.” As 1 participant explained, “If I get sensations, I call them sensations, I don't call them pain. If I get sensations, I can pay attention to them and work with them, and I don't have to be terrified about them. I know now that they're temporary, that they come and go, and they can go” (ID 1036, 58F, painpre = 2, painpost = 1). Conversely, he implied that identifying sensations as “pain” means he is less able to deal with their onset because his initial response is fear, a more challenging emotion to cope with. The overarching idea is that “sensations are temporary,” whereas “pain” is viewed as more permanent and detrimental. This novel way of viewing and responding to discomfort helped participants change how they perceived their familiar pre-treatment pain.
Theme 2: The Link Between Pain, Emotions, and Stress
The second major theme involves participants’ realizations that their pain and emotions are connected and that this reciprocal relationship impacts their daily lives (see Table 3 for representative quotes).
Subtheme 1: Gaining Insight into the Connection Between Pain, Emotions, and Stress
Participants described important revelations throughout treatment that involved recognizing, and then processing, the connection between pain and other emotions and thoughts. The connection of pain with emotions and stress was discussed by 24 participants (75%), who described how feelings of depression, anxiety, anger, and generalized stress exacerbated the pain. Most of these participants developed insight into this relationship during treatment, discussing a new awareness that pain and emotional experiences are more deeply connected than they had originally realized. For example, some participants reported that if they do not effectively cope with uncomfortable emotions, the emotions manifest as physical discomfort because they “have to go somewhere” and therefore “create this pain.” Additionally, participants described this new awareness as giving them the ability to distinguish between 2 types of pain: pain that is caused by peripheral tissue conditions and pain that results from emotional discomfort or maladaptive thought patterns.
Subtheme 2: Experiencing, Allowing, and Resolving Difficult Emotions
Discussing emotional experiences—for example, feelings of sadness, anger, shame, and anxiety that often had been present long before the onset of pain—was mentioned by 19 participants (59.4%) as an important aspect of the therapy. Ten participants (31.3%) reported addressing uncomfortable emotions, prior trauma, and “psychological pain from my childhood” (ID 1113, 66F, painpre = 3, painpost = 1) that had continued to negatively impact their lives. Through the therapeutic process, participants “dug deep” into emotions. For example, a female participant discussed her longtime struggle with feelings of shame:
I'm very shame-bound…The most concrete way is I'll kind of say my inner bully starts shaming me for being afraid and shaming me for not being able to overcome the pain, and then I get more afraid… [My therapist] and I worked on this quite a bit during the psychotherapy. For me, the manifestation of the inner bully related to pain is pretty intense (ID 1036, 658F, painpre = 2, painpost = 1).
Participants not only discussed emotions, but also learned how to give themselves “permission” to feel emotional discomfort that they had otherwise learned was unsafe or inappropriate to experience. As one participant stated, it is
…like that 5-year-old kid that has these things that they want to express but they just can't. And that other voice is pretty much just telling it to shut up…So it's been like tapping into that other voice that wants to be heard…It's all, I think, tied to vulnerability. Being willing to be vulnerable because I was just very closed off (ID 312, 25M, painpre = 3, painpost = 1).
Participants described this therapeutic element as a difficult process, though they acknowledged that they felt safe with their therapist and the emotional work was crucial in their healing process.
Participants discussed reductions in negative emotions and increases in positive emotions that resulted from engaging in these emotional processes, most commonly, reductions in anxiety, stress, and anger. All participants who discussed positive emotions identified happiness as being more prevalent in their daily lives following treatment. This happiness was expressed as both internal (“[Treatment] has actually made me a happier person” [ID 319, 48M, painpre = 6, painpost = 0]) and external (“I'm sure I'm a lot happier to be around” [ID 575, 59F, painpre = 3, painpost = 0]) changes. Additionally, 6 individuals (18.8%) described their enhanced awareness of emotional experiences in general, and their perceived safety to identify, feel, and process these experiences. One participant eloquently described this change:
So, it was being present with that pain but also being present with my emotions, the emotions that we label as negative because those are also very much part of me or who I am. So, allowing myself and giving myself permission to feel and experience those emotions has been big. It's still a challenge. But it's like leaning into that instead of running from it… (ID 312, 25M, painpre = 3, painpost = 1).
