Pain Reprocessing Therapy

Caroline J Davies

A breakthrough in the treatment of pain is starting to change the landscape of what is thought to be possible for people in pain

_{Figure 1 Caroline Davies Reprocess Your Pain: Generated with Chat GPT}

A promising research study was published in early 2022, showing that the majority of people, with a history of decades of back pain, who were in the Pain Reprocessing Therapy (PRT) group, were getting better to the point where they either had no pain at all, or so little pain it didn’t stop them from doing what they wanted to.¹

I was working in a national pain management team when I first heard about PRT, from an inspiring documentary about people recovering from chronic pain.² Although I managed to get a few of my colleagues to watch the film with me, frustratingly, there wasn’t any further interest in pain reduction as an immediate goal for our patients. I continued to do the training and now have been using PRT with patients for the last two years, from those who “just woke up with pain” to those who “have had pain for years and have tried everything”. I am as hopeful now, as I was when I first heard about PRT, that this is, indeed, a breakthrough in the treatment of pain.

Quick Primer on Pain

Before we get further into PRT, let’s revisit our new understanding of pain. If you haven’t already done so, please consider reading this article first, for a more in depth look at pain: Five Questions about Pain That You Might Not Have Thought to Ask

An essential thing to remember about pain is that it is all about threats: threats to the smooth functioning of your body or your life. Pain can come on without any damage to the body; it can also be missing when there is damage to the body when pain would interfere with other survival needs like escaping or helping others; and it can stick around long after injuries have healed. After much research, discussion and multiple examples in our own lives and those of others, it has finally been agreed that our brains are “in charge of pain” and, as a result, “pain is complex”.

Our brains basically use pain as an emergency communication tool to signal a problem that we might not have noticed or that needs our attention. Our brains can’t use this tool anywhere other than in our bodies, which means we always need to start there to rule out a problem— but keep at the back of our minds—the possibility that the threat is an external rather than an internal one

_{Figure 2 Caroline Davies Reprocess your Pain: Generated with Chat GPT}

Imagine you have back pain that came on without any obvious cause…except you also just started a new job with a demanding set of new people to impress and a bunch of new software to learn. Your brain might have literally thought you were under some kind of attack; starting in a difficult new workplace could produce similar bodily responses to being under attack. And, although not very helpful, your brain wanted to warn you about it! Having pain does not always mean that there is a clear and present danger in either our bodies or our lives— it just means our brains think there could be.

Before we talk about the promising research being done into PRT, let’s start with something more tangible, like what it would be like to come in for PRT.

What is it like to do Pain Reprocessing Therapy?

I will describe the process that I would go through if you were to come to see me for PRT; it might vary according to who you go to see; there is a nice mixture of professionals doing PRT, from doctors, psychologists, and physiotherapists to health coaches.

Assessment

Although it can be very tiring for you to go through the history and background of your pain again, and what you have already tried, I will pick up a lot from this and will have several questions to ask you that you might not have been asked before, about your pain and what else is or has been happening in your life.

Then, I will do a more regular physiotherapy assessment, looking at how you walk and move, testing for sensation, muscle weakness and looking for any swelling or skin changes.

The overall aim of this assessment is to rule out any serious injuries or illnesses that might be causing your pain; if there are any doubts about this, I will send you back for further consultation with your GP or consultant. Your treatment might include a number of different therapeutic approaches alongside the PRT.

Understanding Pain

Learning what pain is really about and how it is created in our brains is a key part of PRT. This isn’t just a nice introduction or a soft entry to the harder work— learning new things about pain will literally start the process of rewiring your brain. Although I do have some slides, more of the learning is through discussion and stories from our lives. This stage can take from one to several sessions to go through, depending on your history and situation.

Practice

Pain reprocessing itself, is all done in the only way this therapy will work – in a way that feels safe to you. Usually, we start it sitting or lying down in the clinic and, similarly, you will then try this at home. In time, we will add new positions or activities to practice it in. These steps will always be in your control.

_{Figure 4 Copyright Caroline J Davies Physiotherapy Reprocess Your Pain}

Once comfortable, I will talk you through how to do the pain reprocessing, which involves noticing all of the different sensations that make up your pain; for example, is it a sharp or stabbing feeling, or more of a dull sensation, does it move around, or does it stay in one place? The important things to keep in mind are that this is a safe thing to do;to feel rather than think; and not to have any expectations or outcomes for your practice. All much easier said than done! This new way of feeling your pain is how you start to reset and rewire your brain. You might also see this step being referred to as Somatic Tracking.³

Confidence-Building

It takes some time to incorporate your new understanding of pain into your life and find a regular time to practice. Pain reprocessing works in a similar way to learning a new language, instrument, sport or job, you keep getting up to practice every day, but one day you will suddenly find you are doing it without thinking, it will flow. Similarly, one day or week you will suddenly realize you haven’t noticed as much pain as usual.

