What is Pain Reprocessing Therapy?
By Kent Bassett
Pain Reprocessing Therapy (PRT) is a new diagnosis and treatment paradigm that helps patients unlearn chronic pain by retraining their brains. A key method is to work directly with the fear of pain, which is often a primary driver of symptoms.
A critical step for PRT is to differentiate structural pain from non-structural, or primary pain. You can see an example of what assessment looks like in the video below. Many doctors and pain psychologists skip this step, but it is essential to transforming chronic pain. Alan Gordon, LCSW, who coined Pain Reprocessing Therapy and developed the protocol with his colleagues, demonstrates:
How Common is Non-Structural Pain?
Studies have shown that about 85% of people with chronic back pain do not have structural damage that explains their pain. And many other symptoms like migraines, digestive disorders, abdominal pain, and fibromyalgia are also not characterized by structural or tissue damage. It’s great news to not have structural damage, because non-structural pain symptoms are 100% reversible with the correct treatment. PRT helps people retrain their nervous systems to unlearn neuroplastic pain pathways that are creating severe, debilitating, and very real pain.
PRT is part of a radical paradigm shift that neuroscience has enabled, which challenges conventional pain psychology and medicine. It harnesses breakthroughs in understanding how the brain uses predictive coding for sensory processing, which means that by expecting pain, and by fearing injury, the brain can create or maintain symptoms. These processes happen outside of awareness in thousands of predictive calculations based on prior experience.
Below is a somatic tracking exercise (guided) that you can use to experiment with your own symptoms. The exercise itself can help discover if the pain switches on and off, goes up or down, moves around— which can add to the evidence list of being neuroplastic. (The more pain changes in response to gentle, curious awareness, the more likely it is to not be structural in nature.)
What Does Pain Reprocessing Look Like?
After an assessment for structural versus neuroplastic pain, Pain Reprocessing practitioners help people transform their experience of neuroplastic pain by using somatic tracking. By paying close attention to sensations of pain with the knowledge that the body is safe and that the pain is not a sign of damage, people can experiment with being more curious about the sensations, and over time transform their fear of pain.
Since fear is often a key fuel source for chronic pain, reducing fear over time leads to reduced chronic pain. Alan Gordon, LCSW was presenting at a training conference with Howard Schubiner, MD called “Breaking The Pain Cycle”:
After a successful PRT treatment, patients know intuitively their chronic pain is not a fundamentally threatening sensation. The pain can come and go without triggering as much fear, tends to lessen over time (66% become pain-free), and is no longer mistaken for a structural injury. Two of the co-authors of the study on PRT, Yoni K. Ashar, PhD, and Alan Gordon, LCSW go into more depth in this article. The PRT protocol was published here.
PRT Featured in the Press
Isip Xin for the Washington Post
Nathaniel Frank writes in the Washington Post: “Neuroplastic pain treatment has become a rare and exciting example of practitioners and patients coming together to help reduce suffering on a wide scale.”
Gimlet Media and Spotify produced a great introductory podcast for their show “Science VS” on chronic pain and Pain Reprocessing Therapy featuring Lorimer Moseley, PhD, and Alan Gordon, LCSW. They include a touching story of one of their staff members who has struggled with fibromyalgia. Highly recommended!
What are the components of PRT?
Here are the three steps of the PRT protocol from the JAMA Psychiatry paper:
(1) "an in-depth medical and psychological assessment generating personalized evidence for centralized pain
(2) reattribution of pain to reversible learning- and affect-related brain processes rather than bodily injury
(3) a unique combination of cognitive, somatic, and exposure-based techniques supporting pain reappraisal”
In the study conducted at the University of Colorado, Dr. Howard Schubiner was involved in steps 1 and 2: evaluating chronic back pain patients for tissue damage and educating them about the neuroscience of chronic pain, which shows how it is learned and can be unlearned. (To see intimately what Dr. Schubiner’s diagnostic process looks like, you can view our film that features him, This Might Hurt.)