Theme 3: Social Connections
This final theme discusses content related to the therapist and pain peers, which participants described as valuable in adopting the new model of pain and maintaining their motivation to engage in treatment (see Table 4 for representative quotes).
Subtheme 1: The Patient-Provider Relationship
Thirteen participants (40.6%) identified the therapeutic alliance as enhancing participation treatment motivation and engagement. This ranged from commenting on the therapist’s “soothing voice” and ability to put the participant at ease to acknowledging the therapists’ prominent role in their treatment outcomes. Some participants identified a process of the therapist first guiding the participant through the treatment components and then empowering the participant to individually implement the techniques: “At first I felt like [my therapist] is the one who's making me do it, but now I'm feeling like I'm the one, I've been empowered to do it for myself…[My therapist] helped me get there” (ID 1027, 68F, painpre = 4, painpost = 1). Participants also discussed the emotional bond and comfort they felt with their therapist, which developed initially for some (“I clicked like I've never clicked with another therapist” [ID 38, 57F, painpre = 6, painpost = 1]) and over time for others after they discovered they could trust and felt safe with their therapist.
Subtheme 2: Therapist Belief in the Treatment Model
Seven participants (21.9%) identified their therapists’ belief in the PRT model and in participants’ ability to change as key components that drove initial treatment engagement and influenced participant expectations of how treatment would impact their lives and pain. Participants described the pre-treatment conversation with the physician and the therapists’ presentation of PRT as “convincing,” saying they presented as positive and confident and clearly communicated their positive perceptions of the treatment modality and belief that it would change the lives of participants. This, in turn, left participants feeling committed to treatment and believing it would effectively reduce their pain. As 1 participant said, “This is definitely going to work” (ID 1027, 68F, painpre = 4, painpost = 1).
Subtheme 3: Peer Models of Recovery
Participants identified talking with former PRT patients as a therapeutic element that enhanced engagement. The therapists encouraged some participants to connect and discuss treatment with successful patients from prior clinical work (not study participants). We interpret this as a form of therapeutic modeling, generating hope and social norms of recovery from pain. Seven participants (21.9%) described helpful therapist-initiated connections, especially for participants who expressed skepticism at various points during treatment. As one participant described:
I got really skeptical…and talking to two previous [patients] actually made a huge difference for me… I got to hear real people talk about, "Wow, here's what I had before, here's how it shifted for me," et cetera, and that made the study feel possible (ID 1036, 58F, painpre = 2, painpost = 1).
Participants who were put in touch with former patients discussed their desire to have someone “back up” the therapists’ claims to fully “buy in” to the therapy. These participants expressed the desire for confirmation that this novel therapy would be beneficial to others with back pain. The perceived effectiveness of talking with other patients suggests that peer support and connection can have a powerful impact on treatment perceptions and motivation to engage in treatment.
Ancillary Findings
Nine participants (28.1%) described discussing their PRT experiences with friends, family, and others outside of the study. As 1 participant stated: “I'm telling all my friends that I know who have chronic pain that they need to go work with this kind of process. It's been a real gift, absolutely” (ID 1036, 58F, painpre = 2, painpost = 1). These discussions ranged from general recommendations to others, to attempting to use specific tools learned in therapy to help others. For example, 1 participant mentioned sharing the “lists of things” learned from his therapist with friends with back pain and making attempts to “convince” others that his success can be replicated. We viewed these participant reports as indicators of treatment satisfaction rather than as reflections of change processes, and therefore did not include them in the model of mechanisms presented above.
Conclusions
The current study explored participant-reported mechanisms of change in PRT, a promising novel therapy for chronic pain.20 The analyses revealed 3 major themes describing how participants understood PRT to be helpful in treating their pain. Overall, some participants' perceptions of the mechanisms of PRT support the original hypothesized model of this therapy, whereas other perceptions were not emphasized or even included in the original hypothesized model.