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Pain reprocessing can look different for everyone. There might be other changes to make, such as a new approach to work or relationships, a kinder or more compassionate approach to yourself, or a new direction or goal in your life. Gradually, over time, your pain will fade into the background and your new less painful life will start to emerge.

If you have had pain for many years, it makes sense that this rewiring of your brain will take some time and perseverance. Conversely, if your pain is relatively recent, pain reprocessing can be refreshingly quick to reduce your pain.

How Pain Reprocessing Therapy Started

An American Psychologist, Alan Gordon, co-author of The way out: a revolutionary, scientifically proven approach to healing chronic pain. ⁴ had unrelenting pain himself as a young man. He describes someone remembering him at university as being “the person pushing the chair”; his pain was so bad at that time that he could only manage to sit in one particular chair that he had to drag between classrooms. After years of pain, he finally got better using his own approach, pain reprocessing. This led Alan to work with other leading thinkers, including Dr Howard Schubiner, in the fields of Psychology, Medicine, Neuroscience, and Emotion, to develop PRT, which was then tested in its first randomized controlled research trial.

Research

The results in this first trial were truly exciting.⁵ In a segment on the Today programme, Drug-free Treatment Offers New Hope to Patients with Back Pain, ⁶for the US network, NBC, a gentleman with back pain describes his transformation, from being unable to stand for more than a few minutes without back pain, to being back in the gym and out along the trails in Colorado on his mountain bike.

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_{Figure 6 Drug-free Treatment Offers New Hope to Patients with Back Pain}

The following three figures summarize the results of the trial. The 151 subjects were divided into three treatment groups: orange, being the active placebo, a treatment that gives the subject the feeling that something is being done for them even if it isn’t- in this case it was an injection with saline; dark turquoise being whatever care the patients were already receiving, like medications or other therapies or procedures; and light blue, being the group having the PRT.

Figure 7, below, shows that in the PRT group, the patients’ pain dropped from, on average, 4 out of 10 (where 0 is no pain at all and 10 is the worst pain you have ever had) to between 1 and 2 out of 10. Their pain stayed close to these reduced levels for the rest of that year.

_{Figure 7 Copyright 2021 Ashar YK et al. JAMA Psychiatry}

Figure 8, below, is like one of those glass liquid-filled cylinder thermometers with the floating temperature baubles. Instead of temperature, they show how much everyone’s individual pain changed over the time of the treatment which was over one month.

Everyone in the PRT group had less pain than when they started, other than one person. In the other groups, some people improved, although not as much as the PRT group, but, a number, also got worse. In a nice way, this also shows that even if PRT doesn’t help you as much as we would want it to, you are not likely to get worse by doing it, and you are more likely to get better than other things you are trying.

_{Figure 8 Copyright 2021 Ashar YK et al. JAMA Psychiatry}

Finally, Figure 9, below, shows what number of subjects in each group reached the levels of having no pain at all or being nearly-pain-free, which are levels 0 or 1 out of 10 on the pain intensity scale. Clearly, the chances of getting rid of your pain or “just about” getting rid of it may be considerably greater doing PRT than whatever your usual care is you’re doing or the attention from having a placebo treatment.

_{Figure 9 Copyright 2021 Ashar YK et al. JAMA Psychiatry}

Other significant improvements were seen in disability, mood, and sleep. Brain scans also showed significant changes in the participants’ neural processing.

