Pain Reprocessing Therapy

Original Editor - Tara DiRocco

Top Contributors - Farah Al Dweik, Tara DiRocco, Vidya Acharya and Alexandra Stead

==Page Under Review== This article is currently under review and may not be up to date. Please come back soon to see the finished work! (18/09/2026)

Introduction

Chronic pain is a complex experience influenced by interacting biological, psychological and social factors. In some people, pain may persist beyond expected tissue healing or occur without clear evidence that ongoing tissue damage fully explains the symptoms. Altered nociceptive processing within the nervous system may contribute to persistent pain, including presentations described as nociplastic pain or primary chronic pain.

Pain Reprocessing Therapy (PRT) is a psychological approach developed for some forms of primary chronic pain. It uses cognitive, somatic and exposure-based techniques to address pain-related beliefs, fear and avoidance . PRT does not suggest that pain is imagined or purely psychological, but considers pain as a real experience influenced by multiple processes within the nervous system and the context in which pain occurs.

Definition

PRT is based on the understanding that threat appraisal and learned associations can contribute to the persistence of pain. When pain sensations are interpreted as threatening or as signs of injury, this may increase fear, hypervigilance and avoidance of movement or activity. Over time, associations may develop between particular sensations, movements or situations and perceived danger.

PRT aims to modify these associations through cognitive reappraisal, attention to bodily sensations and exposure to feared sensations or movements.

PRT shares some principles with Pain Neuroscience Education (PNE), cognitive behavioural approaches and exposure therapy, but the approaches are not interchangeable. PNE primarily supports individuals to reconceptualise pain through education about pain mechanisms. PRT incorporates education while placing additional emphasis on changing pain-related threat appraisals through cognitive, somatic and exposure-based experiences. Cognitive behavioural and acceptance-based approaches may focus more broadly on coping pain, improving function and engagement in meaningful activities, including when pain persists.

Evidence for Pain Reprocessing Therapy

Evidence for PRT is promising but remains limited. In a randomised clinical trial, 151 adults with chronic back pain were assigned to PRT, an open-label placebo intervention, or usual care. Following four weeks of treatment, 66% of participants randomised to PRT were pain-free or nearly pain-free, compared with 20% in the placebo group and 10% receiving usual care. Treatment effects on pain were maintained at one-year follow-up.

Longer-term findings from the same trial were reported at five-year follow-up. Among the 113 participants who provided follow-up data, 55% of the PRT group reported being pain-free or nearly pain-free, compared with 26% of the placebo group and 36% of the usual-care group. Improvements were also reported in pain interference and some pain-related beliefs.

Most of the current evidence comes from one clinical trial and follow-up studies of the same participants. The study included adults with chronic back pain from one area in the United States, with generally low to moderate levels of pain and disability. More research is needed to understand how well PRT works for other chronic pain conditions and in different populations and healthcare settings.

Clinical Assessment

PRT should be considered following a comprehensive clinical assessment rather than simply when structural findings are absent. Assessment should include the person's pain history, symptom behaviour, medical history and relevant clinical findings, including screening for red flags that may indicate serious underlying pathology. Biological, psychological and social factors that may contribute to the pain experience should also be explored.

Clinical Assessment Considerations for PRT

Assessment Area	What to Consider	Suggested Tools
Pain presentation	Onset, duration, location, variability, aggravating and easing factors, previous injuries, previous treatment and relevant medical findings.	Clinical history and physical examination.
Red flags	Signs or symptoms that may indicate serious underlying pathology or the need for further investigation or referral.	Appropriate condition-specific screening and clinical examination.
Yellow flags	Fear of movement, catastrophising, anxiety, low mood, avoidance behaviours and pain-related beliefs that may influence recovery.	Tampa Scale for Kinesiophobia-11 (TSK-11); Pain Catastrophizing Scale (PCS).
Function and participation	Impact of pain on daily activities, work, sleep, physical activity and participation.	Patient-Specific Functional Scale (PSFS).
Coping and behavioural responses	How the person responds to pain, including avoidance, activity modification, reassurance seeking and strategies already used to manage symptoms.	Coping Strategies Questionnaire–Revised (CSQ-R).

Assessment findings should guide the treatment plan rather than relying on a single finding to decide whether PRT is appropriate. It is also important to consider the person's understanding of their pain, their goals and expectations, and their willingness to engage with the approach. For more complex presentations, input from other healthcare professionals may be needed.