The first core change process derived from interview data was the participants’ recognition that the experience of physical pain is not a signal of danger (ie, tissue damage). Participants’ focus on the reattribution of the source of the pain as a key change process (Theme 1) strongly aligns with the hypothesized model of PRT.20 The PRT model is based on the idea that participants typically attribute pain to tissue damage or other peripheral/bodily anomalies, but this attribution is incorrect—in cases of primary (nociplastic) pain, mind and brain processes are the primary drivers of pain. PRT aims to correct this misattribution. This is closely related to pain neuroscience education-based interventions and other “brain retraining” interventions, which also produce changes in pain beliefs and promote an increased appreciation for brain influences on pain, with positive benefits on pain severity, interference, pain catastrophizing, and kinesiophobia.32, 22, 30, 31
A main goal of reattribution in PRT is fear reduction: an understanding of the pain as brain-generated indicates that it is not an indicator of bodily threat. Participants reported that with guidance, they learned how to respond to pain not with fear, but with mindful reappraisal of pain as nondangerous. The fear reduction was further supported by relating to pain as a helpful indicator of one’s emotional or psychological state (eg, a sign of feeling stressed), by psychotherapeutic techniques promoting mindful reappraisal of pain sensations (“somatic tracking”), and by relabeling pain as “just a sensation.”
A second major theme reported by participants is the value of addressing a range of emotional issues during PRT (Theme 2). This aspect is often presented as a peripheral/secondary treatment element in PRT; our results show that it may be more central than previously appreciated. PRT focuses on reducing the emotion of fear related to pain and movement, and the value of differentiating pain from anxiety. Targeting patients’ emotional experiences more generally may have helped to facilitate the shift to viewing pain as not indicating dangerous bodily harm, thereby reflecting a synergy between Themes 1 and 2. Addressing the broad range of emotional experiences, such as feelings related to one’s sense of self (eg, shame), emotional challenges experienced in relationships with others, and even emotional memories stemming from life adversity or trauma, is not a focus of the original PRT model. Prior research has shown that emotional expression is a powerful predictor of effective therapy outcomes in general,37 and even cognitive-behavioral therapies are more effective when they focus on underlying, core emotional processes and emotion-laden cognitions.38 Despite a therapy’s intended clinical targets, patients often will move in needed directions, and skilled clinicians, such as those who provided PRT in this trial, will facilitate such processes. It is noteworthy that PRT shares its historical development and elements of its underlying model with Emotional Awareness and Expression Therapy (EAET), which emphasizes the processing of the trauma and emotional conflict driving chronic pain.39, 18, 40
The third major theme that was reported by participants is the importance of relationships, both with their therapists and with peers (Theme 3). Specifically, they discussed the importance of a safe patient-provider relationship in creating a safe and supportive environment to address their fears and beliefs about their pain as well as other emotional issues. Their reports reflect the well-replicated value of a positive therapeutic alliance.41 The specific attributes that participants described of their therapists (eg, warmth, friendliness, respectfulness, trustworthiness, support) are classic aspects of a positive alliance,41, 42 and these factors may have increased participants’ motivation and comfort to engage in this challenging work.
Interestingly, participants also spoke about the ongoing motivation facilitated by therapists, both of whom had a strong belief in the PRT treatment model, which helped participants adopt that belief as well and overcome initial doubts about treatment. Although considered somewhat of a background rather than a core feature of PRT, therapists were persuasive about the possibility of recovery from pain stemming, in part, from their own personal experiences of pain recovery as well as from having helped numerous patients recover. Indeed, a surprising observation, one not planned as a part of PRT originally, is that some participants in the PRT trial were connected by their therapists to prior patients (from the therapists’ practices) who had experienced positive outcomes. The combination of a strong therapeutic alliance, high therapist commitment to and belief in the model, and connections with prior patients who had recovered from pain using similar techniques likely augmented PRT outcomes in this study, as noted from the participant perspective, such that the safe and convincing environment created by therapists and the support of peers laid a solid foundation for participants and contributed to the reappraisal of pain, exploration of emotions, and subsequent reduction in pain.
