Pain Reprocessing Therapy Part 3 - Separating the hope and hype

In this solo episode, I explore Pain Reprocessing Therapy (PRT), a novel approach to managing chronic pain that focuses on changing the brain's interpretation of pain signals. I compare PRT with existing therapies like Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT), discussing the neuroscience behind pain and the effectiveness of PRT. The episode emphasizes the importance of understanding pain as a complex emergent interplay of neurological and psychological factors, advocating for an integrated approach to pain management that includes PRT alongside traditional therapies.

Takeaways

1. Chronic pain may not indicate physical damage but a nervous system issue.
2. PRT offers a new perspective on pain management.
3. Changing the brain's interpretation of pain can lead to recovery.
4. PRT is gaining attention due to its potential effectiveness.
5. The nervous system plays a crucial role in chronic pain.
6. Evidence supports PRT's effectiveness in specific pain populations.
7. PRT differs fundamentally from CBT and ACT in approach.
8. Predictive processing theory explains how the brain perceives pain.
9. PRT can lead to significant reductions in pain intensity.
10. Integrating various therapies can enhance pain management outcomes.

Keywords

Pain Reprocessing Therapy, Chronic Pain, Neuroscience, CBT, ACT, Predictive Processing, Pain Management, Pain Neuroscience, Emotional Awareness, Therapy Techniques

Disclaimer:
This podcast is for education and general information only and does not replace personalised medical advice. If you are experiencing ongoing pain or distress, please consult your healthcare professional.

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The Pain Speak podcast is presented by Prof Deepak Ravindran, a NHS Consultant specialising in Pain and Lifestyle Medicine. Dr Ravindran is also the author of the book, 'The Pain Free Mindset'

Get in touch:
Twitter: @deepakravindra5
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For Clinical Queries and consultations, please go to Berkshire Pain Clinic



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For Season 1 and 3:
Mixed and edited by Rob Cao at...