An enlightened follow-up article interviewed the subjects who had experienced improvements with the PRT, to understand what they thought had helped them get better. ⁷ The reasons given by the subjects were that they:

• were no longer as afraid of their pain and saw it more as a useful signal about what else might be going on in their lives
• were able to engage in more activities as a result of being less afraid of the pain
• developed a greater understanding of the idea that their pain could originate in their brains and not necessarily be related to what is going on in their bodies
• appreciated understanding how emotions affected pain and what deeper meanings there might be behind their pain
• found the encouragement and optimism of the therapists important to their recovery

_{Figure 10 Copyright Caroline J Davies Physiotherapy Reprocess Your Pain}

PRT is not just the act of sitting down to feel your sensations of pain in a new way, it has accompanying elements that are equally important, such as: understanding the meaning of your pain and what in your life might have, subconsciously, set you up to be more likely to develop it; making changes to the way you work or approach your life in general; rethinking elements of your personality- that have led you to great success in other ways but are, ironically, tripping you up now; and processing your emotions around the pain and anything else that has happened or is happening in your life.⁸

Although it can be included in PRT, emotional processing is also a therapy in its own right, Emotional Expression and Awareness Therapy ( EAET) has now seventeen controlled research studies showing that this is a more effective approach to pain reduction than standard pain management approaches, which, incidentally, do not have pain reduction as their primary aim.⁹¹⁰

It’s the personal stories that convey the real achievements of this therapy, one participant in the trial revealed: “I can honestly say I have zero back pain; it’s a drastic difference, I was at 7, 8, 9 [out of 10], for 18 years it never stopped hurting, I can’t believe I am saying it, but it’s true”.¹¹

_{Figure 11 Copyright Caroline J Davies Physiotherapy Reprocess Your Pain}

Interestingly, quite a number of the patients in this study were initially quite skeptical but still agreed to do the treatments; many felt they, “would try anything if it might help” or had run out of other options.

These early studies will need to be backed up by further research. At the moment, two other studies are under way, one into PRT involving a more diverse group and higher levels of pain and disability, and another into EAET, comparing standard pain management approaches, Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy ( ACT) for people with low back pain, which we hope will both substantiate these positive findings.

The lack of enthusiasm I had from my pain management colleagues, has been more than made up for by the enthusiastic response of my patients and the results we are getting together. What I might say to my colleagues is, patients are skeptical too at first, but they are, at least, willing to try it.

Takeaway Thoughts

• For people who have been in pain for many years or even decades, the exciting takeaway is that it is possible to make your pain go away with this therapy and, at the very least, significantly reduce it.
• For others, whose pain is more recent, this understanding of pain will speed up your recovery from pain and help to prevent you from getting chronic pain. 
• While PRT is rooted in science, helping people get out of pain is a creative process, and as varied as your lives all are.
• In the process of learning to reprocess your pain, you will also come to process what else might be going on in your life that’s worthy of your attention.

1. Ashar YK, Gordon A, Schubiner H, Uipi C, Knight K, Anderson Z, Carlisle J, Polisky L, Geuter S, Flood TF, Kragel PA, Dimidjian S, Lumley MA, Wager TD. Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial. JAMA Psychiatry. 2022 Jan 1;79(1):13-23. doi: 10.1001/jamapsychiatry.2021.2669. PMID: 34586357; PMCID: PMC8482298. ↩︎
2. https://www.thismighthurtfilm.com/ ↩︎
3. While somatic tracking is an excellent name for this part of PRT, I have found it doesn’t necessarily resonate with everyone, so I am using “pain reprocessing” instead ↩︎
4. Gordon, A., & Ziv, A. (2021). The way out: a revolutionary, scientifically proven approach to healing chronic pain. Avery ↩︎
5. See Footnote 1. above ↩︎
6. NBC Today Programme, Drug-Free Treatment Offers New Hope to Patients with Back Pain Nov. 9th 2023 ↩︎
7. “I don’t have chronic back pain anymore”: Patient Experiences in PRT for Chronic Back Pain Tankha, Hallie et al. The Journal of Pain, Volume 24, Issue 9, 1582 – 1593 ↩︎
8. Course Material from Dr Howard Schubiner’s “Assessment and Education for Patients with Neuroplastic Disorders: An Advanced Training Course for Medical providers” PRT Institute Jan. 2025 ↩︎
9. Email me for a summary of the EAET research trials. Most recent trail is: Yarns BC, Jackson NJ, Alas A, Melrose RJ, Lumley MA, Sultzer DL. Emotional Awareness and Expression Therapy vs Cognitive Behavioral Therapy for Chronic Pain in Older Veterans: A Randomized Clinical Trial. JAMA Netw Open. 2024 Jun 3;7(6):e2415842. doi: 10.1001/jamanetworkopen.2024.15842. PMID: 38869899; PMCID: PMC11177167. ↩︎
10. Guidelines for Pain Management Programmes for adults. An evidence-based review prepared on behalf of the British Pain Society July 2019 ↩︎
11. See Footnote 7. above ↩︎