Many providers fear that patients will balk if mind or brain processes are identified as causing or amplifying physical symptoms. Our results indicate that most participants (reflecting retrospectively) recount being at least somewhat open to this notion, though there was also substantial initial skepticism—this aligns with prior studies on pain neuroscience education, implying that early skepticism is quite common for patients who have otherwise been told by providers that their pain is solely the result of tissue damage or bodily anomalies.31 In this study, participants who were initially relatively skeptical also described a shift in their thinking throughout the course of the intervention, and many were pain-free or nearly so after treatment and expressed belief in the PRT treatment model. This is encouraging.
In sum, this study provides support for the hypothesized core change processes of PRT—changing fear-based beliefs of the origins of pain from the body to the brain—but also highlights additional processes dealing with emotions and the therapeutic relationship that occurred in PRT as actually practiced. It should not be surprising, we think, that a complex process like individual therapy involves both targeted and unexpected processes or emphases. Identifying these elements can help researchers and clinicians more thoroughly understand what actually occurs in PRT—at least from the perspective of the patients—and it will be important to study empirically whether these processes are indeed active mechanisms of positive treatment outcomes. If so substantiated, these elements could be added to future versions of PRT and included in PRT training.
More generally, we think that the findings here point to the need for a broader integrative pain treatment based on the “brain-generated pain” model that includes key elements of PRT, EAET, pain neuroscience education, pain exposure therapy, and perhaps other approaches, while also attending to the importance of having interpersonally skilled therapists who are committed to the model and creative in the ways that they help patients shift in their beliefs about pain and address their pain-related and other fears. One such integrative pain assessment and treatment model has been proposed.18
To address the connection between emotional experiences and pain, we recommend that clinicians, regardless of the specific model they are using (PRT, EAET, or others), be trained in how to help patients successfully recognize these connections and process or work through, rather than avoid, their important emotional experiences. Additionally, peer models of recovery may be important, which can be incorporated by conducting PRT and related therapies in a group format and providing patients with access to recovery stories (eg, through podcasts or connecting current patients with prior patients who volunteer for this peer model role). Additionally, therapist self-disclosure of recovery may be beneficial for PRT patients, especially those who find themselves skeptical of the model before or during treatment.
There are several limitations of this work. First, participants’ recall of therapeutic processes depended on the interview questions, which were relatively general, broad, and could be viewed as somewhat leading. We did not ask about parts of treatment that participants did not like or respond well to, which would have provided us with more refutational data. Second, participants were questioned about their pre-treatment beliefs and expectations after completing treatment, which presents the risk of recall bias in reflecting on their pre-treatment beliefs. We also acknowledge variability in the quality and length of the interviews, which could be strengthened in future work by making the interview guide more substantive and providing in-depth interview training for research assistants. We acknowledge the potential for bias in the interpretation of the data; although the 2 coders of the interviews were not knowledgeable or vested in PRT, the other authors are involved with PRT’s development and implementation. Additional study limitations include the generalizability of the sample, which was largely highly educated and White. Finally, although the majority of PRT participants were interviewed, and those who were interviewed had similar outcomes as those who were not interviewed, it would have been ideal to interview all participants.
In future research, it would be of interest to know how participants’ recollections and impressions align with those of the therapists and what would be found in a third-party review of actual session recordings. For example, it would be valuable to know how often participants engaged in certain behaviors, such as disclosing prior traumas, and how often the therapist used certain techniques, such as purposely evoking pain in session, referring participants to speak with others who have recovered from pain, or using humor to create a positive mood. Triangulation of such approaches, combined with empirical associations with treatment outcomes, would reveal key aspects of effective change techniques and mechanisms.
The personal and lived experiences of PRT that we identified from interview data were not captured by the study’s quantitative measures, highlighting the importance of utilizing qualitative methods in intervention research. Our qualitative analyses help identify key change processes in PRT that can guide future treatment refinement and advancement as well as training of therapists to use this treatment.
