For decades, chronic pain has been treated as a problem of damaged tissue — a bad disc, a worn joint, a pinched nerve. But a growing body of research is reframing the picture. Much of long-lasting pain, scientists now argue, lives less in the body and more in the brain’s prediction circuits. And those circuits, it turns out, can be retrained.
That is the premise behind Pain Reprocessing Therapy (PRT), a psychological treatment that has produced some of the most striking chronic-pain results published in recent years. In a randomized trial published in JAMA Psychiatry, two-thirds of participants with chronic back pain became pain-free or nearly pain-free after just four weeks of treatment — and the benefits held a year later.
Chronic pain is a public health crisis hiding in plain sight
According to the U.S. Centers for Disease Control and Prevention, about 51.6 million American adults — roughly 20.9% — live with chronic pain. An estimated 17.1 million experience “high-impact” chronic pain that substantially limits daily life, work, and relationships.
Standard care has leaned heavily on imaging, injections, surgery, and medications. Yet outcomes for chronic back pain in particular have stayed stubbornly poor, and the opioid epidemic underscored the cost of relying on pharmacology alone. That gap is where a new generation of brain-based treatments has stepped in.
What “neuroplastic pain” actually means
Pain is often described as a signal traveling from an injured area to the brain. Modern neuroscience tells a more nuanced story: the brain does not passively receive pain signals; it generates the experience of pain based on incoming sensory data, memories, beliefs, and threat assessments.
When pain persists past normal healing time — typically three to six months — the brain can become sensitized. Neural pathways involved in detecting and amplifying pain become more efficient, while pathways that regulate pain become less so. The result is what researchers call nociplastic or neuroplastic pain: real, often disabling pain that no longer reflects ongoing tissue damage.
The International Association for the Study of Pain formally recognized this category in 2017. Conditions where it commonly plays a role include chronic low back pain, fibromyalgia, irritable bowel syndrome, tension headaches, and many cases of long COVID-related pain.
Inside the JAMA Psychiatry trial
The pivotal PRT trial was led by Yoni K. Ashar, then at Weill Cornell Medicine, and Tor D. Wager of Dartmouth College, with collaborators at the University of Colorado Boulder. The team enrolled 151 adults who had lived with chronic back pain for an average of 10 years. Participants were randomized to one of three groups: PRT, open-label placebo injections, or usual care.
The PRT arm involved one telehealth session with a physician and eight one-hour psychological treatment sessions delivered over four weeks. The therapy aimed to help participants reinterpret their pain signals as safe — not dangerous — and to break the fear-pain feedback loop.
What the numbers showed
- 66% of PRT participants reported pain-free or near pain-free status (a score of 0 or 1 on a 10-point scale) at the end of treatment.
- That compared with 20% in the open-label placebo group and just 10% in usual care.
- At a one-year follow-up, the gains held: PRT participants maintained substantially lower pain than the comparison groups, with large effect sizes across pain interference and disability measures.
- Functional MRI scans showed reduced activity in pain-related brain regions — including the anterior insula and anterior midcingulate cortex — suggesting a measurable shift in how the brain processed pain.
Researchers were careful to note the trial focused on people whose imaging did not point to a clear structural cause, and who passed screening for “primary” chronic back pain. PRT is not a treatment for acute injury, cancer pain, or pain driven by ongoing tissue damage.
How PRT actually works
PRT blends elements from cognitive behavioral therapy, mindfulness, exposure therapy, and pain neuroscience education. A trained clinician walks the patient through several core techniques:
Pain reprocessing and “somatic tracking”
Patients are guided to observe their pain with curiosity rather than fear, paying attention to sensations while reminding themselves that the signal is not dangerous. The goal is to reduce the brain’s threat response that perpetuates chronic pain.
Cognitive reappraisal
Patients explore evidence for their pain being “neuroplastic” rather than structural — for example, pain that moves around, flares with stress, or appeared during a stressful life period. Reframing the pain as a learned brain pathway, rather than tissue damage, reduces fear and avoidance behaviors.
Positive affect induction
Sessions cultivate safety, pleasure, and emotional connection — states associated with reduced pain perception. This is consistent with research showing that emotional regulation and the brain’s reward system directly modulate pain pathways.
What this does and does not mean
It is important to be precise. PRT is not “the pain is all in your head” repackaged. Pain that originates in altered brain processing is fully real — it activates the same neural circuits and produces the same suffering as pain from tissue injury. What the research suggests is that, in carefully selected patients, retraining brain pathways can change the pain itself.
Limitations are also worth noting. The trial enrolled people whose pain was unlikely to be driven by structural disease. It used skilled, specialized therapists. Real-world replication studies are underway, but PRT is not yet widely available and is not appropriate for every kind of pain.
Researchers also stress that PRT is one of several emerging brain-based approaches. Mindfulness-based stress reduction, cognitive behavioral therapy, and acceptance and commitment therapy all have evidence for chronic pain — though typically with smaller effect sizes than the PRT trial reported.
The bigger picture: moving beyond opioids
The 2016 to 2024 period saw a meaningful decline in opioid prescribing for chronic pain, but the gap left behind has not been fully filled. The CDC’s updated guidelines emphasize non-pharmacologic and non-opioid approaches as first-line treatment for chronic non-cancer pain — including exercise, physical therapy, psychological therapy, and mind-body interventions.
What makes PRT and similar approaches striking is not just that they reduce pain, but that they treat pain as a process the brain has learned — and therefore one it can unlearn. That reframing has implications well beyond back pain, including for the millions of people whose chronic symptoms have defied conventional explanations.
If you live with chronic pain
Research suggests several practical steps for anyone considering brain-based approaches. First, get a thorough medical evaluation; serious structural and inflammatory causes need to be ruled out. Second, ask your provider about non-pharmacologic options that have evidence behind them — including PRT-informed therapists, pain neuroscience education programs, and mindfulness-based pain management. Third, recognize that movement, sleep, and stress regulation remain foundational, even when the primary issue is brain-based sensitization.
For decades, pain medicine treated the body and ignored the brain that creates the experience of pain. The science increasingly suggests that the brain itself may be one of the most promising places to look — and that for many people, lasting relief is more possible than the old model implied.
Disclosure: This content is for informational purposes only and is not medical advice. Always consult a qualified healthcare provider before making changes to your health regimen.