Pain Reprocessing Therapy: Retraining the Brain to Ease Chronic Pain

By Dr. Xiao Yuan MD CCFP, Medical Director, White Oak Pain Clinic

Most people think pain always means something is damaged in the body. And often, that's true. If you sprain your ankle or pull a muscle, the pain is a warning sign that tissue is hurt. This is called structural pain, because it comes from a structure in the body.

But there is another kind of pain that works differently. Sometimes pain keeps going long after an injury has healed. Sometimes it shows up when there is no injury at all. In these cases, the problem is not damaged tissue. The problem is that the brain and nervous system have learned to keep sending pain signals — even when there is nothing left to protect. Doctors call this nociplastic pain (also called neuroplastic pain). A simpler way to think of it is a "false alarm."

The encouraging news is that this kind of pain can often be turned back down. One of the most promising ways to do that is a treatment called Pain Reprocessing Therapy, or PRT.

What is nociplastic pain?

Your brain is always deciding whether your body is safe or in danger. Pain is one of the tools it uses to keep you safe. It works a lot like a smoke alarm. A smoke alarm is helpful when there is a real fire. But sometimes an alarm becomes too sensitive and goes off when you are only making toast.

Chronic pain can work the same way. After an injury, a stressful time, or a long stretch of pain, the nervous system can become extra sensitive. It starts to read normal signals from the body as danger. The result is real, physical pain — but it is being driven by the nervous system, not by damaged tissue. This pain is 100% real. It is simply coming from a different source than most people expect.

This is NOT "all in your head"

This is one of the most important things to understand: nociplastic pain is not imaginary, and it does not mean you are weak, crazy, or making it up. The pain is completely real.

Here is the science in plain terms. Your nerves, spinal cord, and brain make up your nervous system, and that system carries and sorts every pain signal you feel. In nociplastic pain, this system goes through a change called central sensitization. In simple words, the nervous system turns up the "volume" on pain. The pain nerves fire more easily, so signals that should feel normal — or only mildly uncomfortable — get amplified into real pain.

They are physical changes that scientists can actually measure. Brain scans of people with this kind of pain show real, increased activity in the areas that process pain. In the Boulder study described below, researchers could even watch those brain patterns change after treatment. In other words, the pain lives in a real, physical system — the nervous system — even when scans of the joint, muscle, or back look normal.

So when a test comes back "normal," it does not mean nothing is wrong. It often means the problem is in how the nervous system is processing pain, rather than in the tissue itself.

Note: there are certain types of structural injuries that are currently not detectable by imaging. So a "normal" MRI doesn't mean there isn't structural damage. At White Oak Pain Clinic, we are experts in finding sources of pain that are not visible on MRIs by using a combination of dynamic ultrasound scans and diagnostic injections, where the doctor injects a local anesthetic (numbing medication) into specific structures and then test your pain levels to find whether a specific anatomical structure is causing your pain.

Common examples of nociplastic pain

Nociplastic pain shows up in a number of well-known conditions, including:

• Fibromyalgia — widespread pain, tiredness, and tenderness throughout the body

• Central sensitization syndrome — an umbrella term for conditions driven by a "turned-up" nervous system

• Irritable bowel syndrome (IBS) — ongoing belly pain and gut symptoms

• Chronic tension headaches and some migraines

• Temporomandibular disorder (TMD) — ongoing jaw pain

• Interstitial cystitis — ongoing bladder pain

• Chronic fatigue syndrome (ME/CFS)

• Long-lasting back or neck pain where scans and tests find no clear physical cause

These conditions often overlap, and one person can have more than one at the same time.

What is Pain Reprocessing Therapy?

Pain Reprocessing Therapy helps the brain "unlearn" this kind of pain. It was developed by a therapist named Alan Gordon, and it builds on decades of research into how the brain and body work together.

The main idea is simple: if the brain can learn to send pain signals, it can also learn to stop. PRT teaches people to see their pain as a false alarm rather than a sign of damage. As the brain begins to feel safe again, the pain signals can fade.