It is quite common for people with chronic back pain to have abnormalities in their spines that have been picked up by MRIs. Their doctors may have diagnosed them incorrectly. Any falses messages are deactivated through careful medical examination and summarizing the literature that shows that most cases of herniated discs or “degenerative disc disease” do not cause pain (steps 1-2).
In other words, most chronic back pain is not the result of injury, but comes from reversible “learning and affect-related brain processes.” (What if you do have an injury? PRT is not indicated for people with fractures, infections, tumors, and other tissue damage problems.)
To see what guided mindfulness for pain reappraisal can look like (step 3), scroll up to view the video with Alan Gordon.
Below is a general introductory conversation about PRT that includes a somatic tracking exercise:
Are Herniated and Bulging Discs Considered Structural Damage?
If MRIs show degenerative discs, bulging discs, or herniated discs, this is not sufficient to be diagnosed with structural damage. This is a critical piece of information because patients with so-called spinal “abnormalities” are able to become pain-free from PRT treatment just like other patients.
The paper notes that “Twenty patients in the PRT group had preexisting spinal imaging, all of which showed at least 1 spinal anomaly, assessed by a physician (H.S.) as not causal of pain.”
The literature shows that the vast majority of “degenerative disc disease” is really just normal aging like “skin degeneration” (wrinkles) or “hair degeneration” (grey hairs). Of course, sometimes MRIs do reveal structural damage in the form of cancer, infections, or extreme herniations that also have muscle control issues.
It’s also worth noting that 95% of the patients with chronic back pain randomized to PRT, who were assessed by Dr. Schubiner, did not have structural damage in their backs that were responsible for causing pain.
From the PRT study: these abnormalities seem scary but they don’t necessarily cause pain. For instance, 15 people had MRIs showing degenerative changes, but they could still benefit from a neuroplastic therapy and overcome chronic back pain.
The lead author, Yoni Ashar, PhD, in a podcast interview with Curable said:
“We measured people’s pain attributions, and what we found is people who had the largest drops in their injury beliefs (belief that the pain indicates an injury) had the largest drops in pain.”
Dr. Schubiner presents counterintuitive findings on MRIs and Chronic Back Pain
“One of my greatest challenges has been unlearning the belief that my body was broken and that I was bound to live with pain for good. Numerous doctors had reinforced that idea, telling me over and over again that I had had a serious back injury and multiple surgeries, and I’d never be “good as new”.”
Lilia Graue, MD has an incredible story of recovery from years of debilitating back pain after an injury. Even physicians can become bedridden and hopeless after years of trying everything.
Is PRT an Evidence-Based Treatment?
In short, yes, but so far there is only one study — it’s a brand new treatment. More research is needed, including studies with larger sample sizes. Yet the efficacy captured is remarkable.
66% became Pain-Free or Nearly Pain-Free
You read that right. The NIH-funded trial found that 66% of patients randomized to Pain Reprocessing Therapy were pain-free or nearly pain-free at posttreatment, compared with 20% for placebo injections, and 10% for usual care.
At a one-year follow-up, the treatment effects largely held: 52% of PRT patients were still at 0 or 1 out of 10 on the pain scale. The average duration of pain was 10 years.
Go here to read the brain imaging study on chronic back pain and PRT (number of participants=151), published in JAMA Psychiatry. “Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain,” written by Yoni Ashar, Tor Wager, Alan Gordan, Howard Schubiner, Mark Lumley, et al, was conducted at the Cognitive and Affective Neuroscience lab run by senior author and supervisor Tor Wager.
Yoni Ashar, PhD, again from his podcast interview with Curable:
““We saw large and long-lasting reductions in pain, so big that we created a category that hasn’t been used much in the research before: “pain-free or nearly pain-free,” if they reported 0 or 1 out of 10 pain after treatment.””
And look at these pictures of the brain healing!
What the fMRI brain imagining showed: “When people in the PRT group (Pain Reprocessing Therapy) were exposed to pain in the scanner post-treatment, brain regions associated with pain processing – including the anterior insula and anterior midcingulate —had quieted significantly.” by Lisa Marshall at SciTechDaily.