Transcript

SPEAKER_00: 0:02

This is PainSpeak with Dr. Deepak Ravindran. Hello and welcome to PainSpeak. I'm Deepak Ravindran, consultant in pain and lifestyle medicine, honorary professor at the Teesside University, Director at the Bakshire Pain Clinic, and author of the Pain Free Mindset. In this podcast, I bring you the science, the stories and the strategies that are transforming how we think about and treat persistent pain. You'll hear from leading clinicians, researchers, and most importantly, people living with pain as we explore what truly helps. From neuroscience and nutrition to trauma recovery, sleep, movement, and mindset. Together, we'll uncover practical insights, the most advanced neuroscience understanding, and fresh hope for a life beyond pain. I'm glad you're here, so let's begin today's conversation. So, what if chronic pain isn't a sign of damage, but a nervous system stuck on eye hullet? And what if changing how the brain interprets pain, we could actually make it disappear. Sometimes completely become pain free. So that's the promise of pain reprocessing therapy or PRT. And it's just hit mainstream TV. Just over a week ago, we had a great episode with Dr. Rangan Chatterjee talking about living life drug-free. And in his one-hour documentary on ITV, I think screened on January 8th, 2026, he had three patients that he talked about, one with diabetes, one with depression, and one with chronic pain. And the patient he talked to with regards to chronic pain mentioned this technique called pain reprocessing therapy. And of course, there's another podcast that I've done with Fiona, which you can have a listen to in another episode of mine. But I just thought I'd take this chance to really dive deep into this particular technique. Because it can be powerful, it has its share of being emotional. And for many people living with pain, that documentary showing that somebody could become pain-free and have a remarkable recovery, it sparks a big question. Why hasn't anyone told me before? Why hasn't this been talked about more often? Well, there are a number of reasons for that, and let's go into it in this episode. So, in this episode of Pain Speak, this is one of the solo episodes that I'm doing, and this is more about understanding this technique, and probably I'm going to give you my opinion of where we are with regards to PRT in the United Kingdom, how it compares to some of the other existing techniques that are available in the NHS, for example, like CBT or ACT, and actually with the newer framework of what's called predictive processing, where we think of the brain not as a passive recipient of information and then acting on it, but as a sort of active predictor of how to protect you, I'm going to look at PRT from that lens. And realistically, I do think there's a great promise in PRT, but again, it's horses for courses. So if you live with chronic pain and you watch the documentary and thinking, well, is PRT my answer? I think this episode is definitely made for that person, if that is you. And if you're a clinician wondering, does PRT something that I get need to get trained in, or do I need to have PRT replacing CBT or ACT? Well, actually, this is something I've spoken to a PRT practitioner as well in another episode that I've done for Pain Speak now. It's sort of a three episode that's been released. So have a listen with that. But in this episode, I'll just go into a little bit of comparison between these three techniques. So stay with me on this. And so today I want to slow things down. I want to look at the science and compare PRT with CBT and ACT as we understand in early 2026, and hopefully separate a little bit of the hope and the hype. I want to talk honestly about PRT, and now I'm trained in it myself, and I have spoken to other practitioners who use PRT alongside other techniques for my chronic pain patients, and I work with a network of PRT practitioners. So I have a feeling that it's worth talking about what it is, how it compares with these techniques from my perspective. You can listen to Caroline's podcast as well about the same, and actually see who it might make a big difference, who it might not help, and who it might be absolutely right for. So let's set the stage. Why is PRT getting so much attention? Chronic pain affects millions of people, and many have tried everything. Certainly, people coming into my pain clinic, they've tried medications, they've done their share of injections, they've gone for surgery, they've had their infusions, they've had lots of osteopathy, chiropractic, physiotherapy, other complementary therapies, but have not got the resolution they need. So when a therapy then comes along showing people becoming pain-free, people talking that they have had remarkable recovery, it's not easy and it's not difficult to understand why that understandably grabs attention. Pain reprocessing therapy, PRT for short, isn't a sort of new psychology or something brand new, but it's a new way of framing and reframing pain. It sits very, very firmly within the modern pain neuroscience. Indeed, it is so elegantly explained with some of the latest neuroscience theories, and it really focuses on this newer type of pain where the nervous and immune system is sensitized, called nociplastic pain or chronic primary pain or neuroplastic pain. Where the pain is often driven by this amplification within the nervous system than necessarily by any ongoing tissue damage in another part of the body. This is key. PRT is not saying that pain is imaginary or that it's in your head or you're making it up. It's saying very much and accepting very much that pain is real. But sometimes the danger signal is being generated by a sensitized nervous and possibly immune system. So, in that context, what is pain reprocessing therapy? Now, at its core, when I did the training and I've done my share of training in ACT and CBT, at least I've done the theory bit there, and I've spoken to a lot of colleagues who practice in each of these three ways and sometimes blend these as well. PRT helps people reinterpret the pain as a safety rather than threat or danger. That's fundamental. Therefore, it reduces fear and hypervigilance. It allows then patients to gently re-engage with the sensations and the movement, and thereabout bring about a calming of the nervous and immune system through a variety of learning, exposure, and emotional awareness. Now I use immune system often in between. I think the PRT is being studied strictly within the frame of a nervous system, but in my mind, a lot of chronic pain, there is a lot of immune talk happening at the nervous system level, so it wouldn't be surprising. And I think clinically there would probably be some low-grade changes within the nervous and immune system, within the spinal cord and the brain. Now, many people have found this false alarm analogy quite helpful. Certainly, it's one of the examples