PRT usually includes a few key parts:

• Learning about how the brain creates pain, so the pain feels less frightening

• Paying attention to the pain slowly and safely, in a calm and curious way, instead of fearing it

• Lowering the fear and stress that keep the alarm switched on

• Building more positive feelings and a stronger sense of safety in the body

• It does not include taking medication or injections

• It can be done hand-in-hand with a trained professional or be completely self-guided by you
  

What does the research say?

PRT has been tested in a careful clinical trial. In 2021, researchers at the University of Colorado Boulder published a study in the medical journal JAMA Psychiatry. They worked with 151 people who had chronic back pain that had no clear physical cause.

The results were striking. About two-thirds of the people who received PRT became pain-free or nearly pain-free after just four weeks of treatment. Most of them still felt better a full year later. Brain scans even showed changes in the parts of the brain that process pain. This was some of the strongest evidence yet that the right kind of therapy can bring real, lasting relief for this type of chronic pain.

Two patients who found relief

Here are two examples from my own practice. Details have been changed to protect privacy, and everyone responds differently — but these stories show what PRT can do.

One patient developed fibromyalgia after a wrestling injury in high school. He had lived with this pain for at least seven years. He watched the Pain Brain documentary and worked through the book The Way Out. Within just two weeks, his widespread pain dropped by about 80%. He was able to take on a heavier course load at school and even start working while he studied.

Another patient came to me after years of low back pain. I treated several structural injuries in her back with PRP injections, and her pain became minimal. But after a few months, the pain slowly returned and grew severe again. Even gentle physiotherapy exercises would flare it up. When I examined her and used diagnostic injections, they no longer eased her pain. That told me the pain was no longer coming from a damaged structure in her back — it had become a nervous-system pain. I recommended PRT, and she chose to work one-on-one with a counsellor. About six weeks later, her low back pain had almost completely gone away.

Does PRT work for everyone?

No. PRT does not work for everyone, and it is not the right fit for every kind of pain. It is meant for nociplastic pain — pain coming from the nervous system — not for pain caused by active tissue damage or disease. That is why it is so important to have your pain properly assessed first, so you understand which kind of pain you are dealing with.

That said, the results can be remarkable. Among my own patients who have benefited from PRT, I have often seen at least a 50–80% reduction in their pain. Many notice improvement quite quickly, often within two to six weeks of starting.

How to try Pain Reprocessing Therapy

PRT is not offered at White Oak Pain Clinic. But because I have seen so many patients improve with it I want to make it easy for you to learn more and get started on your own.

Here are the main ways to access PRT.

1. Watch a documentary. A good first step is to watch one of these films to understand how PRT works:

• Pain Brain — available to rent/purchase for a small fee (around $5) on Vimeo

  
  

2. Read a book. Pair the film with one of these books. You can buy a copy, or check whether your local library has one:

• The Way Out by Alan Gordon

• The Pain Reprocessing Therapy Workbook

  
  

3. Curable app. Curable is a self-guided app you can use on your phone or computer. It walks you through PRT step by step. A subscription fee applies.

4. Work with a trained practitioner. If you would like personal, one-on-one support, you can work with a counsellor trained in PRT. You can find a list of practitioners here: https://www.painreprocessingtherapy.com/directory-of-practitioners-new/

5. Watch free videos. There are also many helpful videos about PRT on YouTube if you would like to explore at no cost.

A note on cost and coverage

If you see a trained practitioner and you have extended health insurance, ICBC, or WorkSafeBC (WSBC) coverage for counselling, your sessions may be covered. It is worth checking your plan before you start.

The bottom line

Chronic pain is real, even when it is not caused by damaged tissue. When pain is coming from the nervous system, Pain Reprocessing Therapy offers a safe, drug-free way to help the brain turn that pain back down. It does not help everyone, but for the right person it can bring fast and lasting relief. If you think your pain might be a "false alarm," it may be well worth a try.

Reference

Ashar YK, Gordon A, Schubiner H, et al. Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial. JAMA Psychiatry. 2022;79(1):13–23. doi:10.1001/jamapsychiatry.2021.2669

This article is for general education only and is not medical advice. Please speak with your doctor about your own pain and which treatments are right for you.