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M.K. Bagg, B.M. Wand, A.G. Cashin, H. Lee, M. Hubscher, T.R. Stanton, N.E. O'Connell, E.T. O'Hagan, R.R.N. Rizzo, M.A. Wewege, M. Rabey, S. Goodall, S. Saing, S.N. Lo, H. Luomajoki, R.D. Herbert, C.G. Maher, G.L. Moseley, J.H. McAuley
Effect of graded sensorimotor retraining on pain intensity in patients with chronic low back pain: A randomized clinical trial
JAMA, 328 (2022), pp. 430-439, 10.1001/jama.2022.9930
M. Sandelowski
Whatever happened to qualitative description?
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Qualitative content analysis: A focus on trustworthiness
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J.K. Morse
Critical analysis of strategies for determining rigor in qualitative inquiry
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P.R. Peluso, R.R. Freund
Therapist and client emotional expression and psychotherapy outcomes: A meta-analysis
Psychotherapy, 55 (2018), pp. 461-472, 10.1037/pst0000165
A. Samoilov, M.R. Goldfried
Role of emotion in cognitive-behavior therapy
Clin Psychol: Sci Pract, 7 (2000), pp. 373-385, 10.1093/clipsy.7.4.373
M.A. Lumley, H. Schubiner
Emotional awareness and expression therapy for chronic pain: Rationale, principles and techniques, evidence, and critical review
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B.C. Yarns, M.A. Lumley, J.T. Cassidy, W.N. Steers, S. Osato, H. Schubiner, D.L. Sultzer
Emotional Awareness and Expression Therapy achieves greater pain reduction than cognitive behavioral therapy in older adults with chronic musculoskeletal pain: A preliminary randomized comparison trial
Pain Med, 21 (2020), pp. 2811-2822, 10.1093/pm/pnaa145
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A review of therapist characteristics and techniques positively impacting the therapeutic alliance
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Application of a Clinical Approach to Diagnosing Primary Pain: Prevalence and Correlates of Primary Back and Neck Pain in a Community Physiatry Clinic
2024, Journal of Pain
Citation Excerpt :
In our clinical work, the determination of primary pain is typically followed by patient education emphasizing that the pain is caused by the brain, is not an indication of bodily injury (ie, the body is healthy/uninjured), and can be reversed with treatments targeting psychological and behavioral processes.37,39,45 A shift in patients’ attributions for the etiology of their pain “from body to brain” appears to be a key mechanism in pain reduction.48 Our diagnostic approach is consistent with, but expands upon, the criteria proposed by others,31–36 and includes pain characteristics indicating changes in neural circuits, such as pain that is inconsistent, variable, functional in scope, and triggered by innocuous stimuli.
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The study from which these data were obtained was funded by National Institutes of Health grants R01 DA035484 (Wager), R01 MH076136 (Wager), National Center for Advancing Translational Sciences grant TL1-TR-002386 (Ashar), the Psychophysiologic Disorders Association, the Foundation for the Study of the Therapeutic Encounter, and community donations. Author Y.K.A. reports grants from the National Institutes of Health during the conduct of the original RCT study and personal fees from UnitedHealth Group, Lin Health, Inc, Pain Reprocessing Therapy Center, Inc, and Mental Health Partners of Boulder County outside the submitted work. Author A.G. is a consultant with UnitedHealth Group, director of the Pain Psychology Center and the Pain Reprocessing Therapy Center, and the author of the book The Way Out. Author H.S. is the co-owner of Freedom from Chronic Pain, Inc, earns book royalties for Unlearn Your Pain, Unlearn Your Anxiety and Depression, and Hidden from View, serves as a consultant with UnitedHealth Group, Karuna Labs, and Curable Health, and receives personal fees from OVID Dx outside the submitted work. Author C.U. serves as a consultant for UnitedHealth Group. Author M.A.L. reports grants from the NIH and personal fees from CognifiSense, Inc, outside the submitted work. Author T.D.W. reports grants from the National Institutes of Health and the Foundation for the Study of the Therapeutic Encounter, and funding to support trainees from the Radiological Society of North America and the German Research Foundation; he is on the Scientific Advisory Board of Curable Health. No other disclosures were reported.