Components of Pain Reprocessing Therapy

PRT uses a combination of educational, cognitive, and exposure-based strategies. These are used to reduce pain-related threat and fear and to develop different responses to pain sensations and activities associated with pain.

PRT includes several components that can be adapted to the person's needs:

• Pain education and reappraisal: helping the person reconsider beliefs that pain always means damage. Example: a person with persistent low back pain believes bending will injure their spine. The therapist reviews the assessment findings and helps them explore a less threatening interpretation of pain during bending.
• Somatic tracking: observing a painful sensation with curiosity while reducing fear and threat. Example: while sitting comfortably, the person notices their back pain and describes its location, intensity and whether it changes, while observing how the sensation changes without immediately responding to it as a threat.
• Exposure to feared sensations and activities: gradually practising movements or activities that the person has avoided because of pain or fear of injury. Example: a person who avoids bending gradually practices reaching towards the floor while noticing the sensations and reducing protective responses.
• Addressing emotional contributors: identifying situations or emotions that may increase pain or perceived threat. Example: the person notices that their pain becomes more intense during stressful situations and explores this pattern without assuming that increased pain means increased tissue damage.
• Positive sensations and experiences: deliberately noticing sensations associated with comfort, ease or safety. Example: during a comfortable movement, the person focuses on areas of the body that feel relaxed or move without pain, rather than directing all attention towards the painful area.

These components are adapted to the individual rather than applied as a fixed sequence. Somatic tracking is therefore one component of PRT and may be used alongside cognitive reappraisal, exposure and other strategies depending on needs.

Physiotherapy Relevance and Clinical Application

Physiotherapists can bring a functional perspective to the management of persistent pain by supporting improvements in movement, physical capacity and participation. PRT principles may be incorporated into a broader rehabilitation programme where appropriate, alongside exercise and progression towards individual functional goals.

Physiotherapy management should be guided by the findings of the clinical assessment and the person’s functional goals. Progress can be monitored through changes in function, activity tolerance and participation, rather than pain intensity alone.

Practical Example

A person with persistent knee pain avoids stairs because they expect pain to mean further damage. Assessment identifies reduced lower-limb strength, limited stair tolerance and fear of loading the knee. Their goal is to use the stairs at work again.

The physiotherapist develops a rehabilitation programme that combines strengthening and functional stair training with relevant PRT principles, including:

• Pain education and reappraisal: The physiotherapist discusses the person's concerns about loading the knee and uses the assessment findings to explore the belief that pain during stair climbing necessarily means further damage.
• Somatic tracking: During stair practice, the person notices the location, intensity and changes in the knee sensation without immediately stopping the activity or responding with protective movement.
• Exposure to feared activities: Stair climbing begins at a manageable level and gradually progresses from a few steps to a full flight as strength, tolerance and confidence improve.
• Addressing emotional contributors: The physiotherapist explores whether fear, stress or anxiety influence symptoms or willingness to use the stairs. Concerns outside the physiotherapist's scope are discussed with the wider healthcare team or referred appropriately.
• Positive sensations and experiences: Attention is also directed towards comfortable aspects of movement, such as feeling stronger, moving more easily or completing steps with less guarding, helping the person recognise experiences of safety during movement.

Throughout rehabilitation, the physiotherapist assesses and progresses strength, movement, loading and functional activity while monitoring the person's response. Progress can be measured through strength, stair tolerance and achievement of functional goals, alongside changes in pain and pain-related fear.

Considerations for using PRT

PRT may be appropriate for some people with chronic pain, but it should not be assumed to be suitable for everyone. Pain mechanisms can overlap, and identifying the relative contribution of nociceptive, neuropathic and nociplastic mechanisms is not always straightforward.

How pain is explained is also important. Describing pain as being “in the brain”, a “false alarm” or having “no physical cause” may oversimplify the person's experience. Communication should validate that the pain is real while explaining that biological, psychological and social factors can all influence pain and its impact on daily life.

A person-centred approach should allow the individual to share their understanding of their pain, concerns, and goals. These should be considered when deciding whether PRT principles are relevant and how they may fit within the wider management plan.

Summary

Pain Reprocessing Therapy is a relatively new approach used for some people with primary chronic pain. It works mainly by addressing pain-related fear, threat and learned responses to pain. Research so far has shown promising results, particularly for chronic back pain, but more studies are still needed in other pain conditions and populations.

For physiotherapists, some PRT principles can be used alongside pain education, exercise and functional rehabilitation when appropriate. A good clinical assessment, clear communication and the person's individual goals remain important when deciding how these principles fit within rehabilitation.