I use in my clinic, like a smoke alarm that keeps going off long after the fire's gone off. And the goal of PRT, therefore, isn't coping with pain. It's actually reframing the entire meaning of pain so that the brain can actually stop producing it. That's key. And the evidence that's really backing this up is very different. And I think we need to talk about evidence because stories are stories, but a lot of times science and data is important for commissioning and for it to be made available widely and to be scaled up. There was this landmark fantastic control trial that was done as part of the Boulder Back Study published in 2021 with some fantastic authors involved in it, like Howard Schubiner, Alan Gordon. So do check that out there if you want to. But it showed that back pain in that study, two-thirds of the people receiving PRT became pain-free or nearly pain-free. And this was far, far more than placebo or usual care. Of course, this study is waiting to be replicated at that scale, and that's been one of the pushbacks against broad acceptance of this technique. Quickly, is that we need more replicability of a trial like this. And that those trials are underway, but right now they haven't been peer-reviewed or published as yet. Brain imaging studies also showed changes in how the pain was processed. It was able to show these different nerve circuits lighting up on the fancy functional MRI imaging that was done. And that means that there were reduced threat responses, better brain-body connectivity in people who had the PRT and became pain-free. And that's exciting. And this matters. This big but in the sentence matters because the evidence is right now strongest for that back pain population. It was carefully selected population as well. So with both these caveats in place, it's useful in that population. But whether we extrapolate it to everything else, well, there's lots of anecdotes and stories that I have within my patient population, but that's not where science is right now. So how does PRT then compare with existing NHS-approved treatments like CBT or ACT? ACT stands for acceptance and commitment therapy. Let's put this in context. CBT, cognitive behavioral therapy, as all of us understand, has the largest evidence base. There's been lots of studies over two, three decades of it being in practice. And overall, the Cochrane analysis that came out a few years ago essentially showed that it focuses on changing the unhelpful thoughts and behaviors around pain. So like catastrophizing or boom and bust cycles, and it's great at reducing the distress, but not necessarily the pain. This is crucial. Remember this for later. So CBT is excellent for improving function, reducing distress, increasing the confidence. But on average, CBT leads to very small reductions in the actual pain intensity. So while you have confidence and distress, your pain intensity or what you score as pain doesn't necessarily go down by a great deal. And that's okay. That's okay because the primary goal is to help people lead more valued lives and to live better with pain. ACT is called the second wave of behavioral therapies, acceptance and commitment therapies. A lot more of the pain clinics in the UK have psychologists and physiotherapy colleagues who are trained up in ACT. I myself have done a course on ACT there, so I know some of the principles. And ACT comes at it from a slightly different perspective. Instead of trying to change the pain thoughts, while CBT tries to restructure the pain thoughts, ACT introduces flexibility. ACT helps people make space for the pain. It reduces the struggle, it improves acceptance, it tries to reconnect with what are the important values, what matters to the patient. And therefore, it builds that level of what's called psychological flexibility. And that's very crucial. Act is very powerful for people who feel stuck, who feel exhausted, or who feel that they're being defined by their pain. Again, pain may reduce, but the number of studies scientifically for ACT are a lot less than CBT, and on the basis of evidence, it still hasn't got even the level of evidence that CBT has. So the wins are quality and meaning and values in life, but not necessarily pain reduction. And this is where PRT is important. PRT starts from a completely different vantage point. The key difference is PRT directly influences the meaning of pain and therefore the pain intensity itself. It changes how threatening or danger-like the pain is meaning to the brain. And once you change that meaning, you can have remarkable reductions in pain intensity. So let's think of it like this. In CBT, you're changing how you think and behave around pain. With ACT, you're saying let's change our relationship with pain. But in PRT, you're saying let's change whether the brain really needs to create pain at all. And that's why with PRT you have such remarkable responses of true reduction in the intensity of pain, whereas we haven't picked it up with CBT or ACT per se. They do overlap. There's obviously some overlap when you practice it in clinical space, but they're not really interchangeable. And that's really one of the challenges of how we think about introducing this into the NHS, is that for a lot of services that use CBT or ACT as their psychological technique to support people with pain, you have to start with the vantage point that this is my pain. You have your pain. We are not going to do anything about the pain, but we are going to teach you how to structure your thoughts or how to live a more valued and meaningful life. That's the framework and the foundation on which CBT and ACT are built. Whereas PRT, you have to enter it as a different thing. It's about saying, well, is the pain required at all if I can tell you that what you have is not threatening? Then the brain doesn't need to have that. That's a completely different starting point. And often I think sometimes practitioners themselves feel conflicted because, in one kind of technique, you're saying you just got to accept the pain. In PRT, you're actually saying, well, you don't need to accept the pain, you can actually change it and minimize it completely. And that really means that we still have to do a better job of case selection. PRT may not be right for everyone or may not be at the right time for everyone. And to me, in my mind, PRT is a very powerful treatment, but the right person and the right type of condition is someone who's got a primary nociplastic or neuroplastic pain. That's their main thing. They've got a high level of fear and threat-related beliefs. They've got no or little ongoing tissue changes in their scans or images. And most importantly, are they open to accepting that the brain and the nervous system can do this, can adopt this bit. So their openness to a brain burst model is very crucial in my view. So at this time, I feel that CBT and ACT are essential. They are evidence-based, they