Tor D. Wager and Yoni K. Ashar are co-senior authors.
Address reprint requests to Hallie Tankha, PhD, Department of Wellness and Preventative Medicine, Cleveland Clinic, Cleveland, OH. E-mail: tankah@ccf.org.
© 2024 © Published by Elsevier Inc. on behalf of United States Association for the Study of Pain,
11/23/25
Credit to Tanner Murtagh, MSW, RSW
What is Pain Reprocessing Therapy?
Can PRT Help in Retraining my Brain out of Chronic Pain and Symptoms?
By Tanner Murtagh, MSW, RSW
For 3 and a half years I experienced widespread chronic pain that continued to worsen over time. To try and reduce or eliminate my chronic pain I did what most people do which included: being examined by several physicians, MRI and x-rays, physiotherapy, chiropractic work, pain medication, and several other physical treatments. However, all the medical tests and treatments did not resolve my pain and in fact, caused my pain to increase.
This is a common story I hear when providing therapy to clients with chronic pain or symptoms. “The medical system has failed me. No treatment is helping.”
The reality is that medical procedures have poor results when it comes to reducing or eliminating chronic pain and symptoms. Surgery, injections, and narcotic pain medications are no more effective than placebo or conservative treatments.1.
So, what is the solution to healing chronic pain and symptoms? The answer lies in the brain. Chronic pain, fatigue, dizziness, or other physical symptoms are often neuroplastic. Neuroplastic pain/symptoms are when the brain changes in such a way that it reinforces chronic pain/symptoms2,3.
When our brain or nervous system feels in emotional danger or dysregulated, chronic pain or symptoms can be triggered and perpetuated2,3. Over time, as pain or symptoms are repeatedly produced, the brain learns to generate these sensations better and better. It is vital to understand that a significant portion of chronic pain and symptoms are neuroplastic, meaning the brain is responsible for triggering and perpetuating them4.
For myself, after 3 and a half years of being in pain I came to understand that my symptoms were neuroplastic in nature. This realization allowed me to shift my focus to rewiring my brain instead of fixing my body. I began to utilize brain retraining exercises, in combination with emotional processing and nervous system regulation, and in doing so over several months I was able to become pain-free.
Research on Pain Reprocessing Therapy (PRT), which is a psychological approach focused on rewiring the brain out of chronic pain, has shown that reversing neuroplastic pain is possible5. In a clinical trial on PRT 66% of participants who received the treatment were able to become pain-free or nearly pain free after 9 sessions5. Over 98% of participants in the study had pain reductions. This research and my personal experience showcase how it is possible to retrain your brain out of chronic pain!
At our clinic we support clients in utilizing brain retraining practices from PRT to heal their chronic pain and symptoms. PRT brain retraining practices for chronic pain and symptoms can include:
Creating New Beliefs about Your Body, Pain, or Symptoms
Understanding that our symptoms are neuroplastic and our body is not permanently damaged is essential. At our clinic, we support people in looking for evidence that their pain or symptoms are in fact neuroplastic. We want to foster the belief that healing is possible. Retraining our brain to develop new beliefs about our body and symptoms, with less fear and more safety, can result in the sensations of pain or symptoms reducing over time 2.
Developing Cognitive Safety Messages
Fearful, frustrated, or despairing thoughts about our pain or symptoms can worsen the sensations2. Brain retraining can involve changing our thoughts about our symptoms by utilizing cognitive safety messages. These could include:
“I know I’m okay; my brain is just misinterpreting normal sensations in my body.”
“I see how my symptoms are inconsistent, moving around, and triggered by emotions. This shows me it’s neuroplastic and my body is healthy and capable.”
“I don’t need to control or change these sensations. There is nothing to fix or figure out!”
“My muscles and tendons are healthy. My nerves and ligaments are perfectly intact. My brain is just sensitized and overprotective.”
“It’s physically safe to move this way.”