Neuroscientist Tor Wager told SciTech Daily, “This isn't suggesting that your pain is not real or that it's 'all in your head.' What it means is that if the causes are in the brain, the solutions may be there, too."
What Does Assessing a Patient for Neuroplastic Pain Look Like?
Dr. Howard Schubiner, a co-author of the PRT study, allowed us to film with him and his patients as he examines them, takes a detailed psycho-social history, reviews their MRIs and CT scans, and often updates incorrect information they’ve received from other medical professionals.
To get an idea of that process, here’s the trailer for the film:
How Can Someone Add PRT to Their Practice?
We keep a running list of upcoming trainings on our site, for PRT trainings but also for related therapies like EAET, ISTDP, and AEDP.
Alan Gordon, LCSW also has a comprehensive website on PRT, and you can find his upcoming trainings here.
PRT principles and exercises can be incorporated into the practices of therapists trained in CBT, ACT, MBSR, or other common cognitive and emotional therapies, and this been shown to dramatically increase success rates for the MBSR treatment, for example, for chronic pain in a study out of Harvard that compared MBSR with and without these principles (see our evidence-based medicine page for details).
Alan Gordon, LCSW has written a popular book about PRT, The Way Out.
What Does Neuroscience Research Say About Predictive Interoceptive Coding?
Lisa Feldman Barrett’s book, “How Emotions Are Made,” about predictive processing for body sensations, was written for a popular audience, and it is a fascinating, mind-opening place to start.
In her more technical neuroscience paper, co-authored with Simmons, “Interoceptive predictions in the brain,” in Nature Reviews Neuroscience, she outlines the findings from her research.
What predictive coding means on a practical level is that the all of the sensations we perceive are primarily predicted and created in the brain, with a lesser emphasis on external inputs that modify the predictions. This is insanely counterintuitive to everyday experience— what?!
Our everyday experience is mostly the result of the brain’s predictions, or “top-down” processing, with limited “bottom-up” processing that revises our predictions based on external input. This is a necessary process to conserve energy and make sense of thousands of bits of data coming through our five senses at all times.
In more scientific words: “Interoceptive perception is largely a construction of beliefs that are kept in check by the actual state of the body (rather than vice versa). What you experience is in large part a reflection of what your brain predicts is going on inside your body, based on past experience.”
How Does Predictive Coding Create Pain?
In her book Sleeping Beauties, neurologist Suzanne O'Sullivan, MD provides a helpful shorthand for how the brain uses predictive coding for vision:
Just as predictive visual processing can automatically transform a “7” into a “T,” — because of expectations of a “T” — predictive sensory processing can take expectations of pain and make pain.
Do you see an expanding black hole? It is a static image and the black circle is not moving, but if you see an expanding black hole, you are getting a window into your brain’s predictive coding process. This process is usually helpful, but with chronic pain it can create a fear-feedback loop that descends into ever-worsening perceptions that create disability. (h/t New York Times)
The latest findings in neuroscience help explain how people can be locked in a vicious cycle of ever-intensifying pain, even if there is little or no incoming sensory input of danger detection in the body (there may be no damage, or minor damage, but HUGE pain).
How does that happen? Neuroscientists have shown that believing is perceiving. This is also why in Pain Reprocessing Therapy, working with patients around changing their convictions about their bodies can dramatically reduce pain perceptions.
Another resource for understanding how predictive coding is affecting the neuroscience of chronic pain is the article, “Symptoms and the body: Taking the inferential leap.” This paper tackles the problem of Medically Unexplained Symptoms, which account for roughly one-third of doctor visits.
Rather than explaining pain in terms of psychology, beliefs, and emotions — which can be a useful way to discuss pain — the latest research explains chronic pain from a biological, neuroscience perspective. But the key takeaway is that these nervous system changes are reversible, and so is chronic pain. Here is how dramatically the brain changes before and after Pain Reprocessing Therapy:
In other words, the pain is not “all in the head,” but it is generated in the brain. It’s real and it is usually reversible.