are good foundations for pain care for a lot of pain conditions that happen due to a variety of reasons after surgery, after chemotherapy, and all that, you may still need that. But where you have this element of chronic primary or neuroplastic or nociplastic pain, then I think PRT has a role to play. So don't think about replacing one for the other. It's about saying, can we match the right kind of tool to the right person to the right nervous system at the right time? And here I'm going to take a segue to actually talk about something very interesting, to me at least, and I hope to you as well, is this concept of predictive processing. We've talked a lot, and these days, if you've heard me talk in any of my sort of clinical talks as well, and even in the literature in pain science, we talk about predictive processing. And effectively, what we are saying is that at the heart of this predictive processing theory, we are saying that the brain is not a passive receiver of information, it's an active prediction and protection machine. And effectively, the brain's primary job is not to guess truth or come at truth. Its primary role is to act like a CEO of the body. Its primary role is about efficiency of energy utilization and to ensure survival. Remember this energy efficiency and survival. So every movement, every sensation that the brain receives or has received, it's asking what do I expect to happen? Has this happened before? Do I need to do anything to protect this organism? And how costly would be that change or what I need to do to protect the organism? It then uses a lot of prior beliefs, present information, past experience, the context somebody is in, and various bodily signals to generate a variety of predictions and it stores these predictions but also then brings it forward and it only updates these predictions when the error signal, you know, what comes each time in the future is strong enough. And this is a very great way to explain pain in a neuroscience model, especially chronic pain. Not every kind of pain lends itself to being explained clearly through this predictive processing model, but chronic pain I think fits nicely into this way of explaining. How? Well, let me explain that. Pain, you have to think of it as a prediction aiding survival. That's the point here. It's not just a signal. In predictive processing terms, pain is not simply a read-off a body signal, it's the brain's best guess, it's the opinion about threat to the body. So when there is clear injury, like an acute injury, surgery, fracture, tissue signals are going to dominate. Yeah, there are going to be a lot of signals coming from that injured part. That means the prediction error between whatever the brain has predicted in the past and the signal that comes now is going to be so different. The error is so big that the brain will change and the pain is adaptive but it is short-lived. So that change happens. But in chronic pain, in primary pain, especially nociplastic pain, something different happens. The brain has learned at one time how to protect, whether that's through an injury, through a stress, through an immune signal, through fear, through repeated occurrences of adversity, that this body is unsafe. And that means over time, this prior prediction of not being safe enough and danger becomes strong and becomes dominant. And that means any incoming sensory signals from any part of the body, whether it's even ambiguous or mild or very little or lots, is often interpreted through the lens of that prior signal and predictive model that's already there. So the system just becomes very comfortable and overconfident in that first prediction when it made it. And so the pain persists because not that because the body is damaged, but because the brain's model feels that this is safe enough. And when you look at it from the perspective of energy optimization, why the brain won't let go of pain, it means that from an energy perspective, if you think about it, once this prediction has been done, once the categorization has been done, then the brain, if it has to update itself, that is a lot more energy usage. So it would rather say, well, you know what, I'd rather prefer predictable safety in whatever way rather than accuracy. It would prefer an old model rather than trying to make new expensive updates. So in some ways, if you like your Windows 11 and it's working well, or if you like your phone, you're not going to keep updating every six months or every 12 months. You probably are going to let it be for as long as it can be because it helps. It works, it does the job, so why change it? So updating a deeply held prediction that your back is dangerous actually costs energy. So holding on to it, even if it's wrong, is sometimes energy efficient. And so the system keeps generating that pain because that reduces uncertainty, it discourages any movement, and there is therefore a sense of control. In some ways, chronic pain is an energy efficient mechanism, but it really is a maladaptive prediction that's gone wrong. And this is where PRT, I told you, fits very neatly in this predictive processing model. It's quite elegant in that sense that PRT doesn't argue with pain, it does not try to suppress any sensation, it does not present any positive think or you know any kind of easy thinking process. But essentially, PRT works by changing the brain's predictions. It allows for that energy change to happen in a better manner. It does three things. When you look at it from the predictive processing purposes, PRT does three things. One, it changes what's called precision reweighting. It helps reduce the precision and the brain assigns to that danger prediction. It changes that. So the brain learns that this pain is safe, that the sensation is not damaged, that I can experience pain without harm. That means that prior, that first belief that's been held dominant starts to lose its dominance because of starting to do this technique. So the brain becomes willing, malleable to listen again to incoming sensory signals and be willing to change. A little bit more energy, expensive, so that's why it takes a bit of time and it takes a bit of repetition and doing. But that's the first thing, that precision reweighting that it does. The second, it is allowing for that prediction error to be taken into account without catastrophization or having that excessive change. Because you're having a gentle exposure to these sensations, PRT creates that bit of gentle gap in what ought to have happened to what's happening. So the brain is now in a place where it can say, I expected danger, but nothing bad happened. That means that this exposure is felt in the body, it's emotionally regulated and safe, and therefore this context of safety allows for the brain to update itself. It doesn't trigger the threat system and it doesn't trigger the rest of the spasm, all the things that bring about a pain