“I don’t need to like the sensations; I just need to remember they’re safe!”
Using messages of safety consistently when you notice yourself having negative thoughts about your symptoms and body can support you in rewiring your brain2. In our clinic, we support people in creating unique messages of safety about their body.
Visualizing Yourself Healing and Moving Your Body
Visualization can be a supportive tool in rewiring the brain. Consistently visualizing yourself becoming pain or symptoms free, being able to approach life again, and being able to exercise and use your body the way you want to can support teaching your brain that your body is healthy and capable.
Somatic Tracking
Often, we have an emotional response of fear, frustration, despair, or annoyance to our pain or symptoms. This negative emotional response to our chronic symptoms can actually worsen our symptoms over time as it increases the level of danger and dysregulation our brain is experiencing2. Somatic tracking is a skill that can support us in changing our emotional response to our chronic pain or symptoms2. Utilizing somatic tracking can teach us to respond to our symptoms with lightness, ease, calmness, and compassion. By changing our emotional response to the symptoms, it can result in our symptoms reducing or becoming eliminated2. Our therapists are experienced in teaching somatic tracking and making it individualized for each client.
Here is a free somatic tracking practice to try:
Graded Exposure to What You Fear
Our natural response to chronic pain or symptoms is to start avoiding anything and everything that could be triggering our symptoms, which can include: certain movements, positions, activities, environments, foods, sounds, or time of day. This causes us to enter into a symptom-avoidance cycle where our symptoms cause us to avoid, the avoidance causes our brain to feel more in danger which triggers more symptoms, more symptoms cause more avoidance, and more avoidance causes more symptoms. We have seen clients stuck in this cycle for decades.
It often isn’t the condition that is triggering our pain or symptoms, but the fact that the brain has learnt to view the condition as dangerous2. Essentially the brain has made a mistaken association between the condition and the symptom. Healing chronic pain and symptoms involves slowly, gently, and compassionately approaching conditions we fear while using somatic tracking to create safety. Approaching these conditions can be REALLY SCARY, however, it supports our brain in breaking these mistaken associations2. This can allow us to live more fully with less pain or symptoms!
Leaning into Pleasant Sensations
When we experience chronic pain or symptoms we get really good at hyper-focusing on unpleasant sensations in our body. Part of retraining our brain is teaching it to focus on pleasant sensations. Consistent practice of leaning into pleasant sensations cultivates nervous system regulation and supports the brain in more easily gravitating towards these sensations in the future2. Leaning into pleasant sensations could look like:
Feeling the warmth of the sun on your skin
Feeling the pleasant sensations of breathing slowly
Noticing loose or relaxed sensations in your body
Attending to sights or sounds that are calming
Enjoying a warm coffee or tea
Using soothing touch (making circles on your chest or giving yourself a hug)
Conclusion
As you can see there are many ways we can utilize PRT to retrain our brain out of chronic pain or symptoms. If physical treatments have provided limited results in healing your symptoms, it may be time to start focusing on treating the brain.
Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating chronic back pain: time to back off?. Journal of the American Board of Family Medicine : JABFM, 22(1), 62–68. https://doi.org/10.3122/jabfm.2009.01.080102
Pain Reprocessing Therapy Center (2021). Pain reprocessing therapy training.
Gordon, A., & Ziv, A. (2021). The way out: A revolutionary, scientifically proven approach to healing chronic pain. Sony/ATV Music Publishing LLC.
Woolf C. J. (2011). Central sensitization: implications for the diagnosis and treatment of pain. Pain, 152(3 Suppl), S2–S15. https://doi.org/10.1016/j.pain.2010.09.030
Ashar, Y. K., Gordon, A., Schubiner, H., Uipi, C., Knight, K., Anderson, Z., Carlisle, J., Polisky, L., Geuter, S., Flood, T. F., Kragel, P. A., Dimidjian, S., Lumley, M. A., & Wager, T. D. (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. https://doi.org/10.1001/jamapsychiatry.2021.2669
11/23/25
Boulder back Pain Study - Read Conclusion
Randomized Controlled Trial
JAMA Psychiatry
. 2022 Jan 1;79(1):13-23.
doi: 10.1001/jamapsychiatry.2021.2669.
Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial
Yoni K Ashar 1 2 3, Alan Gordon 4, Howard Schubiner 5 6, Christie Uipi 4, Karen Knight 7, Zachary Anderson 2 3 8, Judith Carlisle 2 3 9, Laurie Polisky 2 3, Stephan Geuter 2 3 10, Thomas F Flood 11, Philip A Kragel 2 3 12, Sona Dimidjian 2 13, Mark A Lumley 14, Tor D Wager 2 3 15
Affiliations Expand
PMID: 34586357
PMCID: PMC8482298
Abstract
Importance: Chronic back pain (CBP) is a leading cause of disability, and treatment is often ineffective. Approximately 85% of cases are primary CBP, for which peripheral etiology cannot be identified, and maintenance factors include fear, avoidance, and beliefs that pain indicates injury.
Objective: To test whether a psychological treatment (pain reprocessing therapy [PRT]) aiming to shift patients' beliefs about the causes and threat value of pain provides substantial and durable pain relief from primary CBP and to investigate treatment mechanisms.
Design, setting, and participants: This randomized clinical trial with longitudinal functional magnetic resonance imaging (fMRI) and 1-year follow-up assessment was conducted in a university research setting from November 2017 to August 2018, with 1-year follow-up completed by November 2019. Clinical and fMRI data were analyzed from January 2019 to August 2020. The study compared PRT with an open-label placebo treatment and with usual care in a community sample.
Interventions: Participants randomized to PRT participated in 1 telehealth session with a physician and 8 psychological treatment sessions over 4 weeks. Treatment aimed to help patients reconceptualize their pain as due to nondangerous brain activity rather than peripheral tissue injury, using a combination of cognitive, somatic, and exposure-based techniques. Participants randomized to placebo received an open-label subcutaneous saline injection in the back; participants randomized to usual care continued their routine, ongoing care.
Main outcomes and measures: One-week mean back pain intensity score (0 to 10) at posttreatment, pain beliefs, and fMRI measures of evoked pain and resting connectivity.
Results: At baseline, 151 adults (54% female; mean [SD] age, 41.1 [15.6] years) reported mean (SD) pain of low to moderate severity (mean [SD] pain intensity, 4.10 [1.26] of 10; mean [SD] disability, 23.34 [10.12] of 100) and mean (SD) pain duration of 10.0 (8.9) years. Large group differences in pain were observed at posttreatment, with a mean (SD) pain score of 1.18 (1.24) in the PRT group, 2.84 (1.64) in the placebo group, and 3.13 (1.45) in the usual care group. Hedges g was -1.14 for PRT vs placebo and -1.74 for PRT vs usual care (P < .001). Of 151 total participants, 33 of 50 participants (66%) randomized to PRT were pain-free or nearly pain-free at posttreatment (reporting a pain intensity score of 0 or 1 of 10), compared with 10 of 51 participants (20%) randomized to placebo and 5 of 50 participants (10%) randomized to usual care. Treatment effects were maintained at 1-year follow-up, with a mean (SD) pain score of 1.51 (1.59) in the PRT group, 2.79 (1.78) in the placebo group, and 3.00 (1.77) in the usual care group. Hedges g was -0.70 for PRT vs placebo (P = .001) and -1.05 for PRT vs usual care (P < .001) at 1-year follow-up. Longitudinal fMRI showed (1) reduced responses to evoked back pain in the anterior midcingulate and the anterior prefrontal cortex for PRT vs placebo; (2) reduced responses in the anterior insula for PRT vs usual care; (3) increased resting connectivity from the anterior prefrontal cortex and the anterior insula to the primary somatosensory cortex for PRT vs both control groups; and (4) increased connectivity from the anterior midcingulate to the precuneus for PRT vs usual care.
Conclusions and relevance: Psychological treatment centered on changing patients' beliefs about the causes and threat value of pain may provide substantial and durable pain relief for people with CBP.