I don't have chronic back pain anymore: Patient Experiences in Pain Reprocessing Therapy for Chronic Back Pain

Chronic back pain affects millions of people worldwide, and while traditional psychological treatments like cognitive behavioral therapy show modest benefits, emerging neuroscience suggests that some patients with primary (nociplastic) pain—driven primarily by central nervous system processes rather than tissue damage—may achieve substantial pain reduction or elimination through targeted interventions. Pain Reprocessing Therapy (PRT) is a novel psychological treatment based on the principle that patients can shift their understanding of pain from a signal of bodily danger to a brain-generated experience, potentially reversing chronic pain. A recent randomized controlled trial demonstrated that two-thirds of PRT participants reported elimination or near-elimination of chronic back pain, but the mechanisms underlying this success from patients' perspectives remained unexplored.

This qualitative study analyzed semi-structured posttreatment interviews with 32 adults (73% of trial completers) who received PRT for chronic back pain. Using multiphase thematic analysis with both deductive (theory-driven) and inductive (data-driven) coding approaches, two independent coders identified major themes reflecting participants' understanding of how treatment led to pain relief. Participants were asked about their pain history, previous treatments, initial expectations, and specific aspects of PRT that they found helpful. Interview quality and depth varied, with an average duration of 14.2 minutes, and some interviews were conducted weeks or months after treatment completion.

The analysis identified three major themes explaining participants' pain relief: (1) Reappraisal to Reduce Fear of Pain, including learning to view pain as a helpful signal rather than a threat, overcoming pain-related fear and avoidance through exposure, and reconceptualizing pain as a non-dangerous "sensation" rather than a pathological "pain"; (2) The Link Between Pain, Emotions, and Stress, involving gaining insight into connections between emotional experiences and physical pain, and resolving difficult emotions including shame, anxiety, and unprocessed trauma; and (3) Social Connections, encompassing the therapeutic alliance with skilled, believing therapists and peer models of recovery from prior patients. Notably, 75% of interviewed participants were pain-free or nearly pain-free at posttreatment, with average pain reduction of 71 points. Participants who were initially skeptical were more likely to shift their views after therapist-facilitated connections with prior successful patients.

These findings validate PRT's hypothesized core mechanisms of pain reattribution and fear reduction while revealing that emotional processing and therapeutic relationships play more central roles than originally emphasized in the PRT model. The study underscores that qualitative research is essential for understanding how novel pain therapies work from patients' lived experiences. Clinically, these results suggest that effective pain treatment should integrate pain neuroscience education with genuine attention to emotional processing, skilled therapeutic alliance, and peer support models. Training PRT therapists and similar interventions should emphasize not only specific techniques like somatic tracking but also interpersonal competence, authentic belief in the treatment model, and the capacity to help patients process underlying emotional conflicts and trauma.