flare-up. And the third part, we talked about precision reweighting, we talked about creating a prediction error. The third thing that PRT does when looking at pain through a predictive processing model is that the updating then does not happen just at the thought level, it is throughout the body. It allows the body safety to start coming back. That embodiment is what is crucial because PRT doesn't just change the thoughts, it also changes the bodily expectations because you start becoming aware of the signals that are coming from inside your body and on the surface of your body, you're able to do a more stable emotional processing, you can track what how the body is doing. That's what somatic tracking is, and you are asked to move with a bit of curiosity, you bring that wonderment in how you're doing that movement rather than fear, and that is crucial. When you bring this set together, the brain almost learns along with the body that my previous predictions were kind of wrong, and I'm still safe, so I think I can get back to being feeling safe in the body and moving. And that at that point, the pain predictions, everything that's been collapses. And the collapse is fantastic because you might think that somebody's become pain-free from just reading a book or or listening to a story or just turning around and seeing some one session. But it's this crucial moment that the pain predictions have collapsed. And that means that when this prediction collapses, people suddenly have a remarkable improvement in their pain. Because the brain has updated its model finally, and the cost of now producing the previous pain is starting to become too much energy. And that's the magic in how techniques like PRT can suddenly produce this dramatic recovery. Because the system has realized pain is no longer serving either survival or energy efficiency, and it stops. That's it. This is where the magic or pain freeness of PRT can appear from the framework of looking at it through predictive processing. It's not because the person is fixed, but it's because the model has changed. And that means you might be saying, Well, can it happen in everyone? And the sad truth is, no, it doesn't happen in everyone. Predictive models over time, and this is our understanding as of early 2026. This has been some brilliant work done by some great minds in the last 10 to 15 years on how predictive models are, what they do, a lot of what in neuroscience and all these LLMs and all these fancy things that you hear about neural networks is all coming from this understanding of the brain. And these predictive models that have been gathered over many years are shaped by trauma, are shaped by adversity in childhood or adversity in utero. They are shaped by ongoing stress. They may be shaped by neurodivergence, by social contact, by identity, by even some other secondary factors in the ecosystem, and probably the tissue-related injuries or surgery or anything that comes along. So that nosciceptive and neuropathic factors could also all be playing a part in how a predictive model is created and maintained. That means that if the prediction error cannot be safely tolerated, or if the environment or the ecosystem keeps reinforcing the threat or the danger, the model that has been there will not update, will just stay the way it is, and that might explain why PRT doesn't work for some people, and it allows us to go back and say, well, what has not changed in the ecosystem? Why is the prediction error not being able to be introduced? So that's why PRT works brilliantly for some. You will still need CBT and ACT for others, and it's more about integrating this and starting to look at offering PRT alongside CBT and Act in many clinics rather than being stuck in one ideology and say this is what we'll do. We need to say, well, how can we find out in whom PRT can work and offer it and do the trials to say where do we then give CBT an Act and where can we offer PRT? And so to end it all, I'd probably say, how can we now use this to complement the CBT and Act that we have? CBT works at the level of explicit beliefs and behaviors. ACT works at the level of relationship to the prediction. So I can act even if this prediction persists, but PRT works at the level of the prediction itself. So from a predictive processing model, I don't think that CBT or ACT or PRT are competing. I think they are just different levels and hierarchy of where each of these techniques is acting. So if I had to summarize PRT in one predictive processing sort of sentence, it would be that PRT helps the brain learn through safe, embodied experience that its prediction of danger is no longer necessary. Pain fades not because we fight it, but because the brain no longer needs it to make sense of the world. So I'll leave you with a few key messages to the end of this pod here. I want to reassure you pain is very much real, but what treatments like PRT show is that it's reversible. And understanding pain, I think is a big feature of changing our relationship with pain. And that means fear, which is a fuel for chronic pain, can be diminished when we understand it better. It is true that we are not going to get one single therapy, one quick fix, one magic pill, is never going to be the answer. And I think we need to be very honest and transparent in saying that there is a lot of hope, but we need to be pairing it with honesty. So if you watch that documentary and you've listened to the other two episodes on Pain Speak that I've had with Fiona and with Caroline, and you felt hopeful, then I would want to assure you that that hope is valid. That the real progress happens when we can combine neuroscience, when we can combine the psychological changes and the movement and nutrition and most importantly, compassion. And we bring it all together rather than chasing one magic fix. That's certainly the role for your medications and interventions in the right people, but this episode is about saying how do we integrate some of these other wonderful techniques that I have. So thank you for listening to this episode and coming this far. If this episode has helped you make sense of PRT, make sense of CBT and act, please share it with someone who needs it, who will benefit from this. I've been wanting to also do some work and some videos around some of the other techniques like internal family systems, emotional awareness, and expression therapy. And I'm going to make that in the next few videos. But if you feel you want to explore that as well, do let me know in the comment section. Like and subscribe to this pod as well. It improves the ratings in whichever channels, wherever you're consuming this information. And remember, your pain is real, your nervous system is adaptable, recovery is very much possible and is often about relearning the safety, not fighting your body. Thank you once again for listening to Pain Speak, and I'll see you in the next episode.