The science behind the new model of pain

What brain imaging shows as pain becomes chronic.

• 2012 ·
  Nature NeuroscienceBaliki et al.

  Corticostriatal functional connectivity predicts transition to chronic back pain

  In people with recent back pain, brain connectivity measured early helped predict who went on to develop chronic pain.

  Imaging study

• 2013 ·
  BrainHashmi et al.

  Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits

  As back pain became chronic, the brain activity tied to it shifted from circuits for sensing pain toward circuits for emotion.

  Imaging study

Trials of Pain Reprocessing Therapy.

• 2022 ·
  JAMA PsychiatryAshar et al., the Boulder trial

  Pain Reprocessing Therapy vs placebo and usual care for chronic back pain

  66% of the therapy group were pain free or nearly so, vs 20% on placebo and 10% on usual care, with gains largely maintained at one year.

  RCT

• 2023 ·
  JAMA Network OpenAshar et al.

  Reattribution to mind-brain processes and recovery from chronic back pain

  Secondary analysis of the Boulder trial. Recovery was linked to people coming to see their pain as driven by mind-brain processes rather than tissue damage.

  Secondary analysis

• 2025 ·
  JAMA PsychiatryAshar et al.

  Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: 5-Year Follow-Up of a Randomized Clinical Trial

  Five-year follow-up of the Boulder trial (113 of 151 participants). 55% of the PRT group were pain free or nearly so, vs 26% on placebo and 36% on usual care.

  RCT follow-up

• 2025 ·
  Reg Anesth Pain MedSturgeon et al.

  Brief pain reprocessing therapy for fibromyalgia: a feasibility, acceptability, and preliminary efficacy pilot

  A short form of PRT in three one-on-one remote sessions, in 35 people with fibromyalgia, with no comparison group. 94% completed the program, and pain fell among those who did. A randomized trial is needed to confirm it.

  Pilot trial

• 2026 ·
  J Psychosom ResSit et al.

  Pain Reprocessing Therapy in chronic widespread pain

  Feasible in primary care (n = 53). 30% vs 12% reached a 2 point reduction in pain severity; trends favored the therapy on every secondary outcome.

  Pilot trial

• In progress ·
  NCT07287072University of Oslo

  PRIME-PRT: Pain Reprocessing Therapy in primary care

  Norwegian primary care trial of PRT in adults aged 18 to 70 with chronic pain and no clear physical cause, probably nociplastic. Recruitment has closed and results are not yet published.

  Registered

Factors linked with pain becoming chronic.

• 2026 ·
  medRxiv

  Pain Amplifier Loop Framework, umbrella review

  Sleep disturbance, catastrophizing, metabolic inflammation and opioid exposure were each associated with chronification or treatment failure. Observational, so causation is not established.

  ReviewPreprint

Scan findings are common in people with no pain at all. That does not make scans useless, and it does not mean pain is imagined. It simply means a finding on its own does not always explain pain.

• 2009 ·
  SpineTakatalo et al.

  Prevalence of degenerative imaging findings in lumbar magnetic resonance imaging among young adults

  MRI of 558 Finnish 21-year-olds found at least one degenerated disc in almost half and a bulging disc in a quarter. Herniations and Modic changes were rare.

  Observational study

• 2015 ·
  AJNRBrinjikji et al.

  Systematic literature review of imaging features of spinal degeneration in asymptomatic populations

  Pooled studies of people with no back pain. Disc degeneration appeared in 37% of 20-year-olds and 96% of 80-year-olds, so many findings are likely part of normal aging.

  Review

• 2026 ·
  JAMA Internal MedicineIbounig et al.

  Incidental rotator cuff abnormalities on magnetic resonance imaging

  Both shoulders of 602 adults aged 41 to 76 were scanned. Abnormalities showed up in 96% of pain-free shoulders and 98% of painful ones.

  Observational study

Pain is real however it is generated. These studies show that meaning, expectation and emotion change how much pain people feel.

• 1956 ·
  JAMABeecher

  Relationship of significance of wound to pain experienced

  Soldiers with severe wounds asked for pain medication far less often than civilian patients (32% vs 83%). The size of the wound did not reliably predict pain. A historical report, not a controlled experiment.

  Observational study

• 1991 ·
  PainBayer et al.

  Situational and psychophysiological factors in psychologically induced pain

  People connected to a sham stimulator and told it might cause a headache reported pain half the time, against 25% of those not connected. Reports rose as the dummy settings were turned up.

  Experiment

• 2001 ·
  Int J Legal MedCastro et al.

  No stress, no whiplash? Prevalence of "whiplash" symptoms following exposure to a placebo rear-end collision

  51 volunteers were exposed to a fake rear-end collision with no real impact. About 20% reported whiplash-type symptoms within 3 days and 5 still did at 4 weeks.

  Experiment

• 2004 ·
  NeuroImageDerbyshire et al.

  Cerebral activation during hypnotically induced and imagined pain

  Hypnotic suggestion of painful heat, with nothing applied to the skin, activated thalamus, cingulate, insula, prefrontal and parietal regions, as real heat pain does.

  Imaging study

• 2011 ·
  PNASKross et al.

  Social rejection shares somatosensory representations with physical pain

  People who had recently been through an unwanted break-up looked at a photo of their ex. Areas involved in the sensory side of physical pain became active.

  Imaging study

• 2017 ·
  Nature CommunicationsWoo et al.

  Quantifying cerebral contributions to pain beyond nociception

  A brain pattern built from fMRI of 183 people predicts reported pain better than stimulus strength alone does. It also reflects the effect of expectation and perceived control. A research signature, not a diagnostic test.

  Imaging study